MORNING

REPORT
Opthalmology Department
RSUD Kota Makassar
ODS Pterygium Grade II
Patient identity
• Name : Mrs. HJ

• Age : 44 Years Old

• No. RM : 231488

• Address : Sudiang Permai

• Nation : Indonesia

• Religion : Islam

• Date : January 13, 2020

• Anamnesis : Autoanamnesis
History Taking
Main Complaint : Watery Eye
Guided History :

Patients came to RSUD Kota Makassar with a watery eye since 1 week ago and felt a
foreign body sensation in the right eye and the left eye. Patients noticed that theres
fleshy growth in his eye since 1 month ago. At first, its small, which gradually grow
closer to the center of patient’s eye. This was followed by sandy sensation (+), itchy (+)
Decreased vision (+), red eye (-), pain (-), eye discharge (-). History of using eye drops
(-) History of use glasses were denied. History of use contact lens were denied. History
of ocular trauma (-). History of Ocular Surgery (+) with pterygium extirpation

History of Disease :
he didn’t have any history of diseases
SLOD SLOS
Visual Acuity Examination
OD Visual OS

20/25 Uncorrected visual acuity 20/25 False

- Correction -

- Best corrected visual acuity -

- Near visual acuity -

- Correction -

- Best corrected near visual acuity -

Anterior Segment Examination
OD OS
Oedema (-) Hyperemia (-), Oedema (-) Hyperemia (-),
Palpebral
Crust (-) Crust (-)
Cilia Squama (-), Madarosis (-) Squama (-), Madarosis (-)
Lacrimal Apparatus Lacrimation (+) Lacrimation (+)

Hyperemis (+), Fibrovascular tissue (+), and A Hyperemis (+), Fibrovascular tissue (+), and A
Conjunctiva
triangulare membrane appears in the nasal area. triangulare membrane appears in the nasal area.

Cornea Clear Clear

Anterior Chamber Normal Depth Normal Depth

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

Pupil Round, Central Round, Central
Direct/Indirect Light
+/+ +/+
Reflex
RAPD - -
Lens clear clear
Diagnose
ODS Pterygium Grade II

Differential Diagnose
Pseudopterygium
Pinguecula
Palpation
OD OS

Tn Ocular pressure Tn

- Tumor/Mass -

Not palpable Pre Auricular Gland Not palpable

Treatment Insert the title of your subtitle Here

Cendo Floxa Eye Drops 5x1 gtt ODS

Ocuflam Eye Drops 4x1 gtt ODS

Education :

Reassure patient not to rubbed his eyes, keep a good hygiene, suggest avoiding dust

or sun exposure, rest well.

PROGNOSIS
- QUO AD VITAM : BONAM

- QUO AD FUNCTIONAM : BONAM

- QUO AD COMETICAM : BONAM

- QUO ADA SANACTIONAM : BONAM

Thank you