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OPHTALMIC RECORD
I. PATIENT IDENTITY Name Sex Age Occupation Address : Mr. M : Male : 60 years old : Unemployee : Cebungan, Sapuwetan, Sleman
II. INTERVIEW Main Complaint Additional Complaint Chronology of disease : : Red eye and pain on the right and left eye : Blurred vision, watery eyes, glare when exposed to light A 60 years old male patient came to dr.Yap Eye Hospital with complaint red eye and pain on both of his eyes since two weeks ago. The patient also told that he felt watery eyes, glare when exposed to light and the vision get decrease or blurred . Patient taken an eye drop (Visine) to reduce those symptoms but it didnt getting better and then he decided to go to the hospital to receive better treatment. The patient never had this kind of illness before and no one in his family suffer the same complaint. Previous Disease : Unremarkable
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B. Systemic Examination Examination Visual acuity Correction Supercillia Cilia Superior/Inferior RIGHT EYE 3/60 Uncorrected Quiet Quiet Margo Normal Hyperemic Hyperemic Ciliary Injection Keratic Precipitates Flare (+) Posterior Synechiae Pupil Lens Schiotzs Tonometer LEFT EYE 3/60 Uncorrected Quiet Quiet Normal Hyperemic Hyperemic Ciliary Injection Keratic Precipitates Flare (+) Posterior on Synechiae on
Palpebra Sup/Inf Tarsalis Conjunctiva Sup/Inf Fornices Conjunctiva Bulbar Conjunctiva Cornea Anterior Chamber Iris
Temporo posterior Temporo posterior Miosis, light Miosis, light reactive(+) Clear 15,6 reactive(+) Clear 16,4
I. RESUME A 60 years old male patient came to dr.Yap Eye Hospital with complaint red eye and pain on both of his eyes since two weeks
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Temporo posterior Temporo posterior Miosis, light Miosis, light reactive(+) reactive(+)
II. CLINICAL DIAGNOSE Acute Anterior Uveitis Oculi Dextra et Sinistra III.DIFFERENTIAL DIAGNOSE
I. MEDICAL TREATMENT
Midriaticum : Sulphas atropine 1 drops ODS, 3 times daily Corticosteroid drops, 1-2 drops ODS, 4-6 times daily Antibiotic
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I. COMPLICATION
I. PROGNOSE Ad Vitam Ad Sanationum Ad Functionum RIGHT EYE Bonam Dubia ad bonam Dubia ad bonam LEFT EYE Bonam Dubia ad bonam Dubia ad bonam
OPHTALMIC RECORD
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