OPHTALMOLOGY RECORD

CONJUNCTIVITIS

Examiner :
dr. Gilbert W S Simajuntak Sp.M (K)

Observer :
Filda Sharifah
1161050098

DEPARTMENT OF OPHTALMOLOGY
PERIOD OF JULY 28th AUGUST 29th 2015
FACULTY OF MEDICINE
CHRISTIAN UNIVERSITY OF INDONESIA
JAKARTA

STATUS OPHTALMOLOGY
Observer
Student number
Examiner

I.

PATIENT IDENTITY
Name
Age
Address
Occupation
Gender
Status
Religion

II.

: Filda Sharifah
: 1161050098
: dr. Gilbert W S Simajuntak Sp.M (K)

: Mr. S
: 42 years old
: JL Swadaya I Jakarta Selatan
: Employee
: Male
: Married
: Islam

HISTORY
Anamnesis done at August th, 2015
Main complaint
Additional complaint

: Both eyes are red since 2 days ago

: Burning sensation, itching, and lots of eye discharge in
the morning

History of present illness :

Patient came to Poli Mata RSU UKI complaining both eyes are red since 2 days
ago. Patient also complaint about itching, burning sensation, and lots of eye
discharge in the morning in both eyes. So the patient felt difficult to open his eyes in
the morning after wake up. At first, he felt something came into his eyes, something
like dust in the air,when he ride his motorcycle wihtout helmet. He suffered red eyes
after this, and he has not treat his eyes yet. Fever, cough, and sore throat are denied.
He got dazzled, flare, and decreased in visual acuity denied. He didnt wear
eyeglasses before. He claimed theres no one suffering eye disesase like him in his
environment at this time.

History of past illness:

Patient has never experienced a complaint like this before. History of allergy,
eye trauma, diabetes mellitus and hypertension denied.
History of family illness

: Denied.

History of social life

:
Patient never wore contact lens before and not either consumed both alcohol and
cigarretes.

III.

GENERALIST STATUS
General state : Mild
Awareness
: Compos mentis
A Disease/ clinical symptom that has to do with complaints: Denied

IV.

OPHTHALMOLOGY STATUS
A. General examination
General examination
The circumstances
surrounding the eye
General state of the eye
The position of the
eyeball
Eyeball movement
Eyeball pressure
Visual field

OD

OS

Normal

Normal

Mild

Mild

Symmetric

Symmetric

Normal
19 mmHg
Wide

Normal
19 mmHg
Wide

B. Systemic examination
Systemic examination
Acies visus
Correction
Supercilia
Cilia

Palpebral superior

Palpebral inferior
Conjunctiva tarsalis
superior et inferior
Conjunctiva bulbi
Sclera
Cornea
a. Clarity
b. Infiltrate
c. Ulcers

OD
6/6
Grow evenly
Grow evenly, good

OS
6/6
Grow evenly
Grow evenly, good

position
Normal
Edema (-)
Ptosis (-)
Hyperemic (-)
Normal
Edema (-)
Ptosis (-)
Hyperemic (-)
Hyperemic
Follicle (+)
Hyperemic
Normal

position
Normal
Edema (-)
Ptosis (-)
Hyperemic (-)
Normal
Edema (-)
Ptosis (-)
Hyperemic (-)
Hyperemic
Follicle (+)

Clear
(-)
(-)

Clear
(-)
(-)

Hyperemic
Normal

d. Sikatriks
e. Neovascularization
f. Fluorescein test
g. Sensibility
h. Others
Anterior chamber
a. Depth
b. Hyphema
c. Hypopyon
Iris

Pupil
Lens
a. Clarity
b. Turbidity

V.

(-)
(-)
Not evaluated
Normal
-

(-)
(-)
Not evaluated
Normal
-

Deep
(-)
(-)
Radier
Brown
Sinekia (-)
Round, diameter 3 mm, R.

Deep
(-)
(-)
Radier
Brown
Sinekia (-)
Round, diameter 3 mm, R.

direct light (+), R. indirect

direct light (+), R. indirect

light (+), isokor

light (+), isokor

(-)
(-)

(-)
(-)

RESUME
Patient came to Poli Mata RSU UKI complaining both eyes are red since 2 days
ago. Patient also complaint about itching, burning sensation, and lots of eye
discharge in the morning in both eyes. So the patient felt difficult to open his eyes in
the morning after wake up. At first, he felt something came into his eyes, something
like dust in the air,when he ride his motorcycle wihtout helmet. He suffered red eyes
after this, and he has not treat his eyes yet. Fever, cough, and sore throat are denied.
He got dazzled, flare, and decreased in visual acuity denied. He didnt wear
eyeglasses before. He claimed theres no one suffering eye disesase like him in his
environment at this time. Patient has never experienced a complaint like this before.
History of allergy, eye trauma, diabetes mellitus and hypertension denied. Patient
never wore contact lens before and not either consumed both alcohol and cigarretes.
GENERALIST STATUS
General state : Mild
Awareness
: Compos mentis
Systemic examination
Acies visus
Correction
Supercilia
Cilia

