FAKULTAS KEDOKTERAN

Case report UNIVERSITAS MALAHAYATI

Conjunctivitis
by
M. Fergiawan Bagus Hening Pratama. S.Ked.
18360009
Preseptor : dr. Rahmad Syuhada Sp.
 PATIENT IDENTITY

O Name : Ny. R
O Age : 54 Tahun
O Gender : Perempuan
O Status : Menikah
O occupation : IRT
O Address : Bandar Lampung
O MRS : 18/05/2019
O MR : 086113
 ANAMNESIS
O Main Complaints : Os complains of itching in both eyes since 4 days ago.
O Additional complaints : Both eyes hurt, it feels there is a blocking itchy feeling, tears come out and
purulent secretions come out and mottled in the morning.
O Current medical history :
O Since 4 days ago the patient complained of left and right eye itching, redness and pain. So that patients
sometimes rub their left eye and out of tears. The patient admitted that when he woke up there was a lot
of eye droppings and also purulent discharge in the patient's left eye. Blurred eye view. Os hasn't
received treatment before. There was no history of trauma to the patient's left eye. Family history, the
patient's child suffers from the same complaint.
O Past medical history : Hypertension (+), Diabetes (-)
O Family disease history : Children suffer from the same complaint
O About disease history : Denied
O Treatment history : Never before
 GENERALIST STATUS
O General Condition : Good
O Awareness : Compos mentis
O Blood pressure : 110/70 mmHg
O Heart rate : 88x/menit
O Term : 36,6oc
O Respiration rate : 22x/ menit
 STATUS OF OPHTHALMOLOGY
OD OS
20/50 Visus 20/40
S -0,25 = 20/30 Correction S -0,25 = 20/30
Orthoforia Bulbus oculi position Orthoforia
Trichiasis (-) Madarosis (-) Silia Trichiasis (-) Madarosis (-)
Hiperemis (-) tenderness (-) Edema (-) Palpebra superior Hiperemis (-) tenderness (-) Edema (-)

Hiperemis (-) tenderness (-) Edema (-) Palpebra inferior Hiperemis (-) tenderness (-) Edema (-)

Hiperemis (+) Papil (-) Folikel (-) Konjungtiva palpebral Hiperemis (+) Papil (-) Folikel (-)

Hiperemis (+) Papil (-) Folikel (-) Konjungtiva fornices Hiperemis (+) Papil (-) Folikel (-)

Conjunctival injection (+) Konjungtiva bulbi Conjunctival injection (+)

injection (+) Sclera injection (+)
Arcus Senilis (-) edema (-), infiltrate (-) Kornea Arcus Senilis (-), edema (-), infiltrate (-)

Medium, pus (-) blood (-) Camera oculi anterior Medium, pus (-) blood (-)
Iris crypts intact Iris Iris crypts intact
light reflex (+) Pupil light reflex (+)
Clear Lensa Clear
 RESUME
O A patient of Ny.R 54 years came to RSPBA eye poly with left and right eye itchy, red and
painful. So that patients sometimes rub their left eye and out of tears. The patient
admitted that when he woke up there was a lot of eye droppings and also purulent
discharge in the patient's left eye. Blurred eye view. Os hasn't received treatment before.
There was no history of trauma to the patient's left eye. Family history, the patient's
child suffers from the same complaint. From the results of the ophthalmology
examination VOD vision was obtained 20/50 = S –0.25 = 20/30 and VOS 20/40 = S -0.25
= 20/30, hyperdema (+) ODS palpebral conjunctiva, hyperemic conjunctival (+) , and
ODS bulbi conjunctiva is a conjunctival (+) and purulent (+) injection.
 Different diagnosis
• Konjungtivitis et causa bakteri
• Konjungtivitis et causa virus
• Konjungtivitis et causa jamur
• Konjungtivitis et causa alergik
 Work Diagnosis
Konjungtivitis et causa bakteri
OS
 RECOMMENDATIONS TEST
Gram coloring test
 MANAGEMENT
O Non medical
O Don't rub your eyes when itching
O Avoid eyes from dust
O Keep your eyes clean
O Wash your hands first before giving the drug to the eye
O Eat nutritious foods
 Medikamentosa
Topikal :
R/ Floxa EDMD No. I
S 6 dd gtt 1 OS
R/ Cendo Lyteers ED No. I
S 4 dd gtt 1 OS
Oral :
R/ Loratadin No. V
S 1 dd 1 tab
 PROGNOSIS
O Quo ad vitam : dubia ad bonam
O Quo ad fungsionam : dubia ad bonam
O Quo ad sanationam : dubia ad bonam.
THANK YOU..