OPTHALMOLOGY RECORD

Tutor:
DR. dr. Gilbert W. Simanjuntak, Sp.M(K)

Examiner:
Bernadette Indah Larasati
1361050183

DEPARTMENT OF OPTHALMOLOGY
MEDICAL FACULTY
CHRISTIAN UNIVERSITY OF INDONESIA
PERIOD: 8TH MAY 2017 – 10 JUNE 2017
JAKARTA
2017
OPHTHALMOLOGY RECORD
The Examine : Bernadette Indah Larasati
NIM : 1361050183
Date of examination : 8th June 2017
The Examiner : DR. Dr. Gilbert W. Simanjuntak, Sp.M(K)

I. PATIENT IDENTITY
Name : R.S
Gender : Male
Age : 13 years old
Address : Cipinang Muara Baru 3, Jatinegara
Occupation : Student
Religion : Moeslem

II. ANAMNESIS
Anamnesis was done on the 17th May 2017

Main complains : Redness and pain in right eye since 3 weeks ago

Additional complains : Blurred vision, watery, eyes feel itchy and sandy

sensation, along with glare when he see the bright light

History of Present Illness :

Patients came escorted by his mother to the UKI Hospital with complaints of red

eyes and pain in the right eye since 3 weeks ago. These complaints appear

suddenly in the morning, when he wake up, the patient find it difficult to open his

eyes. The patient then realizes that his vision is starting to blur. The patient also

complains that his right eye is now more watery and feels like there is sand

blocking his eyes. Patients also feel disturbed when seeing direct sunlight.

Patients always ride motorcycles to school and in daily activities and do not use

any helmets or goggles to protect his eyes. The patient's mother has given Rohto,

but no improvement. Due to the long-term onset and uncontrolled, the complaints
are also getting worse. The blurry vision also remains the same. According to the

patient, this all happened with no cause. No complaints about headache, nausea,

and vomitting. No complain about his left eye.

Past Medical History :

 Patients never had any complains/illness like this before
 Hypertension denied
 Diabetes Mellitus denied
 Drugs allergies denied

Family Medical History :

None of his family or relatives had complains like this before

III. GENERAL STATUS

General condition : Moderate illness
Awareness : Compos mentis

IV. OPHTHALMOLOGY STATUS

A. General Examination

Parameter OD OS

Periocular Quiet Quiet

Appearance

General Condition of Moderate Quiet

The Eye

Eyeball Position Simetric Simetric

Eyeball Movement All direction All direction

Visual Field Wide Wide

B. Systemic Examination
Parameter OD OS

Visual Acuity 6/20 6/6

 Pinhole No improvement -

Supercilia Normal growth Normal growth

Madarosis (-) Madarosis (-)

Cilia Normal growth Normal growth

Madarosis (-) Madarosis (-)
Trichiasis (-) Trichiasis (-)

Superior/Inferior Palpebra Edema (-) Edema (-)

Ectropion (-) Ectropion (-)
Entropion (-) Entropion (-)
Ulcus (-) Ulkus (-)
Crust(-) Crust(-)
Ptosis(-) Ptosis(-)
Tarsal Conjunctiva Hiperemic(-) Hiperemic(-)
Superior/inferior Cicatrix(-) Cicatrix(-)
Papillae(-) Papillae(-)
Folicle (-) Folicle (-)

Bulbi Conjunctiva Cilliary Injection Cilliary Injection (-)

(+), Pinguekula (-) Pynguecula (-)
Pterigium (-) Pterygium(-)
Cornea
 Clearness Cloudy Clear
 Shape Round Round
 Infiltrat +, central Negative
 Ulkus Negative Negative
 Sikatriks Negative Negative
 Neovaskularisasi Negative Negative

Camera Okuli Anterior Deep Deep

(Anterior Chamber) Hypopyon(-) Hypopyon(-)
Hyphema(-) Hyphema(-)
Iris Radier shape Radier shape
Brown Brown
Cynekia (-) Cynekia (-)
Pupil
 Shape Round, Isokor Round, Isokor
 Light Reflex Direct/Indirect Direct/Indirect pupil
pupil reflex (+/+) reflex (+/+)
Lens
 Clearness Clear Clear
 Shadow Test Negative Negative

V. RESUME
 Patients came escorted by his mother to the UKI Hospital with

complaints of red eyes and pain in the right eye since 3 weeks ago.

These complaints appear suddenly in the morning, when he wake up,

the patient find it difficult to open his eyes. The patient then realizes

that his vision is starting to blur. The patient also complains that his

right eye is now more watery and feels like there is sand blocking his

eyes. Patients also feel disturbed when seeing direct sunlight. The

patient's mother has given Rohto, but no improvement. Due to the

long-term onset and uncontrolled, the complaints are also getting

worse. According to the patient, this all happened with no cause.

Opthalmology Examination
From the opthalmology examination we can conclude that :
OD: Moderate pain, visual acuity 6/20, Cilliary Injection (+), cloudy
cornea and there is an infiltrates in the central part of cornea.

VI. WORKING DIAGNOSIS

OD : Keratitis suspect Bacterial

VII. DIFFERENTIAL DIAGNOSIS

 Vernal Keratitis
 Fungal Keratitis
 Uveitis Anterior
 Acute Glaucoma

VIII. TREATMENT

 Eye ointment chloramphenicol

 Eye drops antibiotics, levofloxacin HCL 5 mg

IX. PLANNED EXAMINATION

  Slit-lamp with fluoresceint test

 Laboratory examination of corneal epithelial scrap

X. PROGNOSIS

OD OS

Ad vitam Bonam Bonam

Ad sanasinoum Dubia ad bonam Bonam

Ad fungsionum Dubia ad bonam Bonam

XI. COMPLICATION

1. Corneal Ulcus

2. Corneal Cicatrix

3. Blindness