OPTHALMIC RECORD

Tutor:
Prof. DR. Dr. J.H.A. Mandang, SpM

Examiner : BARTOLOMEUS RUSMAN

94 072

DEPARTMENT OF OPHTHALMOLOGIC
MEDICAL FACULTY
CHRISTIAN UNIVERSITY OF INDONESIA
JAKARTA 2006
OPHTHALMIC RECORD

Name of Examiner

: Bartolomeus Rusman

NIM

: 94 - 072

Date of examination

: December, 16th 2006

Tutor

: Prof. DR. Dr. J.H.A. Mandang, SpM

I. PATIENT IDENTITY

II.

Name

: Mr. Y

Age

: 60 years old

Address

: Jl. Jatinegara No. 25 Jakarta Timur

Occupation

: Pension

INTERVIEW
Primer complain
Blurred vision on both eyes for about 6 month.
Additional complain
Sensitive to the light
History of disease
A 60 years old male came to UKIs Hospital with primary complain
blurred vision on both eyes for about 6 month. 6 month ago he started
to have a foggy vision and its getting worse. He also complains that
his eyes became sensitive to the light. Patient did not take any kind of
medicine to overcome his eye problem. Patient had never have this
kind of problem before. He comments that he had never an eye
trauma. Moreover, the same complain are not found in his family.
Previous disease
Unremarkable

III.

GENERAL STATUS
General condition

: Well

Symptom or illness related to the complain

IV.

: Unremarkable

OPHTHALMIC STATUS
1.

General Examination

Periocular appearance
General condition of the
eye
Eyeball position
Eyeball movement

Right Eye Left Eye

Quiet
Quiet
Well
Well
Symetric
Normal

Symetric
Normal

B. Systematic Examination
Visual acuity
Super cilia
Cilia
Tarsal conjunctiva sub/inf
Fornices conjunctiva sup/inf
Bulbar conjunctiva
Cornea
Anterior chamber
Iris
Pupil
Lens
Schiotzs tonometric

V.

Right Eye
1/60
Normal
Normal
Normal
Normal
Normal
Clear
Normal
Radier
Round, isochor
Light reflex: positive
Whole part muddy
Shadow test: negative
15,6 mmHg

SPECIFIC EXAMINATION
USG Biometric

Left Eye
3/60
Normal
Normal
Normal
Normal
Normal
Clear
Normal
Radier
Round, isochor
Light reflex: positive
Whole part muddy
Shadow test: negative
17,0 mmHg

VI.

RESUME
A 60 years old male came to UKIs Hospital with primary complain
blurred vision on both eyes for about 6 month. He also complains that
his eyes became sensitive to the light.
Ophthalmic Examination
Visual acuity
Lens

VII.

Right Eye
Left Eye
1/60
3/60
Whole part muddy
Whole part muddy
Shadow test: negative Shadow test: negative

CLINICAL DIAGNOSE
Right Eye
Left Eye
Mature senile cataract Mature senile cataract

VIII.

MEDICAL TREATMENT
Surgical intervention
i.

PROGNOSES

Right Eye
Left Eye
Ad vitam
Bonam
Bonam
Ad sanationum Dubio ad bonam Dubia ad bonam
Ad functionum Dubio ad bonam Dubia ad bonam
IX.

COMPLICATIONS
Secondary cataract
Secondary glaucoma