OPHTALMOLOGY RECORD

The Examine

: Elda Oncossya Panggabean

Student Number

: 1061050134

Date of Examination : January 22nd, 2015

Examiner

I.

II.

: DR. dr. Gilbert W.S. Simanjuntak, Sp.M (K)

PATIENT IDENTITY
Name
: Mrs. M.M
Gender
: Female
Age
: 45 years old
Job
: Employee
Religion
: Christian
Address
: Pondok Bambu, South Jakarta
ANAMNESIS (December 22nd, 2014)
Main problem(s)

: Redness in left eye since 1 week ago

Additional problem(s): Pain, watery and sandy-gritty sensation in left eye along with
blurry vision
History of Present Illness
Patient came to UKI Hospital with redness in left eye since 1 week ago. At first, she
thought that it was only an usual redness around the eyeball caused by pollution, but day
by day it became more severe and it happens continuously along with the pain in the left
eye that is also becoming more painful everyday. She also complained about her blurry
vision that happened 3 days ago, it happened progressively along with the watery and
sandy sensation in left eye everytime she tried to open her eyes. According to the patient,
this all happened in all of a sudden, without any causes; no history of eye trauma, no
history of using contact lens. She havent done anything to treat or cure her complains.
No complain about glare, headache, itchiness, or feeling nauseous. No complain about
her right eye.
Past Medical History

Patient never had any complains/ illness like this before

OPHTALMOLOGY RECORD
ELDA ONCOSSYA PANGGABEAN (10-134)

Hypertension denied
Diabetes Mellitus denied
Long term use of corticosteroid drugs denied
No history of eye trauma or any other trauma

Family Medical History

None of her family or relatives had complains like this before
III.

IV.

GENERAL STATUS
General condition
Awareness

: Mild illness
: Compos mentis

OPHTALMOLOGY STATUS
A. General Examination
General Examination
Appearance Around Eyes
General Condition of Eyes
Position of Eye Ball
Eye Movement

OD
Quiet
Hyperemic, watery
Symmetrical
Normal to all
directions

OS
Quiet
Quiet
Symmetrical
Normal to all
directions

OD

OS

6/20
S -1,00
6/6

6/20
Pinhole not working
-

Normal growth
Normal growth,
Madarosis(-)
Trichiasis (-)
Edema(-)
Hyperemic(-)
Entropion (-)
Ectropion (-)
Ulcus (-)
Crust (-)
Ptosis (-)
Hyperemic (-)
Cicatrix (-)

Normal growth
Normal growth,
Madarosis (-)
Trichiasis (-)
Edema(-)
Hyperemic(-)
Entropion (-)
Ectropion (-)
Ulcus (-)
Crust (-)
Ptosis (-)
Hyperemic (-)
Cicatrix (-)

B. Systemic Examination
Parameter
Visual Acuity
Before Correction
Lens Correction
After Correction
Supercilia
Cilia

Sup/Inf Palpebra

Tarsal Conjunctiva
OPHTALMOLOGY RECORD
ELDA ONCOSSYA PANGGABEAN (10-134)

Follicle (-)
Papillae (-)
Normal
Ciliary injection (-)
Discharge (-)

Follicle (-)
Papillae (-)
Normal
Ciliary injection (+)
Discharge (-)

Round
Clear
-

Round
Cloudy
+
-

Deep
Hypopyon (-)
Hyphema (-)
Black-Brown
Radier shape
Synechia (-)
Icteric (-)
Round, in the middle
Isochore, 3 mm
Direct light reflex (+)
Indirect light reflex(+)
Clear
Havent been done

Deep
Hypopyon (-)
Hyphema (-)
Black-Brown
Radier shape
Synechia (-)
Icteric (-)
Round, in the middle
Isochore, 3 mm
Direct light reflex (+)
Indirect light reflex(+)
Clear
Havent been done

Fornix Conjunctiva
Bulbar Conjunctiva
Cornea
Shape
Clearness
Infiltrate
Ulcus
Cicatrix
Neovascularization
Anterior Chamber
Iris
Sclera
Pupil

Lens
Tonometri
V.

RESUME
Patient Mrs. M.M, 45 y.o came to UKI Hospital with redness in left eye since 1 week
ago which became more severe and it happens continuously along with the proggresive
pain in the left eye. She also complained about her blurry vision that happened 3 days
ago, it happened progressively along with the watery and sandy sensation in left eye
everytime she tried to open her eyes. This all happened with no cause.

From Ophtalmology Examination we can conclude that :

Parameter
Visual Acuity
OPHTALMOLOGY RECORD
ELDA ONCOSSYA PANGGABEAN (10-134)

OD

OS

Before Correction
Lens Correction
After Correction

Bulbar Conjunctiva

6/20
S -1,00

6/20
Pinhole not working

6/6
Ciliary injection (-)
Discharge (-)

Ciliary injection (+)

Discharge (-)

Round
Clear
-

Round
Cloudy
+

Cornea
Shape
Clearness
Infiltrate
VI.
VII.

VIII.

WORKING DIAGNOSIS
Oculi Sinistra Keratitis
DIFFERENTIAL DIAGNOSIS
Bacterial Keratitis
Uveitis
Acute Glaucoma
TREATMENT/ MEDICATION
1. Non-Medication
Dont rub both eyes
Wash hands before and after touching the eyes
Use sunglasses when going out
Cover eye with eye pad (if possible)
2. Medication
Local Antibiotic
Cyclopegic

IX.

X.

PLANNED EXAMINATION
Slitlamp with Fluorescent Test
Microbiology Culture

PROGNOSIS

Ad Vitam
Ad Sanationum
Ad Functionum
OPHTALMOLOGY RECORD
ELDA ONCOSSYA PANGGABEAN (10-134)

OD
Bonam
Bonam
Bonam
4

OS
Bonam
Dubia ad bonam
Dubia ad bonam

XI.

COMPLICATION
Corneal Ulcus
Corneal Cicatrix

OPHTALMOLOGY RECORD
ELDA ONCOSSYA PANGGABEAN (10-134)