ophthalmology record ujian gilbert

8/18/2019 Ophthalmology Record Ujian Gilbert

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OPHTHALMOLOGY RECORD

Name of examine : Gilbert Richard Sulivan Tapilatu

NIM : 07610 0176

!ate of examination : March" 1# th $01

Tutor : dr% Gilbert &%S Siman'unta(" SpM )*+

I. IDENTITY PATIENT

Name : Mr,% -

-.e : $$ /ear, old

-ddre,, : *omodor * G. Sadar No 22 RT 0 301 4a(arta Timur%

4ob : Student

Reli.ion : 5hri,tian

II. INTERVIEW (March, 14th

2016Main complaint : ain in the ri.ht e/e

-dditional complaint : Redne,, " ater/ and ,and/ .ritt/ ,en,ation in ri.ht e/e alon. ith

blurr/ vi,ion

C!"r#$ !% D$a#$

atient came ith pain in the ri.ht e/e ,ince t o ee(, a.o% Thi, complaint i, feltcontinuou,l/ and increa,in.l/ painful% -t fir,t" ,he thou.ht that it a, onl/ an u,ual redne,,

around the e/eball cau,ed b/ pollution" but da/ b/ da/ became more ,evere and it happen,continuou,l/ alon. ith the pain in the ri.ht e/e that i, al,o becomin. more painful ever/da/%She al,o complained about her blurr/ vi,ion that happened 2 da/, a.o" it happened pro.re,,ivel/alon. ith the ater/ and ,and/ .ritt/ ,en,ation in ri.ht e/e ever/time ,he tried to open her e/e,% -ccordin. to the patient " thi, all happened in all of a ,udden" ithout an/ ,pecific cau,e,8

patient had hi,tor/ of u,in. ,oft len, dail/" often rubbin. her e/e," no hi,tor/ of e/e trauma% Toreduce the complaint, of patient, u,in. in,to" routinel/ u,ed" but the complaint ha, not improved"

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even or,en % No complain about .lare" headeache" or fellin. nau,eou,% No complaint about her left e/e%

Ht!r' !% D$a#$

The patient had never had an/ complaint li(e thi, before%i,tor/ of diabete," h/pertention" and aller.ic denied%

a)&*' M$+&ca* Ht!r'

None of her famil/ or relative, had complain, li(e thi, before

III. GENERAL TAT-

General condition : Moderate illne,,

- arene,, : 5ompo, Menti,

IV. OPTHALMOLOGI T TAT-

-% General inve,ti.ator

R& ht E'$ L$%t E'$

-round 9/e -ppearance uiet uiet

General 5ondition of the 9/e ;all /peremic" ater/ Normal

o,ition of The 9/e ;all S/mmetric S/mmetric

9/e Movement Normal to all direction, Normal to all direction,

!onder, 5onfrontation Te,t &ide &ide

;% S/,tematic inve,ti.ator

R& ht $'$ L$%t $'$


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5orrection No correction No correction

Super cilia Normal .ro th" madaro,i, ) + Normal .ro th" madaro,i, ) +

5ilia Normal" madaro,i, ) +"trichia,i,) +

Normal" madaro,i, ) +"trichia,i,) +

alpebra Superior3Inferior 9dema ) +" tenderne,, ) +"ectropion ) +% 9ntropion ) +"

ulcu, ) +" (ru,ta ) +

9dema ) +" tenderne,, ) +"ectropion ) +% 9ntropion ) +"

ulcu, ) +" (ru,ta ) +

Mar.o alpebra Superior3 inferior 9dema ) +" tenderne,, ) +"ectropion ) +% 9ntropion ) +"

ulcu, ) +" cru,t ) +

9dema ) +" tenderne,, ) +"ectropion ) +% 9ntropion ) +"

ulcu, ) +" cru,t ) +

Tar,al 5on'unctiva /peremic ) +" papilar ) +"follicle ) +" bleedin. ) +

/peremic ) +" papilar ) +"follicle ) +" bleedin. ) +

*on'un.tiva =orni(, Superior3inferior



;ulbar 5on'unctiva C&*&ar' &/ $ct&!/ ( , pin.uecula ) +" pteri.ium ) +

5iliar/ in'ection) +" pin.uecula) +" pteri.ium ) +

5ornea Round" cloud/" &/%&*trat$ ( "ulcu, ) +" cicatrix ) +"neova,culari>ation ) +

Round " clear" infiltrate ) +"ulcu, ) +" cicatrix ) +"neova,culari>ation ) +

S(lera Icteric ) + Icteric ) +

-nterior chamber !eep

ipopion ) +

/phema ) +

!eep

ipopion ) +

/pema ) +

Iri, Radier" bro n Radier" bro n

upil i,ochore" round" in themiddle" 2mm" direct li.ht

reflex )?+" indirect li.ht reflex)?+

i,ochore" round" in the middle"2mm" direct li.ht reflex )?+"

indirect li.ht reflex )?+

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@en, 5lear 5lear

Tonometri avenAt been done avenAt been done

V. RE -ME

atient Mr, -" $1 /ear, old" atient came ith pain in the ri.ht e/e ,ince t o ee(, a.o%-t fir,t" ,he thou.ht that it a, onl/ an u,ual redne,, around the e/eball cau,ed b/ pollution" butda/ b/ da/ became more ,evere and it happen, continuou,l/ alon. ith the pain in the ri.ht e/ethat i, al,o becomin. more painful ever/da/% She al,o complained about her blurr/ vi,ion thathappened 2 da/, a.o" it happened pro.re,,ivel/ alon. ith the ater/ and ,and/ ,en,ation inri.ht e/e ever/time ,he tried to open her e/e,% To reduce the complaint, of patient, u,in. in,to"routinel/ u,ed but the complaint ha, not improved even or,en%

General 9xamination ophthalmolo.i,t

Normal

-% S/,tematic 9xamination opthalmolo.i,t

R& ht $'$ L$%t $'$


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Iriti, acute-cute .laucoma

VIII. MEDICAL TREATMENT

1% Non medication!onAt rub both e/e,&a,h hand before and after touchin. the e/e,C,e ,un.la,,e, hen .oin. out5over e/e ith e/e pad%

$% Medication

@ocal antibiotic5/clope.ic

I . PLANNED E AMINATION

a% Slitlamp ith fluore,cent te,t3. Microbiolo./ culture

VIII. PROGNO I

RIGHT EYE LE T EYE

-d


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ophthalmology record ujian gilbert

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