Ophthalmology Record

The Examine Date of Examination Examiner : Melisa Silvia : November 29th, 2012 Student Number : 08-184 : Prof.Dr.dr. J.H.A. Mandang Sp.M (K)

I. Patients Identity Name Sex Age Address Religion Education Occupation II. : Mrs. B : Female : 36 years old : Pete Sidomoyon Godean, Sleman. Yogyakarta : Moslem : Bachelor : Company Employee

ANAMNESES (November 24th, 2012)

Chief Complaint : pain in the right eye since 2 days ago Additional Complaint : saw the rainbow colors around lights, red eye, glare reflection ,watery, headache, nausea, vomiting History of Disease : Patient came with her son to the RSM DR.YAP Yogyakarta with complaints of pain in the right eye since 2 days ago. Pain is felt in the right eyes and around the right eye. Pain is felt tingling and long-lasting. Initially 1 month ago patient often complain of headaches, especially at the right side of the head. Initially the pain lasted about half an hour to 2 hours and then disappear, but over time the complaint was more often and more of the same duration, as well as pain, is increasingly growing pains. Patient said complaint was more severe at night. Patient taking drugs reduce complaints Bodrex and sleep when complaints arise. However, the complaint was only

gone a while, then came back. Patient do not go to the doctor because the patient is only considered ordinary headache. In addition, patients also complain of nausea and vomiting had 2 times as much, red right eye, watery, glare, and see the rainbow colors around lights. Previous Disease : The patient said had never had a complaint like this before. History of Hypertension, Diabetes Mellitus, allergies and use of drugs that contain steroids are denied. History of trauma (-), eye pain before (-), wears glasses (-), operations (-) Family History : The patients father also had this symptoms III. GENERAL STATUS General Condition Consciousness Complains-related Symptoms : Mild illness : Composmentis : Unremarkable

IV. OPTHALMIC STATUS A. General Right Eye Clear Clear Symmetric All directions Left Eye Clear Clear Symmetric All directions

Surrounding of the Eye General Condition of the Eye Eye Position Eye Movement

B. Systematic Right Eye 1/300 Normal, Madarosis (-) Normal, Madarosis (-), Trichiasis (-) Tumor (-), Ptosis (-) Follicle (-) Follicle (-), Secretions (-) Cilliary Injection (+) Left Eye 6/6 Normal, Madarosis (-) Normal, Madarosis (-), Trichiasis (-) Tumor (-), Ptosis (-) Follicle (-) Follicle (-), Secretions (-) Cilliary Injection (-)

Visual Acuity Pinhole Correction Supercillia Cillia Superior/Inferior Palpebra Tarsal Conjunctiva Superior/Inferior Fornices Conjunctiva Superior/Inferior Bulbar Conjunctiva Superior/Inferior Cornea : Clarity Infiltrate Ulcer Scar Neovascularization Anterior Chamber Iris Pupil

Clouded Shallow Radier, Brown Round, Central, Light Reflex (+) slow reflex, 5mm, Mydriatic

Clear Deep Radier, Brown Round, Central, Light Reflex (+), 3mm

V.

Lens : Clarity Field of vision Intra Ocular Pressure RESUME

Hard to be examined Narrow 60mmHg

Clear Wide 18mmHg

The patient, female, 36 years old, came to the doctor with chief complaint pain in the right eye since 2 days ago. Pain is felt tingling and long-lasting.

Initially 1 month ago patient often complain of headaches, especially right. Initially the pain lasted about half an hour to 2 hours and then disappear, but over time the complaint was more often and more of the same duration, as well as pain, is increasingly growing pains. Patient said complaint was more severe at night. Patient taking drugs reduce complaints Bodrex and sleep when complaints arise. However, the complaint was only gone a while, then came back. In addition, patients also complain of nausea and vomiting had 2 times as much, red right eye, watery, glare, and see the rainbow colors around lights. The patient said had never had a complaint like this before. History of Hypertension, Diabetes Mellitus, allergies and use of drugs that contain steroids are denied. History of trauma (-), eye pain before (-), wears glasses (-), operations (-).The patients father also had this symptoms

From basic ophthalmologist examinations were found : Right Eye 1/300 Cilliary Injection (+) Left Eye 6/6 Cilliary Injection (-)

Visual Acuity Pinhole Correction Bulbar Conjunctiva Superior/Inferior Cornea : Clarity Infiltrate Ulcer Scar Neovascularization Anterior Chamber Iris Pupil

Clouded Shallow Radier, Brown Round, Central, Light Reflex (+), 5mm, Mydriatic

Clear Deep Radier, Brown Round, Central, Light Reflex (+), 3mm

Lens : Clarity Field of vision Intra Ocular Pressure

Hard to be examined Narrow 60mmHg

Clear Wide 18mmHg

VI.

CLINICAL DIAGNOSE Acute Primary Glaucoma OD

VII.

DIFFERENTIAL DIAGNOSE Acute Keratitis

VIII. ADDITIONAL EXAMINATION 1. Slit lamp examination 2. Funduscopy 3. Perimetry 4. Gonioscopy

IX.

TREATMENT

Medication Pilocarpin 2-4% eye drops dripped 1 drop per minute for 5 minutes, followed by 1 drop every hour up to 6 hours Asetozolamid 2x250mg then 1 tablet every 4 hours for 24 hours Timolol 0,5% 2x1 Manitol 20% 60 drops per minute (Intravenous)

Surgical Trabeculectomy Iridectomy

X.

PROGNOSIS OS Quo ad Vitam : bonam

Quo ad functionam : dubia ad bonam Quo ad sanationam : dubia ad bonam OD Quo ad Vitam : bonam

Quo ad functionam : dubia Quo ad sanationam : dubia

XI.

COMPLICATION Absolute Glaucoma OD

OPTHALMIC RECORD

Tutor : Prof.Dr.dr.J.H.A.Mandang, Sp.M (K) Created by:

Melisa Silvia 0861050184 DEPARTEMENT OF OPHTAMOLOGY FACULTY OF MEDICINE CHRISTIAN UNIVERSITY OF INDONESIA NOVEMBER 5 DECEMBER 1 2012