OPTHALMIC RECORD

Tutor:
DR. dr. Gilbert W. S. Simanjuntak, Sp.M (K)
Examiner:
Hilda Christ Yulanda Muda
1161050172

DEPARTMENT OF OPHTHALMOLOGIC MEDICAL

FACULTY PERIOD 23rd January 25th February 2017
CHRISTIAN UNIVERSITY OF INDONESIA
JAKARTA 2017

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 OPHTHALMIC RECORD

Name of Examiner : Hilda Christ Yulanda Muda

NIM : 1161050172
Tutor : DR. dr. Gilbert W. S. Simanjuntak, Sp.M (K)

PATIENT IDENTITY
Name : Mrs. SM
Sex : Female
Age : 37 years old
Education : Senior High School
Occupation : House wife
Religion : Moeslim
Address : Jl. Bungur No.56 RT 005/ RW 009 Kecamatan Jatinegara ,
Kelurahan Cipinang Melayu. Jakarta Timur.
Status : Married

I. ANAMNESIS (January 2nd , 2017)

Main complaint
A lump on the right upper eyelid since 5 days ago
Additional complaint
Painful, swelling, and redness.
History of disease
Patient came to hospital with main complaint a lump on the right upper eyelid
since 5 days ago. The problem start as a red small lump on the right upper
eyelid and eventually growing bigger so that the right upper eyelid became
very red and swelling. The swelling was also accompanied by pain especially

OPHTHALMIC RECORD UKI HOSPITAL 2017 Page 2

 when it is touched. Itchy and watery eyes was denied. Decreased on vision
was denied. The patient didnt get any medications yet. There was no problem
at the right eye. The patient didnt use an eyeglass before. The patient often
rub her eyes.

Previous disease
The patient said that he never had this situation before.The presence of
diabetes or high blood pressure denied. History of physical trauma denied,
history of using long-term drug denied, allergies and history of contact lenses
used denied.

Family Disease History

There is nobody in his family who experience the complaints like him.

II. GENERAL STATUS

General condition : Mild illness
Symptom or illness related to the complaint : None

III. OPHTHALMIC STATUS

A. General Examination
Right Eye Left Eye
Periocular appearance Edema Quite
General condition of the eye Mild illness Normal
Eyeball position Symmetry Symmetry
Eyeball movement Normal Normal

B. Systematic Examination

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 Right Eye Left Eye

Visual acuity 6/6 6/6

Correction - -

Super cilia Normal, Normal,

Madarosis (-) Madarosis (-)

Cilia Normal, Normal,

Madarosis (-), Trikhiasis (-) Madarosis (-), Trikhiasis (-)

Margo Palpebra superior
Margo Palpebra inferior
Tarsal conjunctiva superior
Edema (+), tenderness
(+), hiperemis (+)
ectropion (-), entropion
(-), ulcus (-), krusta (-)
Edema (-), tenderness (-),
ectropion (-), entropion
(-), ulcus (-), krusta (-)
Hyperemic (+), Papilar (-),
Follicle (-), Bledding (-)
Edema (-), tenderness (-),
ectropion (-), entropion
(-), ulcus (-), krusta (-)
Edema (-), tenderness (-),
ectropion (-), entropion
(-), ulcus (-), krusta (-)
Hyperemic (-), Papilar (-),
Follicle (-), Bledding (-)

Tarsal conjuntiva inferior Hyperemic (-), Papilar (-), Hyperemic (-), Papilar (-),
Follicle (-), Bledding (-) Follicle (-), Bledding (-)

Bulbar conjunctiva Conjunctiva injection (-), Conjunctiva injection (+),

pinguekula (-), peterigium pinguekula (-), peterigium
(-), secretion (-) (-), secretion (-)
Cornea Clear Clear
Infiltrate (-) Ulcus (-) Infiltrat (-) Ulkus (-)
Arch senile (-) Arch senile (-)
Anterior chamber Normal in depth, Normal in depth,
Bledding (-), hyphema(-) Bledding (-),hyphema(-)

Iris Radier Radier

Colour : Brown Colour : Brown

Pupil Round, isochors Round, isochor

3mm 3mm
Light Reflexs : (+) Light Reflexs : (+)

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 Lens Clear Clear

IV. RESUME
A 37 years old female came to hospital with main complaint a lump on the
right upper eyelid. The colour of the lump is red accompanied by pain
especially when it is touched. The problem start as a red small lump on the
right upper eyelid and eventually growing bigger so that the right upper eyelid
became very red and swelling. The patient didnt get any medications yet.
There was no problem on the left eye. The patient often rub her eyes.History
of physical trauma denied, history of using long-term drug denied, allergies
and history of contact lenses used denied.

Ophthalmic Examination
Right Eye Left Eye

Visual acuity 6/6 6/6

Margo Palpebra Edema (+), tenderness (+) Normal

superior

Tarsal conjunctiva Hyperemic (+) Hyperemic (+)

superior

Bulbar conjunctiva Normal Normal

Cornea Clear Clear

Anterior Chamber Normal in depth Normal in depth

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 Iris Radier Radier

Pupil Round, light reactive (+) Round, light reactive (+)

Lens Clear Clear

V. CLINICAL DIAGNOSE

Right Eye Left Eye

External hordeolum palpebra -

superior

VI. Differential Diagnose

Right Eye Left Eye

Chalazion -

VII. MEDICAL TREATMENT

Warm compresses 3-4 times daily for 10-15 minutes.
Topical antibiotic ointment.
Surgery : incision and drainage

VIII. SPECIFIC EXAMINATION

There is no specific examination for this case.

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 IX. PROGNOSIS
Right Eye Left Eye

Ad vitam Bonam Bonam

Ad sanationum Dubia ad Bonam Bonam
Ad functionum Bonam Bonam

X. COMPLICATIONS
Eyelid cellulitis

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