CASE REPORT

Taufik Rizal, S.Ked

Pembimbing : dr. Helmi Muchtar,
Sp.M

Idendity

Medical Record : 06.66.76

Gender : laki-laki
Nick Name
: Tn. N
Religion : Islam
Age
: 38 Years
Education
: S1
Marital status : Married
Job : Entrepreneur
Adress
: Kedaton, Bandar Lampung City
Sign to Poli RSPBA
: 5 October 2016, At:
14.35 WIB
2

Anamnesis
Main Complaint : Itching of the right
eyelids.
Disease Of History Now:
Os came to the eye clinic RSPBAH with itching
complaints of the right eyelids since less than
6 months ago. In addition os also admitted
that sometimes the right eyelids side feel
pain, also yellowish color. Bumps on the
eyelids (-), watery eyes (-), can not stand the
light (-) eyes are not red (-), blurred vision (-),

Past medical history

A history of trauma to the eye area (-)
Other eye disease history denied
A history of the use of glasses (-)
History of drug allergy and food denied
History of steroid treatment and long-term
medicinal denied
Habitually
Family history is afflicted with this
condition are denied
Family Disease History
Patients is an entrepreneur
Impression : Socioeconomic enough
4

EXAMINATION
PHYSICAL EXAMINATION

general state : Good

Awareness : Compost mentis
vital signs : BP 110/80 mmHg Temperature: 36.5
Nadi:

76x / min
RR: 20x / min

Head: mesosefal
Thorax: The cast: no abnormality
Lung: no abnormality
Abdomen : No abnormality
Extremity : No abnormality

Status
Ophthalmology

OCULUS DEXTER

OCULUS SINISTER

20/20

VISUS

20/20

uncorrected

CORRECTION

uncorrected

not checked

SENSUS COLORIS

not checked

Eye movement freely in any

direction
No abnormalities

PARASE/PARALYSE

Eye movement freely in any direction

SUPERCILIA

No abnormalities

Hiperemis (+)
Tenderness (+)

PALPEBRA SUPERIOR

Margo palpebra superior : yellow

purulent
Edema (-), spasms (-)

PALPEBRA INFERIOR

Edema (-), spasms (-)

Hiperemis (-), secretions (-),

CONJUNGTIVA

Hiperemis (-), secretions (-), spasms (-)

spasms (-)

PALPEBRALIS

Hiperemis (-), secretions (-),

CONJUNGTIVA

Hiperemis (-), secretions (-), spasms (-)

spasms (-)
Injection (-), secretions (-)

FORNICES
CONJUNGTIVA BULBI

Injection (-), secretions (-)

Clear

SCLERA

Clear

Clear

CORNEA

Clear

Depth enoughTyndall Effect (-),

CAMERA OCULI

Depth enough, Tyndall Effect (-), hipopion

hipopion (-)
Kripte (+), sinekia (-)

ANTERIOR
IRIS

(-)
Kripte (+), sinekia (-)

Round, central, regular,

PUPIL

Round, central, regular,

Clear

LENSA

Clear

(+)

FUNDUS REFLEKS

(+)

not checked

TENSIO OCULI

not checked

not checked

SISTEM CANALIS

not checked

LACRIMALIS

Edema (-), spasms (-)

RESUME

Os came to the eye clinic RSPBAH with

itching complaints of the right eyelids
since less than 6 months ago. In addition
os also admitted that sometimes the right
eyelids side feel pain, also yellowish color.
OCULUS

OCULUS SINISTER

DEXTER
Hiperemis (+)
Tenderness+)
Margo

PALPEBRA

palpebra

SUPERIOR

superior :

yellow

Edema (-), spasms

(-)

Photo

V.

DIAGNOSIS
Blefritis Anterior OD

VI. DIFFERENTIAL DIAGNOSIS

Kalazion
Horeolum

VII. TREATMENT

Dosisiklin tab no X/ s 2 dd tab 1

C. Lyteer ED No. I / s 4 gtt dd 1 OD
Xitrol ED No. I / s 4 gtt dd 1 OD
Cendo Mycos Zalp No. I / s 1 dd 1

Prognosis

OD
OS
Quo ad Vitam
Dubia Ad bonam Ad bonam
Quo ad sanam
Dubia Ad bonam Ad bonam
Quo ad Vitam
Ad bonam
Quo
ad
ad bonam
Cosmeticam

X.

EDUCATION

Compress with warm water 3-4 times / day

for 10-15menit / day
Cleaning secret eyelids with baby shampoo
Avoid exposure to dust
Close both eyes with glasses and cloth
Explain to patients that do not rubbed eyes
Patients were asked to keep the immune
system by eating nutritious food and rest
enough to accelerate the healing of disease

Thank You