Академический Документы
Профессиональный Документы
Культура Документы
Ophthalmology Record
Melisa Silvia 08-184
DEPARTMENT OF OPHTHALMOLOGIC MEDICAL FACULTY CHRISTIAN UNIVERSITY OF INDONESIA JAKARTA, 2012
Patients Identity
Name Sex Age Address : Mrs. B : Female : 36 years old : Pete Sidomoyon Godean, Sleman, Yogyakarta : Moslem : Bachelor : Company Employee
with complaints of pain in the right eye since 2 days ago. Pain is
felt in the right eyes and around the right eye. Pain is felt tingling and long-lasting. Initially 1 month ago patient often complain of
Patient said complaint was more severe at night. Patient taking drugs reduce complaints Bodrex and sleep when complaints arise. However, the complaint was only gone a while, then came back. Patient do not go to the doctor because the patient is only considered ordinary headache. In addition, patients also complain of nausea and vomiting had 2 times as much, red right eye, watery, glare, and see the rainbow colors around lights.
Family History :
The patients father also had this symptoms
GENERAL STATUS General Condition : Mild illness Consciousness : Composmentis Complains-related symptoms : Unremarkable OPTHALMIC STATUS General
Right Eye
Surrounding of the Eye Eye Position Eye Movement Clear Symmetric All directions Clear Clear Symmetric All directions General Condition of the Eye Clear
Left Eye
Right Eye Visual Acuity Pinhole Correction Supercillia Cillia Superior/Inferior Palpebra Tarsal Conjunctiva Superior/Inferior Fornices Conjunctiva Superior/Inferior
1/300
Left Eye
6/6 normal, madarosis (-) normal, madarosis (-) normal, madarosis (-), trichiasis normal, madarosis (-), trichiasis (-) (-) Tumor (-), ptosis (-) Tumor (-), ptosis (-) Follicle (-) follicle (-), follicle (-) Cilliary injection (-) follicle (-) Cilliary injection (-)
Systematic
Bulbar Conjunctiva Superior/Inferior Cornea : Clarity Infiltrate Ulcer Scar Neovascularization Anterior Chamber Iris Pupil
clouded shallow radier, brown round, central, light reflex (+) slow reflex, 5mm, mydriatic Hard to be examined
Narrow 60mmHg
Clear deep radier, brown round, central, light reflex (+), 3mm Clear
Wide 18mmHg
Lens : Clarity
Field of Vision Intra Ocular Pressure
RESUME
The patient, female, 36 years old, came to the doctor with chief complaint pain in the right eye since 2 days ago. Pain is felt tingling and long-lasting. Initially 1 month ago patient often complain of headaches, especially right. Initially the pain lasted about half an hour to 2 hours and then disappear, but over time the complaint was more often and more of the same duration, as well as pain, is increasingly growing pains. Patient said complaint was more severe at night. Patient taking drugs reduce complaints Bodrex and sleep when complaints arise. However, the complaint was only gone a while, then came back.
In addition, patients also complain of nausea and vomiting had 2 times as much, red right eye, watery, glare, and see the rainbow colors around lights. The patient said had never had a complaint like this before. History of Hypertension, Diabetes Mellitus, allergies and use of drugs that contain steroids are denied. History of trauma (-), eye pain before (-), wears glasses (-), operations (-).The patients father also had this symptoms
Right Eye Visual Acuity Pinhole Correction Bulbar Conjunctiva Superior/Inferior Cornea : Clarity Infiltrate clouded shallow radier, brown round, central, light reflex (+) slow reflex, 5mm, mydriatic Clear deep
1/300
Lens : Clarity
Field of Vision Intra Ocular Pressure
Hard to be examined
Narrow 60mmHg
Clear
Wide 18mmHg
TREATMENT
Medication Pilocarpin 2-4% eye drops dripped 1 drop per minute for 5 minutes, followed by 1 drop every hour up to 6 hours Asetozolamid 2x250mg then 1 tablet every 4 hours for 24 hours Timolol 0,5% 2x1 Manitol 20% 1,5-2 gr/Kg body weight; 60 drops per minute (Intravenous) Surgical Trabeculectomy Iridectomy
PROGNOSIS OS Quo ad Vitam Quo ad functionam Quo ad sanationam OD Quo ad Vitam Quo ad functionam Quo ad sanationam
Thank You