ophtalmic record
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OPHTALMIC RECORD
EXAMINER : KEITHY DOROTHY SIRAIT - 0861050101
TUTOR : Prof. DR. Dr. JHA Mandang, SpM(K)
Medical Faculty Christian University of Indonesia
April 2013, Jakarta
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PATIENT IDENTITY
Name : Mr. M
Sex : Male
Age : 66 years old
Occupation : Retired
Address : Purwosari Kwadungan, Ngawi
Status : Married
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INTERVIEW
Primary Complaint : Blurred vision in
left eye
Additional Complaint : Red eye, difficut to
see the left side, headache
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Chronology of Disease
A man patient aged 66 years old came to Dr. YapEye Hospital with primary complaint blurred visionin his left eye since one week ago. The patient also
told that he is difficult to see the left side becausethe vision get decrease or blurred. He alsocomplaint headache and red eye in his left eye. Thepatient has taken an eye drop to reduce those
symptoms but it didnt getting better and then hedecided to go to the hospital to receive bettertreatment.
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Previous Disease andHistory of
Family Disease
The patient denied have minus or plus glasses
before. He had never come to the doctor to
check up his eyes. Patient denied that he got theother illness like hypertension, diabetic, etc. The
patient never had this kind of illness before and
no one in his family suffered the samecomplaint.
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GENERAL STATUS
General condition : Mild illness
appearance
Complaint related symptoms : Unremarkable
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OPHTALMIC STATUS
General Examination
Systemic Examination
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General Examination
Examination RIGHT EYE LEFT EYE
Periocular Appearance Quiet Quiet
General Condition of
the Eye Ball
Well Mild illness
appearance
Position of The Eye Ball Symetric Symetric
Ocular Mobility Normal Normal
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Examination RIGHT EYE LEFT EYE
Visual acuity 6/6 1/60
Correction - Can not be corrected
Supercillia Quiet, Black Quiet, Black
Cilia Quiet, Black Quiet, Black
Sup/InfMargo Palpebra Normal Normal
Sup/Inf Tarsalis Conjunctiva Normal Hyperemic
Sup/Inf Fornices Conjunctiva Normal Hyperemic
Bulbar Conjunctiva Normal Conjunctiva Injecton, Ciliary Injection
Cornea Clear Unclear
Camera Oculi Anterior Deep Superficial
Iris Radier, Brown Radier, Brown
Pupil Miosis, diametre
3mm, light reflex (+)
Midriasis, diametre 5mm, light reflex (-)
Lens Clear Clear
Schiotzs Tonometer 13 mmHg 48 mmHg
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RESUME
A man patient aged 66 years old came to Dr. Yap EyeHospital with primary complaint blurred vision in his left eye
since one week ago. The patient also told that he is difficult to
see the left side because the vision get decrease or blurred.
He also complaint headache and red eye in his left eye. Thepatient has taken an eye drop to reduce those symptoms but
it didnt getting better and then he decided to go to the
hospital to receive better treatment.
The patient denied have minus or plus glasses before.He had never come to the doctor to check up his eyes. Patient
denied that he got the other illness like hypertension,
diabetic, etc. The patient never had this kind of illness before
and no one in his family suffered the same complaint.
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Examination RIGHT EYE LEFT EYE
Visual acuity 6/6 1/60
Correction - Uncorrected
Supercillia Quiet, Black Quiet, Black
Cilia Quiet, Black Quiet, Black
Sup/Inf Margo Palpebra Normal Normal
Sup/Inf Tarsalis Conjunctiva Normal Hyperemic
Sup/Inf Fornices Conjunctiva Normal Hyperemic
Bulbar Conjunctiva Normal Conjunctiva Injecton, Ciliary Injection
Cornea Clear Unclear
Camera Oculi Anterior Deep Superficial
Pupil Miosis, diametre
3mm, light reflex (+)
Midriasis, diametre 5mm, light reflex (-)
Lens Clear Clear
Schiotzs Tonometer 13 mmHg 48 mmHg
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DIAGNOSE
CLINICAL DIAGNOSE
Primary Acute Glaucoma OS
DIFFERENTIAL DIAGNOSE
Uveitis Anterior
Keratitis
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TREATMENT AND EXAMINATION
MEDICAL TREATMENT Medikamentosa :
Beta blockers : Timolol 0,5% 1-2 drops/day
Carbon anhidrase inhibitors : Asetozolamide
250mg 2 tab once and then 4 x1 tabOsmotik : Manitol 60 drops/mnt
Surgery : Iridectomy
SUGGESTED EXAMINATION
Ofthalmoscopy
Gonioscopy
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PROGNOSES AND COMPLICATION
PROGNOSES
COMPLICATION
Absolute Glaucoma OS
RIGHT EYE LEFT EYE
Ad Vitam Bonam Bonam
Ad Sanationum Bonam Dubia ad malam
Ad Functionum Bonam Dubia ad malam
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