OPHTHALMIC RECORD

Name of examiner NIM Date of exam Tutor : Chynthia Friama : 05-014 : July 21th, 2011 : Dr. Gilbert Simanjuntak, SpM.

I.

PATIENT IDENTITY
Name Sex Age Religion Occupation Address : Mr. S : Male : 34 years old : Moslem : Farmer : Kaliurang, Yogyakarta

II.

ANAMNESA ( July 13th, 2011 )

Main complain : Blurred vision, red eye and pain on the left eye. Additional complain : Watering and glare when exposed to light. Chronology of disease Patient came to Dr. YAP Eye Hospital, Yogyakarta with main complain blurred vision, red eye and pain on the left eye since 15 days ago. He also complained that his left eye was watering and his left eye glare when exposed to light while outdoors. He told that 15 days before the mud water of the farm was getting into his left eye while he was working in the farm. Patient tried to take a treatment with eye drop to his left eye, but it didnt make any better. Previous disease Denied History of family disease He never had the same symptoms like this before and the same complains were not found in member of family.

III.

GENERAL STATUS
General Condition : Appearance of mild illness Complains related symptom : Denied

IV.

OPHTALMIC STATUS A. General Examination Parameter

Periocular Appearance General Condition of the Eye Eyeball Position Eyeball Movement

Right Eye (OD) Quiet Well Symetric Normal

Left Eye (OS) Quiet Mild illness Symetric Normal

B. Systemic Examination Parameter

Visual acuity Correction Supercilia Cilia Sup/inf margo palpebra Sup/inf tarsalis conjunctiva Sup/inf fornices conjunctiva Bulbar conjunctiva

Right Eye (OD) 6/6 Quiet Quiet Normal Quiet Quiet Quiet

Left Eye (OS) 6/18 Quiet Quiet Normal Hyperemic Hyperemic Ciliary injection

Parameter
Cornea Infiltrat Ulcer Cicatric Neovascularization

Right Eye (OD)

Not found Not found Not found Not found

Left Eye (OS)

Found (numular) Not found Not found Not found

Anterior Chamber Iris Pupil

Clear Radier Round, light reflex (+) Clear +

Clear Radier Round, light reflex (+) Clear +

Lens Fluorescent test Sensibility test

V. RESUME
Patient came to Dr. YAP Eye Hospital, Yogyakarta with main complain blurred vision, red eye and pain on the left eye since 15 days ago. He also complained that his left eye was watering and his left eye glare when exposed to light while outdoors. He told that 15 days before the mud water of the farm was getting into his left eye while he was working in the farm. The result from systemic examination on the left eye found :

Visual acuity

: 6/18

Tarsalis conjunctiva : hyperemic Fornices conjunctiva : hyperemic Bulbar conjunctiva Cornea : ciliary injection : infiltrate (numular)

VI. CLINICAL DIAGNOSE

Numular Keratitis OS

VII. DIFFERENTIAL DIAGNOSE

Disiformis Keratitis OS

VIII.

MEDICAL TREATMENT
Topical : Cendo Citrol 1 drop, 6 times daily. Cendo Tropin 1 drop, 3 times daily.

Systemic :

Vitamin : Vitalux 1 tab per day.

IX. COMPLICATION Cornea ulcer X. PROGNOSE Left Eye Ad vitam Ad sanationum Ad functionum Bonam Dubia ad bonam Dubia ad bonam