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MANAJEMEN KASUS Anak Agung Ary Yuliani

1971121044
IDENTITAS PASIEN
Inisial : IMYP
Umur : 8 Tahun
Jenis Kelamin : Laki - Laki
Pekerjaan : Pelajar
Agama : Hindu
Suku/Bangsa : Bali/Indonesia
Alamat : Tegalalang
Tanggal Pemeriksaan : 04 Februari 2020
Nomor Rekam Medis : 671069
ANAMNESIS
1. Riwayat Penyakit Sekarang

Keluhan utama : Mata Merah

Pasien dating ke poli mata dengan


keluhan mata merah pada mata kiri sejak
5 hari yang lalu. Merah dikatakan timbul
secara mendadak, tetapi tidak sampai
menyebabkan terganggunya aktivitas
pasien. Awalnya keluhan mata merah
pasien baru disadari oleh ayahnya saat
memandikan anaknya. Kemudian
keesokan harinya pasien dibawa ke
puskesmas dan diberikan obat tetes
mata dan obat minum. Ayah pasien
mengatakan tidak ada faktor yang
mempebaik atau memperburuk dari
keluhan pasien. Keluhan lain yang Simple Presentation
dialami pasien yaitu Nyeri (+), Berair (-),
Berpasir (-), Batuk (-) dan Riwayat
Trauma (-).
Lanjutan ANAMNESIS

Riwayat Penyakit Dahulu

1 Get a modern PowerPoint Presentation that is


beautifully designed.

Riwayat Penyakit Keluarga


2 erPoint Presentation that is beautifully designed.

Riwayat Sosial

3 Get a modern PowerPoint Presentation that is


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Oculi Dextra (OD) Pemeriksaan Oculi Sinistra (OS)
6/6 Agenda Style Visus 6/6

Normal Palpebra Normal

Hemorargi (-) PCVI (-) CVI (-) Konjungtiva Hemorargi (+) PCVI (-) CVI (-)

Infiltrat (+)
01 Contents
Get a modern Kornea
PowerPoint Presentation that is beautifully Infiltrat (+)
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Dalam Bilik mata depan Dalam

Bulat, Warna Coklat 02 Contents


Iris Bulat, Warna Coklat
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RP (+) Pupil RP (+)

Jernih
03 Lensa
Contents Jernih
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Jernih Vitreus I hope and I believe that this Template Jernih
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Refleks Fundus (-) Funduskopi Refleks Fundus (-)


04 Contents
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