OPHTHALMOLOGY RECORD

TUTOR: Prof. Dr. dr. JHA Mandang, SpM (K) CREATED BY: Eleazar Christopher L Tobing 0861050035

DEPARTEMENT OF OPHTHALMOLOGY 27 Mei - 22 Juni 2013 MEDICAL FACULTY CHRISTIAN UNIVERSITY OF INDONESIA JAKARTA 2013
OPHTHALMIC RECORD

Examinee NIM

: Eleazar Christopher L Tobing : 0861050073

Date of exam : June, th 2013 Tutor : Prof. Dr. dr. JHA Mandang, SpM (K)

I. PATIENT IDENTITY Name Sex Age Occupation Adress Religion : Mr. S : Male : 24 years old : Self-employed : Piyungan Bantul, Jogjakarta : Moslem

II. INTERVIEW Main Complaint Two bumps on the lower eyelids Additional Complaint Pain and itching if touched Chronologist of the illness
Patient came to YAP hospital with main complaint is two bumps on the lower of eyelids since 3 weeks before admission. Starting from small red bumps then became increasingly large until lower eyelids on both eyes become red and swollen. Bumps accompanied by pain, especially when touched and itchy bumps. Patients also feel like there is a lump on both the lower eyelid.

Previous disease During the ill patients were taking medication eye ointment to reduce the symptoms, but forgot the name of the medicine. Patient has never experienced this illness before. The same illness did not found in other family members. The history of hypertension, Diabetic, asthma and allergy denied.

GENERAL STATUS General condition Disease related complaint : Well : Not found

III. OPHTHALMIC STATUS a. General Examination Right Eye Around aye appearance General condition of eyes Eye ball positions Eye ball movement Normal Moderate illness Symetric Normal Left Eye Normal Moderate ilness Symetric Normal

b. Systematic Examination Right Eye Visual Acuity Correction Supercilia Cilia Superior/Palpebrae Inferior Palpebrae Superior Tarsalis Conjunctiva Inferior Tarsalis Conjunctiva Bulbar Conjunctiva Superior/Inf Fornix Conjunctiva AppratusLacrimalis Sclera Cornea Infiltrate Oedema Ulcus Sensibility Camera Oculi Anterior Iris Pupil Lens Shadow Test 6/6 Quiet Quiet Normal, edema (-) Edema (+), pain (+) Hyperemic (-) Hyperemic (+) Bump (+) Conjunctival Injeksion (+) Hyperemic Normal White Unclear (+), punctate Negative Negative Sensitive Radier, brown Isocor Clear Positive Left Eye 6/6 Quiet Quiet Normal, edema (-) Edema (+), pain (+) Hyperemic (-) Hyperemic (+) Bump (+) Conjunctival Injeksion (+) Hyperemic Normal White Unclear (+), punctate Negative Negative Sensitive Radier, brown Isocor Clear Positive

IV. RESUME Patient, male, 20 years old came to hospital with main complaint is sensation that there is something in the eye with additional complaint pain, redness, blurry vision, tearing and increased sensitivity to the light on both of the eye since that morning. A day before patient was welding and accidently the electric sparks splashed into his eyes and then when patient woke up that morning, he felt unwell in his eyes like the complaints above. Previous diseases: Patient did not do a treatment or take medicine to reduce the symptoms. Patient has never experienced this illness before. The same illness did not found in other family members. The history of hypertension, Diabetic, asthma and allergy denied.

Ophthalmic Examination General condition on both of the eyes: moderate illness Right Eye Visual Acuity Correction Supercilia Cilia Sup/InfPalpebrae Sup/InfTarsalis Conjunctiva Bulbar Conjunctiva Sup/Inf Fornix Conjunctiva AppratusLacrimalis Sclera Cornea Infiltrate Oedema Ulcus Sensibility Camera Oculi Anterior Iris Pupil Lens Shadow Test 6/8 PH 6/7 Quiet Quiet Spasme Hyperemic Normal Hyperemic Normal White Unclear (+), punctate Negative Negative Sensitive Radier, brown Isocor Direct light reflex (+) Indirect light reflex (+) Clear Positive Left Eye 6/8 PH 6/6 Quiet Quiet Spasme Hyperemic Normal Hyperemic Normal White Unclear (+), punctate Negative Negative Sensitive Radier, brown Isocor Direct light reflex (+) Clear Positive

V. CLINICAL DIAGNOSE ODS trauma caused by radiation

VI. DIFFERENTIAL DIAGNOSE Corneal ulceration Iritis

VII. MEDICAL TRATMENT Cycloplegic o Cyclopentolate (0,5-1 %) 1 drop/times. Repeat every 10 minutes Analgesic o Acular 1 drop/4 times daily Antibiotic o Eritrhomycin or gentamicin 1 drop/4 times daily Non medication o Do not rub over the eyes o Use welding mask while working

VIII. SUGGESTED EXAMINATION Bengal Rose test Flurorescein test

IX. PROGNOSIS Right Eye Ad Vitam Ad Sanationum Ad Functionum Bonam Dubia ad Bonam Bonam Left Eye Bonam Dubia ad Bonam Bonam

X. COMPLICATIONS Corneal ulseration Super infection Vision loss