OPHTALMIC RECORD 201 1

OPHTALMIC RECORD

Name of examiner NIM Tutor

: Wulan Ervinna Simanjuntak

: 06-031 : Prof. DR. Dr. J.H.A. Mandang, SpM

Date of examination : 24 December 2010

I. PATIENT IDENTITY Name Sex Age Occupation Address : Mr. M : Male : 60 years old : Unemployee : Cebungan, Sapuwetan, Sleman

II. INTERVIEW Main Complaint Additional Complaint Chronology of disease : : Red eye and pain on the right and left eye : Blurred vision, watery eyes, glare when exposed to light A 60 years old male patient came to dr.Yap Eye Hospital with complaint red eye and pain on both of his eyes since two weeks ago. The patient also told that he felt watery eyes, glare when exposed to light and the vision get decrease or blurred . Patient taken an eye drop (Visine) to reduce those symptoms but it didnt getting better and then he decided to go to the hospital to receive better treatment. The patient never had this kind of illness before and no one in his family suffer the same complaint. Previous Disease : Unremarkable

1|Page

OPHTALMIC RECORD 201 1

III.GENERAL STATUS General condition Complaint related symptoms IV.OPHTALMIC STATUS A. General Examination Examination RIGHT EYE LEFT EYE Periocular Appearance Quiet Quiet General Condition of the Eye Mild illness Mild illness Ball Position of The Eye Ball Ocular Mobility appearance Symetric Normal appearance Symetric Normal : Well : Unremarkable

B. Systemic Examination Examination Visual acuity Correction Supercillia Cilia Superior/Inferior RIGHT EYE 3/60 Uncorrected Quiet Quiet Margo Normal Hyperemic Hyperemic Ciliary Injection Keratic Precipitates Flare (+) Posterior Synechiae Pupil Lens Schiotzs Tonometer LEFT EYE 3/60 Uncorrected Quiet Quiet Normal Hyperemic Hyperemic Ciliary Injection Keratic Precipitates Flare (+) Posterior on Synechiae on

Palpebra Sup/Inf Tarsalis Conjunctiva Sup/Inf Fornices Conjunctiva Bulbar Conjunctiva Cornea Anterior Chamber Iris

Temporo posterior Temporo posterior Miosis, light Miosis, light reactive(+) Clear 15,6 reactive(+) Clear 16,4

I. RESUME A 60 years old male patient came to dr.Yap Eye Hospital with complaint red eye and pain on both of his eyes since two weeks
2|Page

OPHTALMIC RECORD 201 1

ago. The patient also told that he felt watery eyes, glare when exposed to light and the vision get decrease or blurred . Patient taken an eye drop (Visine) to reduce those symptoms but it didnt getting better and then he decided to go to the hospital to receive better treatment. The patient never had this kind of illness before and no one in his family suffer the same complaint. From the ophthalmology examination, founded : Examination Visual acuity Sup/Inf Tarsalis Conjunctiva Sup/Inf Fornices Conjunctiva Bulbar Conjunctiva Cornea Anterior Chamber Iris RIGHT EYE 3/60 Hyperemic Hyperemic Ciliary Injection Keratic Precipitates Flare (+) Posterior Synechiae Pupil LEFT EYE 3/60 Hyperemic Hyperemic Ciliary Injection Keratic Precipitates Flare (+) Posterior on Synechiae on

Temporo posterior Temporo posterior Miosis, light Miosis, light reactive(+) reactive(+)

II. CLINICAL DIAGNOSE Acute Anterior Uveitis Oculi Dextra et Sinistra III.DIFFERENTIAL DIAGNOSE

Conjunctivitis Acute Glaucoma

I. MEDICAL TREATMENT

Midriaticum : Sulphas atropine 1 drops ODS, 3 times daily Corticosteroid drops, 1-2 drops ODS, 4-6 times daily Antibiotic

3|Page

OPHTALMIC RECORD 201 1

I. SUGGESTED EXAMINATION

Laboratory test Cystoid macular oedema Secondary glaucoma Secondary cataract

I. COMPLICATION

I. PROGNOSE Ad Vitam Ad Sanationum Ad Functionum RIGHT EYE Bonam Dubia ad bonam Dubia ad bonam LEFT EYE Bonam Dubia ad bonam Dubia ad bonam

OPHTALMIC RECORD
4|Page

OPHTALMIC RECORD 201 1

Tutor: Prof. DR. Dr. JHA Mandang, SpM(K)

Examiner: Wulan Ervinna Simanjuntak 06-031

DEPARTEMENT OF OPHTALMOLOGY MEDICAL FACULTY OF CHRISTIAN UNIVERSITY OF INDONESIA JAKARTA 2010

5|Page