CHAPTER III

OPHTALMOLOGY STATUS

A. Patient Identity

1. Name : Mr. F

2. Sex : Male

3. Age : 70 years old

4. Address : H.Rais A.Rahman

5. Occupation : None

6. Tribe/ Ethnic : Chines

7. Date of consult : May 18th, 2015

Anamnesis has been done on may 18th, 2015 at 10.00 o’clock am.

B. Chief complaint :

Cloudy vision of the left eye

C. History of Present Illness:

The patient has cloudy vision of the left eye in two monts , which occured spontaneously

after he has infection desease

D. Past Medical History:

1. Patient has history of infection desease (typhus infection)

2. No history of hypertension, hyperlipidemia, or diabetes

E. Family History:

There is no one of her family have the same complaint

F. Ocular Exam:

1. Visual acuity :

OD : 5/60, -1.00 x 100 5/15, add +3.00

OS : 1/60, constant with pin hole

2. Pupils

OD : 3 mm (dark) to 2 mm (light), Shadow test (+), brisk

OS : 3 mm (dark) to 2 mm (light), Shadow test (+), slow (RAPD +)

3. Eye movement :

OD OS

4. Intraocular pressure (applanation):

OD: 11 mmHg, OS: 11 mmHg

5. Confrontation visual fields:

Full to finger confrontation OD and OS

6. Funduscopy :

OD : Transparency of the lens is reduced (any opacity in the lens)

OS : Transparency of the lens is reduced (any opacity in the lens), Pallor of

optic nerve papil

OD OS

Movement(+), ptosis (-), lagoftalmos (-), oedem(-)

Palpebra Movemen (+), ptosis (-), lagoftalmos (-), oedem (-)

redness (-), discharge (-), injection(-), ulcer (), foreign body (-)

Conjungtiva redness (-), discharge (-), injection(-), ulcer (-), foreign body (-)

Oedem (-), ulcer (-), arcus senilis (+)

Cornea Oedem (-), ulcer (-),arcus senilis (+)

Clear, deep sense Anterior chamber

Clear, deep sense

Iris colour : brown, synechia(-)Circular pupil

Iris/pupil Iris colour : brown, synechia (-)Circular pupil, RAPD (+)

opacity in the lens Lens any opacity in the lens

Cannot be described Vitreous Cannot be described

Cannot be described Fundus Pale of the optic nerve papil

7. Ischihara test : -

8. CT-Scan

Hasil CT-Scan : Normal

G. Working Diagnosis

OD : Optic neuritis and immature senile catarat

OS : Immature senile catarat.

H. Treatment

1. Metylprednisolon 16 mg 3 times/days

2. Citicholin 500 mg 2 times/days

3. Omeprazol 1 times/days