Ophtalmic Record

7/30/2019 Ophtalmic Record

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OPHTALMIC RECORD

EXAMINER : KEITHY DOROTHY SIRAIT - 0861050101

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

Medical Faculty Christian University of Indonesia

April 2013, Jakarta


2/15

PATIENT IDENTITY

Name : Mr. M

Sex : Male

Age : 66 years old

Occupation : Retired

Address : Purwosari Kwadungan, Ngawi

Status : Married


3/15

INTERVIEW

Primary Complaint : Blurred vision in

left eye

Additional Complaint : Red eye, difficut to

see the left side, headache


4/15

Chronology of Disease

A man patient aged 66 years old came to Dr. YapEye Hospital with primary complaint blurred visionin his left eye since one week ago. The patient also

told that he is difficult to see the left side becausethe vision get decrease or blurred. He alsocomplaint headache and red eye in his left eye. Thepatient has taken an eye drop to reduce those

symptoms but it didnt getting better and then hedecided to go to the hospital to receive bettertreatment.


5/15

Previous Disease andHistory of

Family Disease

The patient denied have minus or plus glasses

before. He had never come to the doctor to

check up his eyes. Patient denied that he got theother illness like hypertension, diabetic, etc. The

patient never had this kind of illness before and

no one in his family suffered the samecomplaint.


6/15

GENERAL STATUS

General condition : Mild illness

appearance

Complaint related symptoms : Unremarkable


7/15

OPHTALMIC STATUS

General Examination

Systemic Examination


8/15

General Examination

Examination RIGHT EYE LEFT EYE

Periocular Appearance Quiet Quiet

General Condition of

the Eye Ball

Well Mild illness

appearance

Position of The Eye Ball Symetric Symetric

Ocular Mobility Normal Normal


9/15


Visual acuity 6/6 1/60

Correction - Can not be corrected

Supercillia Quiet, Black Quiet, Black

Cilia Quiet, Black Quiet, Black

Sup/InfMargo Palpebra Normal Normal

Sup/Inf Tarsalis Conjunctiva Normal Hyperemic

Sup/Inf Fornices Conjunctiva Normal Hyperemic

Bulbar Conjunctiva Normal Conjunctiva Injecton, Ciliary Injection

Cornea Clear Unclear

Camera Oculi Anterior Deep Superficial

Iris Radier, Brown Radier, Brown

Pupil Miosis, diametre

3mm, light reflex (+)

Midriasis, diametre 5mm, light reflex (-)

Lens Clear Clear

Schiotzs Tonometer 13 mmHg 48 mmHg


10/15

RESUME

A man patient aged 66 years old came to Dr. Yap EyeHospital with primary complaint blurred vision in his left eye

since one week ago. The patient also told that he is difficult to

see the left side because the vision get decrease or blurred.

He also complaint headache and red eye in his left eye. Thepatient has taken an eye drop to reduce those symptoms but

it didnt getting better and then he decided to go to the

hospital to receive better treatment.

The patient denied have minus or plus glasses before.He had never come to the doctor to check up his eyes. Patient

denied that he got the other illness like hypertension,

diabetic, etc. The patient never had this kind of illness before

and no one in his family suffered the same complaint.


11/15


Visual acuity 6/6 1/60

Correction - Uncorrected

Supercillia Quiet, Black Quiet, Black

Cilia Quiet, Black Quiet, Black

Sup/Inf Margo Palpebra Normal Normal

Sup/Inf Tarsalis Conjunctiva Normal Hyperemic

Sup/Inf Fornices Conjunctiva Normal Hyperemic

Bulbar Conjunctiva Normal Conjunctiva Injecton, Ciliary Injection

Cornea Clear Unclear

Camera Oculi Anterior Deep Superficial

Pupil Miosis, diametre

3mm, light reflex (+)

Midriasis, diametre 5mm, light reflex (-)

Lens Clear Clear

Schiotzs Tonometer 13 mmHg 48 mmHg


12/15

DIAGNOSE

CLINICAL DIAGNOSE

Primary Acute Glaucoma OS

DIFFERENTIAL DIAGNOSE

Uveitis Anterior

Keratitis


13/15

TREATMENT AND EXAMINATION

MEDICAL TREATMENT Medikamentosa :

Beta blockers : Timolol 0,5% 1-2 drops/day

Carbon anhidrase inhibitors : Asetozolamide

250mg 2 tab once and then 4 x1 tabOsmotik : Manitol 60 drops/mnt

Surgery : Iridectomy

SUGGESTED EXAMINATION

Ofthalmoscopy

Gonioscopy


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PROGNOSES AND COMPLICATION

PROGNOSES

COMPLICATION

Absolute Glaucoma OS

RIGHT EYE LEFT EYE

Ad Vitam Bonam Bonam

Ad Sanationum Bonam Dubia ad malam

Ad Functionum Bonam Dubia ad malam


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Ophtalmic Record

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