MORNING

REPORT
Opthalmology Department
RSUD Kota Makassar
Pterigium St II
Patient identity
• Name : Mr. RS

• Age : 48 Years Old

• No. RM : 273091

• Address : Jl. BTN Pertamina Goa Ria

• Nation : Indonesia

• Religion : Islam

• Date : 19 November 2019

• Anamnesis : Autoanamnesis
History Taking
Main Complaint : Redness in the Left Eye
Guided History :
Patients came to RSUD Kota Makassar with complaints of red eyes in
his left eye which had been felt since 10 days ago. the patient feels like a
lump in the eye, The first complaint was felt since 10 days ago when
exposed to lime seeds. There is decreased vision, no lacrimation, no pain,
no secretions. No history of the same complaint before. There is a history
of using eye drops
Visual Acuity Examination
OD Visual OS

20/20 Uncorrected visual acuity 20/30

- Correction -

- Best corrected visual acuity -

- Near visual acuity -

- Correction -

- Best corrected near visual acuity -

Anterior Segment Examination
OD OS
Oedema (-) Hyperemia (-), Oedema (-) Hyperemia (-),
Palpebral
Crust (-) Crust (-)
Cilia Squama (-), Madarosis (-) Squama (-), Madarosis (-)
Lacrimal Apparatus Lacrimation (-) Lacrimation (-)

Hyperemis (+),injeksi konjungtiva (+)

Conjunctiva Hyperemis (-) terdapat jaringan fibrovascular
dari tepi hunga melewati limbus

Cornea Clear
Anterior Chamber Normal Depth Normal Depth

Iris Brown, Crypt (+) Brown, Crypt (+)

Pupil Round, Central Round, Central
Direct/Indirect Light
+/+ +/+
Reflex
RAPD - -
Lens clear clear
Palpation
OD OS

Tn Ocular pressure Tn

- Tumor/Mass -

Not palpable Pre Auricular Gland Not palpable

Diagnose
Pterigium St II

Differential Diagnose
Pinguekula
pseudopterygium
Treatment Insert the title of your subtitle Here

• Hyaloph 4 dd 1 gtt ODS

Education :
Patient instructed to :
• Don’t rub his eyes
• Use protective glasses when working or out of the house
Thank you