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  • 1 POMR Entropion Trikiasis

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    D.s. Putri Nastiti
    73 tayangan3 halaman
    1. The patient is a 65-year-old Chinese man who complained of redness, itchiness, blurry vision in both eyes for 3 years. He has been using eye drops but with no improvement. 2. On examination, there was entropion, trichiasis, and pannus in both eyes. Fluorescein test was positive. 3. The diagnosis was entropion, trichiasis, and keratitis in both eyes. The plan was to perform tarsotomy surgery for correction of the entropion and trichiasis, use antibiotic eye drops, and follow up in 2 weeks.

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    Problem Oriented Medical Records POMR Mata Entropion Trikhiasis

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    1. The patient is a 65-year-old Chinese man who complained of redness, itchiness, blurry vision in both eyes for 3 years. He has been using eye drops but with no improvement. 2. On examination, there was entropion, trichiasis, and pannus in both eyes. Fluorescein test was positive. 3. The diagnosis was entropion, trichiasis, and keratitis in both eyes. The plan was to perform tarsotomy surgery for correction of the entropion and trichiasis, use antibiotic eye drops, and follow up in 2 weeks.

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    © All Rights Reserved
    Unduh sebagai DOC, PDF, TXT atau baca online dari Scribd
    Tandai sebagai konten tidak pantas
    73 tayangan3 halaman

    1 POMR Entropion Trikiasis

    Diunggah oleh

    D.s. Putri Nastiti
    1. The patient is a 65-year-old Chinese man who complained of redness, itchiness, blurry vision in both eyes for 3 years. He has been using eye drops but with no improvement. 2. On examination, there was entropion, trichiasis, and pannus in both eyes. Fluorescein test was positive. 3. The diagnosis was entropion, trichiasis, and keratitis in both eyes. The plan was to perform tarsotomy surgery for correction of the entropion and trichiasis, use antibiotic eye drops, and follow up in 2 weeks.

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    © All Rights Reserved
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    D.S. Putri Nastiti 201210401011051 POMR (Problem Oriented Medical Record) DATA BASE Nama: Tn.

    EK Alamat: Pulo, Jombang No.Reg : 21-33-77 Clue and Cue !a i-la i, $% ta&un N#o/o& .ata me#a& 3atal N0e#i 'ilau 'e#ing be# e)i1e)i1 P452 (ulu mata tumbu& e a#a& )alam 6luo#es/in test +7, Problem List E1i8o#a (le8a#os1as me 6oto8obia P452 T#i &iasis Ent#o1ion 6luo#es/in test +7, Initial DX 9- Ent#o1ion 9- T#i/&iasis 9- Ke#atitis
    DIAGNOSIS

    PLANNING THERAPY !e;o/in < )) gtt 2 Re1itel < )) gtt 2 E1ilasi silia To#sotomi ONITORING - Kelu&an 1asien : silau, n0e#i, n#o/o&, se#ing be# e)i1 - (le8a#os1as m - P452 - Pe# embang an 1en0a it ul us = +7>-, - Pe#tumbu&a n silia e1ilasi + a#ena 1asien menola o1e#asi, ED!CATION

    'na1 ba/ test :a1usan o#nea 1enge/atan g#am

    Tanggal: 03.03.2014 Jenis elamin: !a i-la i "mu#: $% ta&un 'u u bangsa: Tiong&oa Agama: (u))&a Pe e#*aan: +-, Pen)i)i an: '-

    Anamnesis : C"ie# $om%laint & .ata anan n#o/o&, n0e#i, )an silau RPS& mata anan se#ing n#o/o& )i#asa an se*a 3 ta&un te#a &i# . 3 minggu te#a &i# mata anan meme#a&, gatal, se#ing be# e)i1- e)i1, /en)e#ung n0e#i, )an te#asasilau *i a te# ena /a&a0a. Ti)a elua# oto#an 'elama 3 ta&un ini se#ing mengguna an obat tetes mata 2nsto

    - .en*elas an 1a)a 1?. (a&@a 1en0a it )isebab an ole& usia tua -egene#asi 8asia otot elo1a mata elo1a mata menga#a& e )alam bulu maata tumbu& ea #a& )alam - .embe#ita&u an emung inan om1li asi o#nea mata se#ing in8e si a#ena bulu mata 0ang tumbu& e )alam ul us o#nea - Pe#lu )ila u an o1e#asi +to#sotomi,

    RP-: :T +-,, -. +-,, #i@a0at o1e#asi st#uma 2 ta&un 0ll. RPK: Ti)a a)a R.'os : -

    P"'si$al e(amination : Kanan <>4% 5isus Te .bola mata Pe#se1s.@a#na P#o0e si /a&a0a Ka/amata lama Ki#i <>4% -

    atau 1en/abutan bulu mata untu men/ega& emung inan om1li asi lan*ut - Kont#ol 2 minggu emu)ian

    Ble%"aros%a sme)*+, e)ema+-, Entro%ion )-+, Tri.iasis )-+ 452+-,, PC/I)-+ 2n8ilt#at+-,, e)ema+-, 0luores$in test )-+ Pannus )-+

    Pal1eb#a

    (le1&a#os1a sme+-,, e)ema+-,

    Kon*u/ti; a Ko#nea

    452+-,, P452+-, 2n8ilt#at+-,, e)ema+-,

    -alam, *e#ni& P(2 A 3mm, R4+7, Regule#, i#is s&a)o@+7,, #egule# Je#ni&

    (.Pu1il 2#is

    -alam, *e#ni& P(2 A 3mm, R4+7, Regule#, i#is s&a)o@+7,, #egule# Je#ni&

    !ensa

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