Beruflich Dokumente
Kultur Dokumente
PTERIGYUM
Examiner:
Dr. Gilbert W S Simajuntak Sp.M (K)
Observer:
Meylani Bith S.Ked
0961050125
OPHTHALMOLOGY RECORD
Name of Examiner
: Meylani Bith
NIM
: 0961050125
I.
II.
PATIENT IDENTITY
Name
: Mrs. A
Sex
: Female
Age
: 49 years old
Education
Occupation
: Housewife
Religion
: Christian
Address
Status
: Married
Main complaint
: Redness in her right eye since one week ago, patient also feels
Additional complaint
History of Disease
Patient came to UKI Hospital with main complaints redness in her right eye and feels
theres a white spot in the center of her right eye since one week ago. Patient actually has
already felt this white since two years ago, First she felt this white spot in the corner of her
right eye, but know she feels the white spot spreading to the center of her right eye. Patient
also complained of itchy eyes and more frequent watering at the eyes. Patient admitted, her
sight is still good and there is no vision problems at all. Patient doesnt feel any pain in her
eyes . Discharge of the eyes denied. Patients not using glasses or contact lenses.
Patient has been treated to the doctor's four months ago and was given eye drops
"Cendo Lyteers" used with a dose of 4 x 2 drops a day, but now shes not taking the eye
drops anymore.
Personal Habit
The patient denied the using of contact lenses, smoke, and consume alcohol.
III.
IV.
GENERAL STATUS
General condition
Consciousness
: Compos mentis
OPHTHALMIC STATUS
1. General Examination
General Examination
Right Eye
Left Eye
Quiet
Quiet
Unwell
Normal
Symmetric
Symmetric
Normal
Normal
Wide
Wide
eye
Eyeball position
Eyeball movement
Visual field
2. Systematic Examination
Right Eye
Left Eye
Visual acuity
Before correction
Correction
After correction
Supercilia
Cilia
Palpebrae
superior/inferior
Margo palpebrae
superior/inferior
6/6
Normal,
Normal,
madarosis (-)
madarosis (-).
Normal,
Normal,
madarosis (-),
madarosis (-),
trichiasis (-).
trichiasis (-).
Edema (-),
Edema (-),
tumor (-),
tumor (-),
hordeolum (-),
hordeolum (-),
chalazion (-),
chalazion (-),
ptosis (-),
ptosis (-),
tenderness (-).
tenderness (-).
Tumor (-),
Tumor (-),
ptosis (-),
ptosis (-),
ectropion (-),
ectropion (-),
entropion (-).
entropion (-).
Bulbar conjunctiva
Smooth surface,
Smooth surface,
bleeding (-),
bleeding (-),
hyperemic (-),
hyperemic (-),
cicatrical (-),
cicatrical (-),
secretion (-),
secretion (-),
papilar (-),
papilar (-),
follicle (-).
follicle (-).
Bleeding (-),
Bleeding (-),
cicatrical (-),
cicatrical (-),
secretion (-),
secretion (-),
pinguecula (-),
pinguecula (-),
pterygium (-).
Hyperemic (-)
Hyperemic (-)
Clear
Clear
(-).
Cornea
Sclera
Anterior chamber
Colour: white,
Colour: white,
bleeding (-),
bleeding (-),
cicatrical (-).
cicatrical (-).
Deep, clear,
hypopion (-),
hyphema (-).
Iris
Pupil
Lens
V.
Radier,
Radier,
Colour: brown,
Colour: brown,
atrophy (-),
atrophy (-),
sinekia (-).
Round, isochor,
sinekia (-).
Round, isochor, 3
3 mm,
mm,
(+).
reflex (+).
Clear,
Clear,
RESUME
Mrs. A ,49 years old, came to UKI Hospital with main complaints redness in her right
eye and feels theres a white spot in the center of her right eye since one week ago. Patient
actually has already felt this white since two years ago, First she felt this white spot in the
corner of her right eye, but know she feels the white spot spreading to the center of her right
eye. Patient also complained of itchy eyes and more frequent watering at the eyes. Patient
admitted, her sight is still good and there is no vision problems at all. Patient doesnt feel
any pain in her eyes . Discharge of the eyes denied. Patients not using glasses or contact
lenses.
Patient has been treated to the doctor's four months ago and was given eye drops
"Cendo Lyteers" used with a dose of 4 x 2 drops a day, but now shes not taking the eye
drops anymore.
GENERAL STATUS
General condition
Consciousness
: Compos mentis
Right Eye
Left Eye
Visual acuity
Before correction
Correction
After correction
Palpebrae
6/6
Normal
Normal
Normal
Normal
Normal
Normal
Quiet
superior/inferior
Margo palpebrae
superior/inferior
Tarsal conjunctiva sup/inf
Bulbar conjunctiva
Cornea
Sclera
Anterior chamber
Iris
Pupil
Lens
Normal
Normal
Clear
Clear
Colour: white
Colour: white
Deep & clear
Deep & clear
Radier, colour: brown Radier, colour: brown
Round, isochor,
Round, isochor,
3 mm,
3 mm,
(+).
Clear,
(+).
Clear,
VI.
VII.
VIII.
CLINICAL DIAGNOSE
Pterygium Grade III OD
DIFFERENTIAL DIAGNOSE
Pseudopterygium
Pinguecula
MEDICAL TREATMENT
Post operation:
o Avoid the exposure of the smoke and dust in the eyes.
o Use a hat or a cap to avoid the direct exposure of ultraviolet rays into the eye.
o Use sunglasses to protect the eyes from ultraviolet rays.
o Control to the doctor after surgery.
IX.
RECOMMENDED EXAMINATION
X.
Corneal topography
PROGNOSIS
Ad Vitam
XI.
Right Eye
Bonam
Left Eye
Bonam
Ad Sanationum
Dubia ad Malam
Bonam
Ad Functionum
Dubia ad Malam
Bonam
COMPLICATION
Infection
Astigmatism
Corneal scar