EXTERNAL HORDEOLUM

OD
Oleh :
A.A.A Lie Lhianna M.P
H1A013001
 Identity

 Name : Mrs. N
 Age : 23 years old
 Address : Bengkel Utara, Labuapi, North Lombok
 Occupation : Housewife
 Religion : Islam
 Tribe : Sasak
 Status : Married
 Educational state : Senior High School
 Date of examination : August 28th 2018
 Medical record : 014831
Subjective

Main Complaint
 Lump on the right upper eyelid
Current medical history
 Patient came to the outpatient clinic of ophthalmologic complaining about lump
on her right upper eyelid since 1 month ago. At first she felt uncomfortable
around her eyelid and there is no pain, but nowadays it becomes bigger like
pimple, redness, painful and bother her look.
 That lump never pop out a pus and never being collapsed. Patient said that she
rarely cleans make up on her eyelids. Patient didn’t complaint about eye
redness, fever and any sticky eye crust.
Subjective

Past medical history

 Opthalmologic disease
 There isn’t any history of eye redness, runny eye, itchy or eye crust.
 There isn’t any same complaint before
 Sistemic disease
 Patient didn’t have any fever.

Family medical history

 Her family didn’t get any same disease or complaint like her.
Subjective

Medication History
 Patient was never getting any treatment before.
Allergic History
 Patient didn’t have any allergic to food and drugs.
Subjective

Riwayat Sosial
 Patient lived in a well afford family.
 Patient felt uncomfortable because the lump couldn’t collapsed.
Objective

General State
 General condition : Well
 Consciousness : Composmentis
Vital sign :
 Blood pressure : 110/80 mmHg
 Respiratory rate : 22 x/menit
 Heart rate : 78 x/menit
 Temperature : 36,8 0C
Opthalmologic
Examination
Objective

Palpation : tenderness on Right Superior Palpebra

Obyektif
Obyektif
Obyektif
Documentation
Problem Identification

Subyektif Obyektif
 Lump on right upper eyelid for 1  Hyperemia on right palpebra
month
 Pseudoptosis on right palpebra
 Looks like pimple
 Tenderness (+)
 Redness
 Painful
 Swollen
 Case Analysis

External
Subjective Objective
Hordeolum

 Lump on right  Hyperemia

upper eyelid for on right
1 month palpebra
 Looks like pimple  Pseudopto
 Redness sis on right
palpebra
 painful
 Tenderness
 swollen (+)
Planning

 Non-medication : warm water compress

 Medication : antibiotic
 Surgery : incision, curetage
Information for Patient

 Explain to patient that she has got external hordeolum which is an inflammation of eyelid’s
glands that commonly caused by bacterial infection.
 Explain about treatment planning to the patient.
 Explain the patient to look after the lump and do the treatment regularly so the complication
wouldn’t occur.
 Prognosis

 Sight Prognosis (ad functionam)

 Dubia ad bonam
 Life prognosis (ad vitam)
 Dubia ad bonam
Conclusion

External
Subjective Objective Hordeolum Treatment
OD

 A 23 y.o woman  Hyperemia on  Warm water

 Lump on right right palpebra compress for
upper eyelid for 10 minutes (3
1 month  Pseudoptosis
on right times daily)
 Looks like pimple
palpebra  Antibiotic
 Redness
 Tenderness(+) (eritromisin
 painful 4x250 mg)
 swollen
References

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