PHYSICAL EXAMINATION

Head: Normocephal
Neck: Enlarged neck lymph nodes (-)
Thorax: Impression is within normal limits
Abdomen: Impression is within normal limits
Extremities: Warm accral, CRT <2 seconds
Ophtalmological Status

Oculi Dextra Oculi Sinistra

Ophthalmological Status

Oculi Sinistra
Ophthalmological Status
Oculi Dextra (OD) Information Oculi Sinistra (OS)

6/15 Visual Acuity 1/∞

Orthoforia Eyeball Positionn Orthoforia

N Intra Ocular Pressure N

+ + + +
+ + Eyeball Movement + +
+ + + +
+ -
+ + Visual Fields - -
+ + - -
+ + - -
+ -
Exophthalmos (-), Exophthalmos (-),
endophthalmos (-), strabismus Bulbus Oculi endophthalmos (-), strabismus
(-), nystagmus (-) (-), nystagmus (-)
Ophthalmological Status
Oculi Dextra (OD) Information Oculi Sinistra (OS)

Normal Supersilia Normal

Edema (-), Hyperemia (-), Edema (-), Hyperemia (-),Discharge

Superior Palpebra
Discharge (-), Trichiasis (-) (+), Trichiasis (-), pseudoptosis (+)

Edema (-), Hiperemis (-), Sekret Edema (-), Hyperemia (-),Discharge

Inferior Palpebra
(-), Trikiasis (-) (+), Trichiasis (-)

Injection (-), discharge (-) Tarsal Conjunctiva Injection (+), discharge (+)

Injection (-) Fornix Conjunctiva Injection (+)

Injection (+)
Injection (-)
Bulbar Conjunctiva discharge (+)
discharge (-)
Ophthalmological Status

Oculi Dextra (OD) Information Oculi Sinistra (OS)

Ciliary Injection (-), icteric (-) Sclera Ciliary injection (-), icteric (-)

Cloudy, infiltrate with irregular

Clear, infiltrate (-), cicatricial (-)
shape, central position 10-5 o'clock,
distance 2 mm from limbus,
Corneal
diameter 4 mm, visible
descementocele, satellite lesion (-),
hypopyon (+) 0.2 mm

Deep COA Deep

Synekia (-) Iris Synekia (-)

Ophthalmological Status
Oculi Dextra (OD) Information Oculi Sinistra (OS)

Round, central, regular, light reflex

Pupil Difficult to assess
(+), size 3 mm

Clear, Shadow test (-) Lens Difficult to assess

None testable Funduscopy None testable

SUPPORTING EXAMINATION

Slit Lamp Biomicroscopy

Oculi Dextra (OD) Information Oculi Sinistra (OS)

Stromal infiltrate at perifer of the

Clear, infiltrate (-), cicatricial (-) Corneal ulcer and feathery like appearance,
indistinct edges
 CASE ANALYSIS – Ophtalmological Status
- Decreased visual acuity

- Conjunctival injection

- Discharge

- The cornea looks cloudy, there

is an infiltrate, there is a
descementocele, satellite
lesions (-), hypopyon (+) 0.2
mm

Mark B. The Approach to Diagnosis and Management of Corneal Ulcers.J Ophthalmol & Vis Sci. 2023; 8(2): 1079.
 CASE ANALYSIS – Ophtalmological Status

- The cornea looks cloudy, there is an infiltrate with an irregular shape, the central
position is 10-5 o'clock, the distance is 2 mm from the limbus, the diameter is 4 mm,
there is a descementocele, satellite lesions (-), hypopyon (+) 0.2 mm, feathery like
edges not strict

Vaishal P Kenia et.al. 2020. Diagnosis and management protocol of acute corneal ulcer. International Journal of Health
Sciences and Research. 10(3): 69-78
CASE ANALYSIS - Physical examination

Stage II Hypertension (Uncontrolled)