OPHTHALMIC RECORD
Name of Examiner
: Anastasia Anggita SaraswatiNIM
: 1161050064Date of examination
: August , 2015Tutor
: dr Gilbert W.S. Simanjuntak SpMPATIENT IDENTITY
Name
: Mrs. Tianur SimanjuntakAge
: 52 years old
Address
: Jl. Cempaka V No. 28, East JakartaOccupation
: House wifeReligion
: ChristianI. ANAMNESIS (August 19th , 2015)
Main complaint
Blurred vision in both eyesAdditional complaint
Glare History of disease
Patient came to hospital with main complaint blurred vision in
both eyes since 1 year ago. The right eye feels more blurry than
the left eye. This complaint was continously and getting worse in
near dan far sight seeing. The problem start as a foggy vision that
eventually growing and caused blurred vision. Complaints of itchy,
red eyes and secrete discharge denied. Patient use glasses to
correct near sight vision but cant remember the correction size of
her glasses.Previous disease
The patient said that she never had this situation before.The
presence of diabetes or high blood pressure is denied. History of
physical trauma, history of using long-term drug, allergies and
history of contact lenses used are denied.
II. GENERAL STATUS
General condition
: Mild illnessSymptom or illness related to the complaint :
NoneIII. OPHTHALMIC STATUS
A. General Examination
Right EyeLeft Eye
Periocular appearance QuietQuiet
General condition of the eye NormalNormal
Eyeball position SymmetricSymmetric
Eyeball movement NormalNormal
B. Systematic Examination
Right EyeLeft Eye
Visual acuity 1/602/60
Correction--
Super cilia Normal,Madarosis (-)Normal,Madarosis (-)
Cilia Normal,Madarosis (-), Trichiasis (-)Normal,Madarosis (-),
Trichiasis (-)
Margo Palpebra superiorEdema (-), tenderness (-), ectropion (-),
entropion (-), ulcus (-), crusting (-)Edema (-), tenderness (-),
ectropion (-), entropion (-), ulcus (-), crusting (-)
Margo Palpebra inferiorEdema (-), tenderness (-), ectropion (-),
entropion (-), ulcus (-), crusting (-)Edema (-), tenderness (-),
ectropion (-), entropion (-), ulcus (-), crusting (-)
Tarsal conjunctiva superior Hyperemic (-), Papilar (-), Follicle
(-), Bleeding (-) Hyperemic (-), Papilar (-), Follicle (-),
Bleeding (-)
Tarsal conjuntiva inferiorHyperemic (-), Papilar (-), Follicle
(-), Bleeding (-)Hyperemic (-), Papilar (-), Follicle (-), Bleeding
(-)
Bulbar conjunctiva Conjunctiva injection (-), pinguekula (-),
pterigium (-), secretion (-)Conjunctiva injection (+), pinguekula
(-), pterigium (-), secretion (-)
Cornea ClearInfiltrate (-) Ulcus (-)Arch senile
(-)ClearInfiltrat (-) Ulkus (-)Arch senile (-)
Anterior chamber Normal in depth,Bleeding (-), hyphema(-)Normal
in depth,Bleeding (-),hyphema(-)
Iris RadierColour : BrownRadier Colour : Brown
Pupil Round, isochor3mmLight Reflexs : (+)Round, isochor3mmLight
Reflexs : (+)
Lens Clear
Shadow test (-)TurbidShadow test (-)
IV. RESUME
A 52 years old female came to hospital with main complaint
blurred vision in both eyes. The right eye feels more blurry than
the left eye. This complaint was continously and getting worse in
near dan far sight seeing. The problem start as a foggy vision that
eventually growing and caused blurred vision. Complaints of itchy,
red eyes and secrete discharge denied. Patient use glasses to
correct near sight vision but cant remember the size of her glasses
History of physical trauma denied, history of using long-term drug
denied, allergies and history of contact lenses used
denied.Ophthalmic Examination
Right EyeLeft Eye
Visual acuity 1/602/60
Margo Palpebra superiorNormalNormal
Tarsal conjunctiva superior Normal Normal
Bulbar conjunctiva NormalNormal
CorneaClearClear
Anterior ChamberNormal in depthNormal in depth
IrisRadier Radier
PupilRound, light reactive (+)Round, light reactive (+)
LensClear
Cloudy
V. CLINICAL DIAGNOSE
Right EyeLeft Eye
Mature CataractMature cataract
VI. Differential Diagnose Right EyeLeft Eye
Immature CataractImmature Cataract
VII. MEDICAL TREATMENT
Pre-operation : measurement of complete blood count, chemical
analysis, urinalysis, electrocardiography and chest radiography
Phacoemulsification + IOL (Intra Ocular Lens) ODS
Post-operation :
Maintain eye higiene
VIII. SPECIFIC EXAMINATION
ophtamoscopy
Biometry IX. PROGNOSIS
Right EyeLeft Eye
Ad vitam BonamBonam
Ad sanationum BonamDubia ad bonam
Ad functionum BonamBonam
X. COMPLICATIONS
Secondary GlaucomaOPTHALMIC RECORD RSU UKI 20156
