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Name of Examiner
NIM
: 1161050064
Date of examination
: August , 2015
Tutor
PATIENT IDENTITY
Name
Age
: 52 years old
Address
Occupation
: House wife
Religion
: Christian
i.
Main complaint
Blurred vision in both eyes
Additional 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.
OPTHALMIC RECORD RSU UKI 2015
1
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 illness
OPHTHALMIC STATUS
1.
General Examination
Periocular appearance
General condition of the eye
Eyeball position
Eyeball movement
Right Eye
Quiet
Normal
Symmetric
Normal
Left Eye
Quiet
Normal
Symmetric
Normal
B. Systematic Examination
Right Eye
Left Eye
Visual acuity
1/60
2/60
Correction
Super cilia
Normal,
Madarosis (-)
Normal,
Madarosis (-)
Cilia
Normal,
Madarosis (-), Trichiasis (-)
Normal,
Madarosis (-), Trichiasis (-)
Bulbar conjunctiva
Iris
Radier
Colour : Brown
Radier
Colour : Brown
Pupil
Round, isochor
3mm
Light Reflexs : (+)
Clear
Shadow test (-)
Round, isochor
3mm
Light Reflexs : (+)
Turbid
Shadow test (-)
Cornea
Anterior chamber
Lens
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
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
Visual acuity
Margo
superior
Right Eye
Left Eye
1/60
2/60
Palpebra Normal
Normal
Tarsal
conjunctiva Normal
superior
Normal
Bulbar conjunctiva
Normal
Normal
Cornea
Clear
Clear
Anterior Chamber
Normal in depth
Normal in depth
Iris
Radier
Radier
Pupil
Lens
Clear
Cloudy
V.
VI.
VII.
CLINICAL DIAGNOSE
Right Eye
Left Eye
Mature Cataract
Mature cataract
Differential Diagnose
Right Eye
Left Eye
Immature Cataract
Immature Cataract
Pre-operation :
TREATMENT
MEDICAL
ophtamoscopy
Biometry
i.
Ad vitam
Ad sanationum
Ad functionum
PROGNOSIS
Right Eye
Left Eye
Bonam
Bonam
Bonam
Bonam
Dubia ad bonam
Bonam
IX.
COMPLICATIONS
Secondary Glaucoma