OPHTALMOLOGY STATUS

A. Patient Identity
1. Name : Fatimah
2. Sex : Female
3. Age : 45 years old
4. Address : Mempawah
5. Ethnic : Melayu
6. Occupation : Housewife
7. Religion : Moslem
8. Date of consult : February 1st 2017

B. Chief complaint :
Redness membrane appeared on the right eye.

C. History of Present Illness:

Patient come to the Klinik Mata dan THT Ayani, complaining about the
reddish white membrane appeared on her right eye since ten years ago. The
membrane form a triangle. At first, patient realized this membrane as a small
membrane on the right eye near the nose (didn’t involved the black part of the
eye) since 10 years ago. Then, the membrane were growing increasingly
creeping closer to the black part of the patient's eye. Patient also getting the
foreign body sensation on her right eye. The complains especially appears
when in hot weather, and also windy weather. Patient is not using any drugs
to cope her complain. There is no itchy eyes and eye discharge. Disturbances
in vision also denied. A history of trauma to the eye denied. History of
chemical exposure to the eye were also denied. The use of glasses or contact
lenses denied. Another ocular disease history was denied.
D. Past Medical History:
Patient said she never experienced a history of trauma to her eyes. Didn’t use
any glasses or lense before. No history of diabetic mellitus, hypertension and
allergy.

E. Family History:
Family members with the same complain were denied, but her aunt was
recently having cataract surgery.

F. General Physical Assessment

1. General Condition : Good
2. Awareness : Compos Mentis
3. Vital Signs
Heart Rate : 84 times/min
Respiration freq. : 18 times/min
Blood Pressure : 120/80 mmHg
Temperature : 36.6o C
G. Ocular Exam:
1. Visual Acuity :
OD : 5/30
OS : 5/6
2. Pupils
OD : round, isokhor, central position, light reflex (+), diameter 3 mm
OS : round, isokhor, central position, light reflex (+), diameter 3 mm
1. Eye movement :
3. Eye Movement :

4. Intraocular Pressure:
OD: 15 mmHg
OS: 16 mmHg

OD OS
Orthoforia Eye ball Orthoforia
position
Ptosis (-), Lagoftalmos (-), Palpebra Ptosis (-), Lagoftalmos (-),
Hiperemis (-), Oedem(-) Hiperemis (-), Oedem (-)

Redness (-), Discharge (-), Conjunctiva Redness (-), Discharge (-)

triangle-shaped reddish Bulbi
membrane with base on
nasal side conjunctiva and
peak on the cornea
Hiperemis (-), discharge (-) Conjunctiva Hiperemis (-), discharge (-)
Tarsal

triangle-shaped reddish Cornea Infiltrate (-), ulcus (-)

membrane with base on
nasal side conjunctiva and
peak on the cornea, in front
 of the pupil

Deep, Clear Anterior Deep, Clear

Chamber
Chocolate color, crypt (+) Iris Chocolate color, crypt (+)

Clear, shadow test (-) Lens Clear, shadow test (-)

Hard to examine Vitreous Clear
Hard to examine Fundus Firm and round margin, cup-
disc ratio 1:3, artery vein
ratio 2:3, reddish retina,
bleeding (-), exudate (-),
cicatrix (-)

H. Diagnosis
Working Diagnosis
Systemic disease : -
Eye disease
OD : Pterygium grade IV
OS :-
Differential Diagnosis
OD : Pseudopterygium, Pinguecula
OS :-
I. Treatment
Non Medikamentosa : Surgical treatment: conjunctival autograft
Medikamentosa : MMC intraoperative
Prognosis
Ad vitam : Bonam
Ad functionam : Bonam
Ad sanactionam : Bonam