OPHTHALMOLOGY RECORD

Name of examine

: Andre Nicholas Tobing

NIM

: 1061050042

Date of examination :
Tutor

I.

: dr. Gilbert W.S Simanjuntak, SpM

IDENTITY PATIENT

Name

: Mr. M

Age

: 52 years old

Status

: Married

Address

: jl.Bojong no 2 Pondok Gede

Last Education

: Senior High School

Occupation

: Private Employee

II.

INTERVIEW (March , 29th 2016)

Main complaint

: Redness on the right eye

Additional complaint : -

History of Present illness:

Patients come to the hospital Eye Polyclinic . UKI with a Redness on the Right eye since
4 days ago . This complaint is ongoing and increasingly red . Patients also felt right eye feels
like a lump minimal itching , pain and watery . Patients already trying to reduce complaints with
Visine eye drops but no improvement . Patients have a habit rubbed his eyes . Complaints
decrease in vision , double vision , glare , and the eyes of discharging is denied. Headaches and
respiratory tract illness denied. Patients not using glasses or contact lenses .

History of Previous Disease

Patients had never had a complaint like this . A history of food allergies and medications
denied. A history of high blood pressure and diabetes is denied . History of trauma and a history
of long- term drug use denied
Family Disease History
There is no family experienced the same thing as a patient .

History Personal Habits

The use of contact lenses denied. Patients have a habit of rubbed his eyes .

III.

GENERAL STATUS

General condition

: Good

Awareness

: Compos Mentis

Blood Pressure

: 120/80 mmHg

Pulse Rate

: 82 times/min

Respiration Rate

: 24 times/min

IV.

OPTHALMOLOGIST STATUS
A. General investigator
Right Eye

Left Eye

Around Eye Appearance

Quiet

Quiet

General Condition of the Eye Ball

Looks Sick

Normal

Position of The Eye Ball

Symmetric

Symmetric

Ocular Mobility

Normal

Normal

Confrontation Test

Wide

Wide

B. Systematic investigator
Right eye

Left eye

Visual Acuity

0,3

0,9

Pin Hole

Correction

No correction

No correction

Super cilia

Normal

Normal

Cilia

Normal

Normal

Palpebra Superior/Inferior

Quiet

Quiet

Margo Palpebra Superior/ inferior

Normal

Normal

Tarsal Conjunctiva

Quiet

Quiet

Konjungtiva Forniks Superior/

inferior

Quiet

Quiet

Bulbar Conjunctiva

Looks sick, ciliary injection

(+), pinguecula (- ), pterigium
(-)

CIliary injection (-),

pinguecula (-), pterigium (-)

Cornea

Clear, infiltrate (+), ulcer (-),

arcus senilis (-)

Anterior Chamber

Deep, bleeding (-)

Deep, bleeding (-)

Iris

Radier,brown

Radier,brown

Pupil

Anisokor, round, 2mm,

central light reactive (+)

Anisokor, round, 3mm,

central,light reactive (+)

Lens

Clear

Clear

Tonometri

Same with the examiner

Same with the examiner

Infiltrate (-), ulcer (-), arcus

senilis (-)

V. RESUME
Mr.M 52 years come to the hospital eye Polyclinic . UKI with a red right eye complaints since 4
days ago . This complaint is ongoing and increasingly red . Patients also felt right eye feels like
a lump minimal itching , pain and watery . Patients already trying to reduce complaints with
Visine eye drops but no improvement . Patients have a habit rubbed his eyes .

A. General Examination on The Right Eye Founded

Visual Acuity

:1

Bulbar Conjunctiva

: Pericorneum injection ,Looks sick

Cornea

: Infiltrate

Pupil

: Isokor

B. Systematic Examination on The Eye Founded

Right eye
Visual Acuity

Pin Hole

Correction

No correction

Super cilia

Normal

Cilia

Normal

Palpebra Superior/Inferior

Quiet

Margo Palpebra Superior/ inferior

Normal

Tarsal Conjunctiva

Quiet

Konjungtiva Forniks Superior/

inferior

Quiet

Bulbar Conjunctiva

Quiet, ciliary injection (-),

pinguecula (- ), pterigium (-)

Cornea

Clear, infiltrate (-), ulcer (-),

4

arcus senilis (-)

VI.

Anterior Chamber

Deep, bleeding (-)

Iris

Radier,brown

Pupil

Anisokor, round, 3mm,

central light reactive (+)

Lens

Clear

Tonometri

Same wih the examiner

CLINICAL DIAGNOSE

Conjunctivitis Occuli Dextra

VII.

MEDICAL TREATMENT

Topical antibiotic drops Polymyxin or ointment (e.g chloramphenicol)

Topical Neomycin

VIII. PROGNOSIS
RIGHT EYE

LEFT EYE

Ad Vitam

Bonam

Bonam

Ad Sanationum

Bonam

Bonam

Ad functionum

Bonam

Bonam

IX.

COMPLICATION
Keratitis