OPHTALMIC RECORD

Tutor :
Dr. Gilbert W.S. Simanjuntak, SpM (K)
Examiner :
Ilham SuryoWibowo A.
1061050190

DEPARTMENT OF OPHTALMOLOGIC
FACULTY OF MEDICINE
CHRISTIAN UNIVERSITY OF INDONESIA
JAKARTA 2014

OPHTALMIC RECORD
Name of Examiner
NIM
Date of examination
Tutor
I.

: Raga Manduaru
: 1061050135
: December 24th 2014
: Dr. Gilbert W.S. Simanjuntak, SpM (K)

PATIENT IDENTITY
Name
Gender
Age
Date of birth
Address
Occupation

:Mr. M.Moch.Yunus.Z
: Male
: 70 years old
: April 16th 1958
:Jalan Raden Inten No.9
: Wiraswasta

II. HISTORY TAKING

Main complaint
Blurry vision on his left eye since 5 days ago
Additional complaint
Red eye, pain surrounding eye, and headache
History of disease
Patient came to hospital with the main complaint blurry vision on his left eye since 5
days ago. Blurrred vision on left eye appeared suddenly. Patient complained that he
just could see blurred shadow. Adverse, patient complained red eye on his left eye, but
there is no itchy and dazzled. In addition, the patient admitted that pain is felt
constantly on his left eye and disappear during sleep. The patient also complained
headache. It felt continuously. Nausea and vomiting is complained by patient. Eye
trauma history and used eye drops are denied.
Previous disease
History eye disease (-)
Hypertension (+)
Diabetes Mellitus (-)
History using eyeglasses (-)
III.

GENERAL STATUS

General condition

: look mild illnes

Symptom or illness related to the complaint : Unremarkable

IV.

OPHTALMIC STATUS
A. General Examination
Periocular appearance
General condition of the
eye
Eyeball position
(Hircshburg Test)

OD
Quiet
Quiet

OS
Quiet
Look mid illnes

Ortophoria
Symmetric

Ortophoria
Symmetric

Normal

Normal

Eyeball movement
B. Systematic Examination
Visual acuity
Correction
Supercilia
Cilia
Margo Palpebra
Superior/Inferior
Superior/ Inferior Palpebra
Tarsal conjunctiva
Fornix conjunctiva
Bulbar conjunctiva
Cornea

COA

OD
6/6
Normal
Symmetric
Madarosis (-)
Normal
Madarosis(-)
Trichiasis (-)
Ectropion (-)
Entropion (-)
Oedem (-)
Hyperemis (-)
Oedem (-)
Hyperemis (-)
Ptosis (-)
Hyperemis (-)
Scar (-)
Papil (-)
Hyperemis (-)
Ciliary injection (-)
Conjunctival injection (-)
Clear
Infiltrate (-)
Ulcer (-)
Scar (-)
Neovascularization (-)
Normal

OS
3/60, with pinhole: nonprogressive
Normal
Symmetric
Madarosis(-)
Normal
Madarosis (-)
Trichiasis (-)
Ectropion (-)
Entropion (-)
Oedem (-)
Hyperemis (-)
Oedem (-)
Hyperemis (-)
Ptosis (-)
Hyperemis (-)
Scar (-)
Papil (-)
Hyperemis (-)
Ciliary injection (+)
Conjunctival injection (-)
Not clear : white ring in the
corneal margin
Infiltrate (-)
Ulcer (-)
Scar (-)
Neovascularization (-)
abnormal

Iris
Pupil

Lens
Field of view
Tonometry

V.

Deep
Radier
Color : Brown
Round, isochor
3 mm
Direct pupil reflex (+)
Consensual pupil reflex(+)
Turbid
Shadow test (-)
Normal
Palpation : Normal
Non contact tonometry:
11,5

shallow
Radier
Color : Brown
Round, anisochor
7 mm
Direct pupil reflex (-)
Consensual pupil reflex(-)
Turbid
Shadow test (-)
abnormal
Palpation : N+3
Non contact tonometry:
24,3

RESUME

Patient came to dr. YAP hospital with the main complaint blurry vision in his right eye
since 2 months ago and now getting worse. His left eye is blurry too, but worse in his
right eye. No red eye, no pain sensation, no photophobia. He came to Bantul Hospital
1 month ago and being diagnosed as cataract so he went to dr. YAP hospital
From the ophthalmology examination, found:
Visual Acuity
Lens
VI.

OD
1/300
Turbid
Shadow test (-)

CLINICAL DIAGNOSE

OD

OS
Acute glaucoma

VII.

DIFFERENTIAL DIAGNOSES

OD

OS
Keratitis
Uveitis orgina

VIII. MEDICAL TREATMENT

OS: timol 25%(s dd 1)
Asetazolamid tab 2x 1 mg
IX.
X.

OS
3/60
Turbid
Shadow test (+)

SPECIFIC EXAMINATION
Oftalmoskop
Slit lamp
Retinometry
PROGNOSES

Ad vitam
Ad sanationum
Ad functionum

XI.

COMPLICATIONS
-

Absolute Glaucoma

OD
Bonam
Bonam
Bonam

OS
Bonam
Bonam
Bonam