Status Ujian m

8/12/2019 Status Ujian m

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OPTHALMIC RECORD

Tutor:

Dr. Gilbert W.S. Simanjuntak SM

E!aminer:

Herli"a Re#riani

$%&'$($$()

DEPARTME*T O+ OPHTHALMOLOGIC

MEDICAL +AC,LT-

CHRISTIA* ,*IERSIT- O+ I*DO*ESIA

/A0ARTA

)$'1


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OPHTHALMIC RECORD

Name of Examiner : Herliza Refriani

NIM : 0961050052

Date of examination : 10thJanruary 201

!utor : "r #il$ert %&'& 'iman(unta) '*M

PATIE*T IDE*TIT-

Name : Mr& M

+,e : 6 year- ol"

+""re-- : N,a.i/ Ea-t Jaa

u*ation : 3armer

A*AM*ESIS 2De3ember '$t45 )$'16

Main 3omlaint

4eft eye an not -ee -ine one year a,o

A77itional 3omlaint

!hro$$in, *ain an" .atery on left eye

Hi8tor9 o# 7i8ea8e

atient ame to ho-*ital .ith main om*laint an not -ee on left eye -ine

one year a,o& +t fir-t/ hi- left eye- ex*o-e" to rie *lant/ an" then hi- left

eye- $e,an to re"ne--& er time/ the *atient- i-ion .a- $lurry until an

not -ee& atient ha" ome to the loal health enter an" .a- ,ien

treatment $ut not reoer .ell& In a""ition *atient al-o om*laint

thro$$in, *ain an" -ometime- .atery on left eye& atient ha- a ha$it of

ru$$in, the eye& Hi-tory of u-in, lon,7term "ru, "enie"/ aller,ie- an"

hi-tory of ontat len-e- u-e" "enie"&

Preiou8 7i8ea8e

atient ha" a hi-tory of trauma an" no hi-tory of "ia$ete- mellitu-/

hy*erten-ion/ a-thma/ heart "i-ea-e& Hi-tory of eye "i-ea-e not *reiou-ly

exi-t& atient- not u-in, ,la--e- $efore&


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I. GE*ERAL STAT,S

#eneral on"ition : Mo"erate illne--

'ym*tom or illne-- relate" to the om*laint : None

II. OPHTHALMIC STAT,S

A. General Examination

Ri;4t E9e Le#t E9e

erioular a**earane 8uiet 8uiet

#eneral on"ition of the eye Normal Normal

Eye$all *o-ition 'ymmetry 'ymmetry

Eye$all moement Normal Normal

A. Systematic Examination

Ri;4t E9e Le#t E9e

i-ual auity 61; 0

?orretion

'u*er ilia Normal/

Ma"aro-i-

Normal/

Ma"aro-i-

?ilia Normal/

Ma"aro-i- / !ri)hia-i-

Normal/

Ma"aro-i- / !ri)hia-i-

Mar,o al*e$ra -u*erior E"ema / ten"erne--

/ etro*ion /

entro*ion / ulu- /

)ru-ta

E"ema / ten"erne--


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@ul$ar on(untia ?on(untia in(etion/ *in,ue)ula /

*teri,ium / -eretion

Conjun3tia inje3tion26

4en- ?lear *ot Clear

III. RES,ME

+ 6 year- ol" male ame to ho-*ital .ith main om*laint an not -ee on

left eye -ine one year a,o& +t fir-t/ hi- left eye- ex*o-e" to rie *lant/ an"

then hi- left eye- $e,an to re"ne--& er time/ the *atient- i-ion .a-

$lurry until an not -ee& atient ha" ome to the loal health enter an"

.a- ,ien treatment $ut not reoer .ell& In a""ition *atient al-o

om*laint thro$$in, *ain an" -ometime- .atery on left eye& atient ha- a

ha$it of ru$$in, the eye& Hi-tory of u-in, lon,7term "ru, "enie"/ aller,ie-

an" hi-tory of ontat len-e- u-e" "enie"&


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O4t4almi3 E!amination

Ri;4t E9e Le#t E9e

i-ual auity 0/= 0

Mar,o al*e$ra

-u*eriorNormal Normal

!ar-al on(untia

-u*erior

Normal H9eremi3 2


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I. MEDICAL TREATME*T

Natamyin

4eofloxain

+etazolami"e

II. SPECI+IC E?AMI*ATIO*

'litlam*

'ra**in, ?ornea

PROG*OSIS

Ri;4t E9e Le#t E9e

+" itam @onam Du$ia a" malam

+" -anationum @onam Du$ia a" malam

+" funtionum @onam Du$ia a" malam

III. COMPLICATIO*S

?orneal erforation

#lauoma

?atara ?om*liata

Ri;4t E9e Le#t E9e

7 +ute #lauomaCon(un,tiiti-

Ceratiti-

En"o*thalmiti-

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