OPHTHALMOLOGY RECORD

Name of examine

: Gilbert Richard Sulivan Tapilatu

NIM

: 0761050176

Date of examination : March, 14th 2015

Tutor

I.

: dr. Gilbert W.S Simanjuntak, SpM (K)

IDENTITY PATIENT

Name

: Mrs. A

Age

: 22 years old

Address

: Komodor HPK Gg Sadar No 33 RT 05/01 Jakarta Timur.

Job

: Student

Religion

: Christian

II.

INTERVIEW (March, 14th 2016)

Main complaint

: Pain in the right eye

Additional complaint : Redness , watery and sandy- gritty sensation in right eye along with
blurry vision
Course of Disease
Patient came with pain in the right eye since two weeks ago. This complaint is felt
continuously and increasingly painful. At first, she thought that it was only an usual redness
around the eyeball caused by pollution, but day by day became more severe and it happens
continuously along with the pain in the right eye that is also becoming more painful everyday.
She also complained about her blurry vision that happened 3 days ago, it happened progressively
along with the watery and sandy-gritty sensation in right eye everytime she tried to open her
eyes. According to the patient , this all happened in all of a sudden, without any specific causes;
patient had history of using soft lens daily, often rubbing her eyes, no history of eye trauma. To
reduce the complaints of patients using insto, routinely used, but the complaint has not improved,

even worsen . No complain about glare, headeache, or felling nauseous. No complaint about her
left eye.

History of Disease
-

The patient had never had any complaint like this before.
History of diabetes, hypertention, and allergic denied.

Family Medical History

None of her family or relatives had complains like this before

III.

GENERAL STATUS

General condition

: Moderate illness

Awareness

: Compos Mentis

IV.

OPTHALMOLOGIST STATUS
A. General investigator
Right Eye

Left Eye

Around Eye Appearance

Quiet

Quiet

General Condition of the Eye Ball

Hyperemic, watery

Normal

Position of The Eye Ball

Symmetric

Symmetric

Eye Movement

Normal to all directions

Normal to all directions

Donders Confrontation Test

Wide

Wide

B. Systematic investigator
Right eye

Left eye

Visual Acuity

6/20

6/6

Pin Hole

Correction

No correction

No correction

Super cilia

Normal growth, madarosis (-)

Normal growth, madarosis (-)

Cilia

Normal, madarosis (-),

trichiasis(-)

Normal, madarosis (-),

trichiasis(-)

Palpebra Superior/Inferior

Edema (-), tenderness (-),

ectropion (-). Entropion (-),
ulcus (-), krusta (-)

Edema (-), tenderness (-),

ectropion (-). Entropion (-),
ulcus (-), krusta (-)

Margo Palpebra Superior/ inferior

Edema (-), tenderness (-),

ectropion (-). Entropion (-),
ulcus (-), crust (-)

Edema (-), tenderness (-),

ectropion (-). Entropion (-),
ulcus (-), crust (-)

Tarsal Conjunctiva

Hyperemic (-), papilar (-),

follicle (-), bleeding (-)

Hyperemic (-), papilar (-),

follicle (-), bleeding (-)

Konjungtiva Forniks Superior/

inferior

Hyperemic (-), papilar (-),

follicle (-), bleeding (-)

Hyperemic (-), papilar (-),

follicle (-), bleeding (-)

Bulbar Conjunctiva

Ciliary injection (+),

pinguecula (- ), pterigium (-)

Ciliary injection(-),
pinguecula(-), pterigium (-)

Cornea

Round, cloudy, infiltrate (+),

ulcus (-), cicatrix (-),
neovascularization (-)

Round , clear, infiltrate (-),

ulcus (-), cicatrix (-),
neovascularization (-)

Sklera

Icteric (-)

Icteric (-)

Anterior chamber

Deep

Deep

Hipopion (-)

Hipopion (-)

Hyphema (-)

Hypema (-)

Iris

Radier, brown

Radier, brown

Pupil

isochore, round, in the

middle, 3mm, direct light
reflex (+), indirect light reflex
(+)

isochore, round, in the middle,

3mm, direct light reflex (+),
indirect light reflex (+)

V.

Lens

Clear

Clear

Tonometri

Havent been done

Havent been done

RESUME

Patient Mrs A, 21 years old, Patient came with pain in the right eye since two weeks ago.
At first, she thought that it was only an usual redness around the eyeball caused by pollution, but
day by day became more severe and it happens continuously along with the pain in the right eye
that is also becoming more painful everyday. She also complained about her blurry vision that
happened 3 days ago, it happened progressively along with the watery and sandy sensation in
right eye everytime she tried to open her eyes. To reduce the complaints of patients using insto,
routinely used but the complaint has not improved even worsen.
General Examination ophthalmologist
Normal
A. Systematic Examination opthalmologist

VI.

Right eye

Left eye

Visual Acuity

6/20

6/6

Pin Hole

Correction

No correction

No correction

Bulbar Conjunctiva

Ciliary injection (+),

pinguecula (- ), pterigium (-)

Ciliary injection(-),
pinguecula(-), pterigium (-)

Cornea

Round, cloudy, infiltrate (+)

Round , clear, infiltrate (-),

CLINICAL DIAGNOSE
Keratitis OD

VII.
-

DIFFERENTIAL DIAGNOSE
Bacterial keratitis
4

Iritis acute
Acute glaucoma

VIII. MEDICAL TREATMENT

1. Non medication
- Dont rub both eyes
- Wash hand before and after touching the eyes
- Use sunglasses when going out
- Cover eye with eye pad.
2. Medication
- Local antibiotic
- Cyclopegic
IX.

PLANNED EXAMINATION
a. Slitlamp with fluorescent test
b. Microbiology culture

VIII. PROGNOSIS

Ad Vitam
Ad Sanationum
Ad functionum

IX.

RIGHT EYE
Bonam
Dubia at bonam

Bonam

Dubia at bonam

Bonam

COMPLICATION
-

LEFT EYE
Bonam

Corneal Ulcus
Leukoma