OD
6/6
Grow evenly
Grow evenly, good

OS
6/6
Grow evenly
Grow evenly, good

position

position

Palpebral superior

Palpebral inferior
Conjunctiva tarsalis
superior et inferior
Conjunctiva bulbi
Sclera
Cornea
a. Clarity
b. Infiltrate
c. Ulcers
d. Sikatriks
e. Neovascularization
f. Fluorescein test
g. Sensibility
h. Others
Anterior chamber
a. Depth
b. Hyphema
c. Hypopyon
Iris

Pupil
Lens
a. Clarity
b. Turbidity
Systemic examination
Acies visus
Correction
After correction
Near correction
Super cilia
Cilia

Normal
Edema (-)
Ptosis (-)
Hyperemic (-)
Normal
Edema (-)
Ptosis (-)
Hyperemic (-)
Hyperemic
Follicle (+)
Hyperemic
Normal

Normal
Edema (-)
Ptosis (-)
Hyperemic (-)
Normal
Edema (-)
Ptosis (-)
Hyperemic (-)
Hyperemic
Follicle (+)

Clear
(-)
(-)
(-)
(-)
Not evaluated
Normal
-

Clear
(-)
(-)
(-)
(-)
Not evaluated
Normal
-

Deep
(-)
(-)
Radier
Brown
Sinekia (-)
Round, diameter 3 mm, R.

Deep
(-)
(-)
Radier
Brown
Sinekia (-)
Round, diameter 3 mm, R.

direct light (+), R. indirect

direct light (+), R. indirect

light (+), isokor

light (+), isokor

(-)
(-)
OD
0,8 pin hole 1,0
-

(-)
(-)
OS
0,8 pin hole 1,0
-

Hyperemic
Normal

Grow evenly
Grow evenly, good

Grow evenly
Grow evenly, good

Palpebral superior

position
Normal, edema (-), ptosis

position
Normal, edema (-), ptosis

Palpebral inferior

(-), hyperemic (-)

Normal, edema (-), ptosis

(-), hyperemic (-)

Normal, edema (-), ptosis

(-), hyperemic (-)

(-), hyperemic (-)

Conjunctiva

tarsalis

superior et inferior
Conjunctiva bulbi
Sclera
Cornea
a. Clarity
b. Infiltrate
c. Ulcers
d. Sikatriks
e. Neovascularization
f. Fluorescein test
g. Sensibility
h. Others
Anterior chamber
a. Depth
b. Hyphema
c. Hypopyon
Iris
Pupil

Hyperemic, follicle (+)

Hyperemic, follicle (+)

Hyperemic
Normal

Hyperemic
Normal

Clear
(-)
(-)
(-)
(-)
Not evaluated
Not evaluated
Arcus senile

Clear
(-)
(-)
(-)
(-)
Not evaluated
Not evaluated
Arcus senile

Deep
(-)
(-)
Radier, brown, sinekia (-)
Round, diameter 3 mm, R.

Deep
(-)
(-)
Radier, brown, sinekia (-)
Round, diameter 3 mm, R.

direct light (+), R. indirect

direct light (+), R. indirect

light (+), isokor

light (+), isokor

(-)
(-)

(-)
(-)

Lens
a. Clarity
b. Turbidity

VI.

DIFFERENTIAL DIAGNOSIS
a. Conjungtivitis et causa allergic ODS
b. Conjungtivitis et causa viral ODS
c. Conjungtivitis et causa chlamydia ODS

VII.

DIAGNOSIS
Conjungtivitis et causa bacterial infection ODS

VIII.

WORKUP
a. Complete blood count
b. Culture eye secret
c. Anel test

IX.

MANAGEMENT
Medication:
Anti-inflammation
Antibiotic/Antiviral

: Cendo Xytrol (Dexamethasone) 1% 2gtt/ 8 hour

: Cendo Fenicol (Chloramphenicol) 0,5% 2gtt/ 6 hour

for 14 days/ Trifluridine (viropic) 1gtt/ 2 hour for 7 days then continued 1 gtt/
4 hour for 7 days

Anti-histamine

Livostin

(Levocabastine

hydrochloride)

0,05% / Emedastine (Emadine) 0,05% 1 gtt/ 6 hour

Patient education:
o Patient should avoid touching their eyes, shaking hands, sharing towel
o Proper isolation of the eye (using glasses) to prevent epidemics
o Patient who wear contact lenses should discontinue lens wear until
symptoms have resolved
o Take care of hand and eyes hygiene
o Patient should return in 1-3 weeks or sooner if the condition worsen

X.

PROGNOSIS
Ad. Vitam
Ad. Fungsionum
Ad. Sanationum

XI.

COMPLICATION
a. Keratoconjunctivitis
b. Keratitis
c. Uveitis

OD
Dubia ad Bonam
Dubia ad Bonam
Dubia ad Bonam

OS
Dubia ad Bonam
Dubia ad Bonam
Dubia ad Bonam