Morning Report

Chronic Anterior Uveitis ODS

26 August 2016
Presenter: Kevin
Supervisor: DR. dr. Vera Sumual, Sp.M(K)
Identity
Name: Mrs. J A
Age: 40 y.o
Sex: Woman
Address: Ternate
Anamnesis
Chief Complaint: Blurred vision on both eyes
History of Present Illness:
Present with both eyes blurred since 4 months before admission.
Both eyes felt blurred suddenly with pain and photophobia.
Referred from Public Eye Center (BKMM) with panuveitis ODS
History of Past Illness:
Diabetes (-)
Hypertension (-)
Physical Examination
VOD: 1/300
VOS: 1/300

TIOD: 7,8 mmHg

TIOS: 14,6 mmHg
Anterior Segment OD
Eyelid: edema(-), hematoma (-)
Conjunctiva: injection (-)
Cornea: edema (+), descemet fold (+)
Anterior chamber: cell/flare +/+
I/P: posterior synechiae (+)
Lens: clear
Anterior segment OS
Eyelid: edema(-), hematom (-)
Conjunctiva: injection (-)
Kornea: edema (+) minimal
Anterior chamber: cell/flare +/+
I/P: posterior synechiae (+)
Lens: clear
Posterior Segment ODS
Fundus reflex (+), color: uniform
Papil, retina, and macula: difficult to evaluate
USG ODS: no spike and echoluscent
OD OS
Assessment
Chronic Anterior Uveitis ODS

Ass/ from internal medicine:

Hipokalemia
Dislipidemia
Urinary tract infection
Myalgia and neuropathy
Planning
Sulfas Atropin eye drop 3 dd gtt 1 ODS
Polydex eye drop 6 dd gtt 1 ODS
Protagenta eye drop 6 dd gtt 1 ODS
Methylprednisolone 3 x 20 mg

Internal medicine:
KSR 2x1
Simvastatin 1x1
B com 2 x1
Levofloxacin 1x500 mg