Name : Tn.

R
Sex : Male
Age : 22 y.o
Address : Hertasning c
Religion : Islam
Ethnic / Nation : Makassar / Indonesia
Occupation : student
Medical Record : 13 – 22 – 91
Date of Examination : April 1th, 2019
Main Complaint : Red Eye
Guaided Histroy :
A 22 years – old male patient came to the BKMM with red eye in his right eye
since 2 days ago.The patient said when he wakeup in this morning, there was eye
discharged and sometimes his eyes feel pain and runny. Other complaints such as
glare and blurred vision are denied. History of use glasses around 5 years.
History of Disease :
He didn’t have any history of Allergy
History Disease of Family :
His Borther have the same disease
 OD Visus OS

4 / 60 Uncorrected visual acuity 4 / 60

His glasses Correction His glasses

20 /60 Best corrected visual acuity 20 / 40 F

- Near visual acuity -

- Correction -

Best corrected near visual acuity

- -
 OD OS

Palpebral Margo Oedema (-) Hyperemia (-), Crusta (-) Oedema (-) Hyperemia (-), Crusta (-)

Cilia Scuama (-), Secret (+), Madarosis (-) Scuama (-), Secret (-), Madarosis (-)

Lacrimal Apparatus Lacrimation (+) Lacrimation (-)

Conjunctiva Injectio (+) Hyperemia (-)

Cornea Tes Fluorecens (+) Clear

Anterior Chamber Normal Depth Normal Depth

Iris Brown, Crypt (+) Brown, Crypt (+)

Pupil Round, Central Round, Central

Direct / Inderct Light Reflex +/+ +/+

RAPD - -

Lens Clear Clear

 OD OS

Ocular pressure Tn Tn

Tumor/Mass (-) (-)

Pre Auriculer gland Not palpable Not palpable

DIAGNOSIS
OD Keratokonjungtivitis

DIFFERENTIAL DIAGNOSIS
Kongjungtivitis Bacterial
Episkleritis
 TREATMENT
01
Farmakologi 02
- Cendo Tobroson ED 4 dd 1 gtt OD
( Tobramycin , Dexamethasone) Education
- Cendo Eyefresh Plus ED 6 dd 1 gtt - Personal Hyginie
ODS ( HPMC, Dextran 70, Gliserin) - Tell the patients
10%and families not
- Natrium Diclofenat 50mg 3 dd 1 to rub their eyes.
- Retinol 100.000 IU 1 dd 1
- If complaints increase
immediately controls again
Quad Ad Visam : Dubia
Quad Ad Sanam : Dubia
Quad Ad Cosmetican : Dubia
Quad Ad Vitam : Bonam