Name of examine NIM

: Lisbeth Juni Verawati Marpaung : 05-100

Date of examination : November, 27th 2012 Tutor : Dr. Gilbert W.S Simanjuntak,SpM(K)

I.

PATIENT IDENTITY Name Age Address Occupation : Mr. H : 55 Years old : Gang Sawo, Dewi sartika :-

II.

ANAMNESIS (November,23rd 2012) Main complains : Sudden pain, redness, blurred vision on the right eye.

Additional complains: Headache, nausea, and swelling on the right eye.

History of Disease Patient came to the Hospital with main complains sudden pain, redness, and blurred vision on her right eye. The pain felt deep in the eye ball and spread to forehead. Besides that, its also followed by headache, nausea, and swelling too. These complain had been happening for 3 days. Patient taken an eye drop (Rohto) and Paramex to reduce those symptoms but it didnt getting better and then he decided to go to the hospital to receive better treatment. This similar complains had not found on the rest of his family member. double vision and itchy eyes denied.

Acute Glaucoma

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Previous disease The patient said that there is no history of trauma on his right eye and he never had the same symptoms like this before. history of diabetic denied, history of

hypertension denied, history of using long-term drug denied.

III.

GENERAL STATUS General condition : Appearance of severe illness Complains-related symptoms : Unremarkable

IV.

OPHTALMIC STATUS A. General Examination Right Eye Around Eye Appearance General Condition of The Eye Ball Position of The Eye Ball Ocular Mobility Symmetric Normal Symmetric Normal Quiet Severe illness Left Eye Quiet Normal

B. Systematic Examination Right Eye Visual Acuity Correction Palpebra Superior/Inferior Tarsal Conjunctiva Bulbar Conjunctiva Hyperemic Ciliarys injection, injection (-), pinguecula (-), pterigium (-) Quiet Quiet, injection (-), pinguecula (), pterigium (-) 1/60 Cant be corrected Edematous Left Eye 6/6 6/6 Quiet

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Cornea

Edematous, infiltrate (-), ulcer (-), arcus senilis (-)

Clear, infiltrate (), ulcer (-), arcus senilis (-) Normal in depth, bleeding (-) Radier Round, central, light reactive (+)

Anterior Chamber

Narrow in depth, bleeding (-)

Iris Pupil

Radier Round, central, dilated, light reactive (-)

Lens

clear

Clear

V.

RESUME Patient, Mr. H, 55 years old came to the Hospital with main complains sudden pain, redness, and blurred vision on her right eye. The pain felt deep in the eye ball and spread to forehead. Besides that, its also followed by headache, nausea, and swelling too. These complain had been happening for 3 days. Patient taken an eye drop (Rohto) and Paramex to reduce those symptoms but it didnt getting better and then he decided to go to the hospital to receive better treatment. This similar complains had not found on the rest of his family member. symptoms double vision and itchy eyes denied.

Acute Glaucoma

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From General Examination on The Right Eye Founded: General condition of eye ball: Appearance of severe illness

From Systematic Examination on The Right Eye Founded: Visual acuity Palpebra superior/inferior Tarsal conjunctiva Bulbar conjunctiva Cornea Anterior chamber Pupil : 1/60, cant be corrected : Edematous : Hyperemic : Ciliarys injection : Edematous : Narrow in depth : Dilated, light reactive (-)

VI.

CLINICAL DIAGNOSE Right Eye Acute Glaucoma Left Eye Normal

VII.

DIFFERENTIAL DIAGNOSE Right Eye Anterior uveitis Keratitis Left Eye -

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VIII. MEDICAL TREATMENT For The Right Eye Acetazolamite 500 mg I.V. then 250 mg tablet, 1 tablet orally 4 times daily Timolol 0,5 %, 2 times daily Pilocarpine 2 %, 2 times daily

If necessary: Oral glycerin 50 % I.V. mannitol 20 % Vitamin K 300 mg tablet, 1 tablet orally 3 times daily

If the intraocular pressure remains increased and the progressive loss, surgery might be advised (Iridectomy)

visual field show

For The Left Eye Pilocarpine 2 %, 3 times daily Preventive peripheral Iridectomy Screening examination: every 2 years or less.

IX.

SUGGESTED EXAMINATION - Campimetric - Gonioscopy - Slit lamp - Tonometry

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X.

PROGNOSIS Right Eye Ad vitam Ad sanationum Ad functionum Bonam Dubia ad bonam Dubia ad bonam Left Eye Bonam Bonam Bonam

XI.

COMPLICATION Right Eye Absolute Glaucoma Left Eye Acute Glaucoma

Acute Glaucoma

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