OPHTHALMOLOGY RECORD

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

Observer:
Ahmad Ari Ibrahim
1361050239

DEPARTEMENT OF EYE DISEASE

PERIOD OF MAY 07th - JUNE 09th, 2018
MEDICAL FACULTY
CHRISTIAN UNIVERSITY OF INDONESIA
JAKARTA
2018
 OPHTHALMOLOGY RECORD

Observer : Ahmad Ari Ibrahim

NIM : 1361050239

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

I. PATIENT IDENTITY

Name : Ny. N
Age : 51 years old
Address : Jl. Kelapa II Wetan RT 007/008 No 16, Jakarta Timur
Gender : Female
Occupation : Entrepreneur
Ethnic : Batak
Religion : Christian
Status : Married

II. MEDICAL HISTORY (Thursday, May 17, 2018)

Main complaint
Blurred vision with red eye
Additional complaint
Left eye gets dazzled, watery, pain and felt like there was sand blocking his eye
History of present illness
Ny. N, age 51, came to Hospital RSU UKI with the main complaint of blurred
vision and red left eye since 4 days before. These conditions felt suddenly in the
morning, when he woke up and he also felt pain on his left eye. The patient then
realized that his vision was starting to get blurred. The patient also complained
that his left eye was becoming more watery and felt like there was sand blocking
his eye.
 Patient then went to Puskesmas and was given eye drops, but he forgot the name
of the medicine. Complaints were reduced, but the feeling there was sand blocking
his eye remained his vision also still got blurred. Complaint such as eye
discharging secretion and itchy denied by the patient. Patient denied dizzy, nausea
and vomit. The history of wearing glasses minus since 1 year ago, contact lenses
was denied by patient.
Previous disease :
Patient never felt the same symptoms before. Patients never wore contact lenses,
glasses minus since 1 year ago. Patient’s denied the presence of a high blood
pressure, allergy, or diabetes mellitus.
History of family disease :
No family experienced the same thing as the patient.

III. GENERALIST STATUS

General state : Moderate illness appearance
Awareness : Compos mentis

IV. OPHTHALMOLOGY STATUS

A. General examination

General examination OD OS

General state of the eye Quiet Quiet

General Condition of The Moderate

Quiet
eye

The position of the eyeball Symmetric Symmetric

Eyeball movement All direction All direction

B. Systemic examination
Parameter OD OS
Visual Acuity 6/9 6/12
Correction Pinhole 6/6 Pinhole not
advanced
 Supersilia Grow evenly Grow evenly
Silia Grow evenly, good Grow evenly, good
position position
Palpebra Normal Normal
Superior/inferior Color matches the color Color matches the color
of the skin of the skin
edema (-) edema (-)
tumor (-) tumor (-)
Tarsal conjungtiva Hyperemic (-) Hyperemic (-)
Superior/inferior Cicatrical (-) Cicatrical (-)

Forniks conjungtiva Hyperemic (-) Hyperemic (-)

Superior/inferior Cicatrical (-) Cicatrical (-)

Bulbi conjungtiva Injection conjungtiva (-) Injection conjungtiva (-)

Injection ciliar (-) Injection ciliar (+)

Cornea
 Clarity (-) (+)
 Infiltrate (-) (+) smooth spots
 Ulcus (-) (-)

 Cicatrix (-) (-)

Sclera White White

Cicatrix (-) Cicatrix (-)
Anterior Chamber
Depth Profunda Profunda
Iris Radier Radier
Brown Brown
Synechia (-) Synechia (-)
Pupil Round, isokor, diameter 3 mm, Direct light
refleks(+), Indirect light refleks (+)

Lens Clear Clear

V. RESUME
Ny. N, age 51, came to Hospital RSU UKI with the main complaint of blurred
vision and red left eye since 4 days before. These conditions felt suddenly in the
morning, when he woke up and he also felt pain on his left eye. The patient then
realized that his vision was starting to get blurred. The patient also complained that
his left eye was becoming more watery and felt like there was sand blocking his eye.
Patient then went to Puskesmas and was given eye drops, but he forgot the name of
the medicine. Complaints were reduced, but the feeling there was sand blocking his
eye remained his vision also still got blurred. Patient had never experienced similar
complaints before. Complaint such as eye discharging secretion (-), itchy (-), dizzy (-
), history of wearing glasses minus since 1 year ago, contact lenses (-) history of
allergies (-), hypertension (-), diabetes mellitus (-), and family experienced the same
thing as the patient (-).
GENERALIST STATUS

General state : Moderate illness appearance

Awareness : Compos mentis
Parameter OD OS
Visual Acuity 6/9 6/12
Correction Pinhole 6/6 Pinhole not
advanced
Tarsal conjungtiva Hyperemic (-) Hyperemic (-)
Superior/inferior Cicatrical (-) Cicatrical (-)

Forniks conjungtiva Hyperemic (-) Hyperemic (-)

Superior/inferior Cicatrical (-) Cicatrical (-)

Bulbi conjungtiva Injection conjungtiva (-) Injection conjungtiva (-)

Injection ciliar (-) Injection ciliar (+)

Cornea
 Clarity (-) (+)
 Infiltrate (-) (+) smooth spots
 Ulcus (-) (-)

 Cicatrix (-) (-)

VI. CLINICAL DIAGNOSIS
Keratitis punctata superficial OS

VII. DIFFERENTIAL DIAGNOSIS

Acute glaucoma OS
Uveitis OS
VIII. SPECIFIC EXAMINATION
Slit Lamp
Flouroscent test
IX. MANAGEMENT
Non-medication :
 Caution to the patient not to rub the eyes or touch the infected eye before
washing hands.
 Caution to use protective goggles when he is outdoor and to use a helm full
face to prevent foreign objects entering the eye while driving.
Medication :
 Antibiotics Neomysin sulfate 0.5% 1 drop, 3x / day, 3-5 days (OS)
 Cyclopegika Sulfas Atropine 1% 1 drop, 3x / day, 2-3 days (OS)

X. PROGNOSIS

Right eye Left eye

Ad vitam Bonam Bonam

Ad sanasinoum Bonam Dubia ad bonam

Ad fungsionum Bonam Dubia ad bonam

XI. COMPLICATION
Ulcus cornea OS
Sikatriks cornea OS