OPHTALMIC RECORD

WINDA LAURA SIAHAAN 0761050084 Medical Faculty Christian University of Indonesia August 2011, Jakarta

Patient Identity

Name Age Sex Address Occupation Religion Nation Tribe Status

: : : : : : : : :

Mr. A 56 years old Male Bantul, Jogjakarta Retired Moslem Indonesian Java Married

HISTORY OF DISEASE
A man aged 56 years old came to DR. YAPS Eye Hospital with primary complain blurred vision in both eyes since one moth ago. He also told that when walking often nudging things around him and when riding a bike is often suprised when preceded by another vehicle but the patient feels his vision is still unclear. He also often feel a headache and had nausea and vomiting. He denied have minus or plus glasses before. He had never come to the doctor to check up his eyes and he never felt the same symptoms before. Patient denied that he got the other illness like hypertension, diabetic, etc. In his family,no one had complain like this.

INTERVIEW
Primary complaint : blurred vision in both eyes since one month ago. Additional complaint : Headache, nausea and vomiting. History of family disease : In his family,no one had complain like this. Previous disease : none

Physical Examination
OD 6 / 12 Quiet Normal Clear Clear in Depth Radier, brown / isochors, light reflex positive Vision Acuity Palpebra Conjunctiva Cornea COA Iris / Pupil OS 6 / 12 Quiet Normal Clear Clear in Depth Radier, brown / isochors, light reflex positive

Clear Clear Lamina cribosa ( + ) + Normal elevated

Lense Funduscopy Media Papil Macula Reflex Retina IOP

Clear Clear Lamina cribosa ( + ) + Normal elevated

RESUME
A man aged 56 years old came to Dr. YAPs Eye Hospital with primary complain blurred vision in both eyes since one month ago. He also told that when walking often nudging things around him and when riding a bike is often suprised when preceded by another vehicle but the patient feels his vision is still unclear. He also often feel a headache and had nausea and vomiting. He denied have minus or plus glasses before. He had never come to the doctor to check up his eyes and he never felt the same symptoms before. On examination on found a sharp left and right eye sight 6/12, not visible abnormalities in the anterior segment, and the lenses are clear. The intraocular pressure were elevated by digital tonometry.

Clinical Diagnose : Primary Open Angle Glaucoma ODS Differential Diagnose : Secondary Open Angle Glaucoma, Chronic Closed Angle Glaucoma Medical Treatment : Education Surgery : Trabeculectomy Medikamentosa : Beta blockers Carbon anhidrase inhibitors

o Suggest examination :

Tonometry Perimetry Ofthalmoscopy Gonioscopy oPrognoses : ad vitam : dubia ad bonam ad sanationum : ad bonam ad functionum : ad bonam oComplications : blindness