Beruflich Dokumente
Kultur Dokumente
Examiner:
Dr. Gilbert WS SimajuntakSp.M (K)
Observer:
Victor Umbu Awang
1061050155
STATUS OPHTALMOLOGY
The Examine
Student number
Examiner
I.
PATIENT IDENTITY
Name
Age
Address
Occupation
Gender
Religion
Status
II.
: Mrs. M
: 61 years old
: Kampung Melayu, East jakarta
: Housewife
: Female
: Moeslim
: Married
HISTORY
Anamnesis done at October 26th, 2016
Main complaint
: Blurred Vision
Additional complaint : tearing eyes
History of present illness
Patients came to the General Hospital UKI with complaint blurred vision like a foggy
since 3 months. Patients feel her vision blurred continuously throughout the day both look
near and far. Complaints perceived gradually becoming more and more blurred. Blurred
vision starts from reading difficulties, so that the eyes felt tired after reading. Patients do
complain of glare if they see the light, red eye (-), pain (-), throbbing pain in head (-), watery
eyes (-), itching (-), out dirt tear (-), seeing double (-) , saw a rainbow around the light source
(-).
sight of both eyes are blurred to interfere with the activity. Patients do not treat both
eyes. Complaints felt increasingly become heavy until the patient feels bothered to move.
Therefore, the patient went to the UKI Hospital.
III.
GENERALIST STATUS
General state : mild
Awareness
: composmentis
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
14 mmhg
Wide
Normal
14 mmhg
Wide
B. Systemic examination
Systemic examination
Aciesvisus
Correction
After correction
Near correction
Super cilia
Cilia
OD
6/30
6/12
-
OS
5/12
6/9
-
Grow evenly
Grow evenly, good
Grow evenly
Grow evenly, good
Palpebral superior
position
edema (-), pseudoptosis (-)
position
edema (-), pseudoptosis (-)
Palpebral inferior
, hyperemic (-)
Normal, edema (-), ptosis
, hyperemic (-)
Normal, edema (-), ptosis
Conjunctivatarsalis
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
Clear, sclera hyperemic
Hyperemic
Clear, sclera hyperemic (-),
Clear
(-)
(-)
(-)
(-)
Not evaluated
Not evaluated
-
Clear
(-)
(-)
(-)
(-)
Not evaluated
Not evaluated
-
Deep
(-)
(-)
Radier, brown, sinekia (-)
Round, diameter 3 mm, R.
Deep
(-)
(-)
Radier, brown, sinekia (-)
Round, diameter 3 mm, R.
Lens
V.
RESUME
Patients come to the General Hospital UKI with complaint blurred vision like a foggy
since 3 months. Patients feel her vision blurred continuously throughout the day both look
near and far. Complaints perceived gradually becoming more and more blurred. Blurred
vision starts from reading difficulties, so that the eyes felt tired after reading. Patients do
complain of glare if they see the light, red eye (-), pain (-), throbbing pain in head (-), watery
eyes (-), itching (-), out dirt tear (-), seeing double (-) , saw a rainbow around the light source
(-).
sight of both eyes are blurred to interfere with the activity. Patients do not treat both
eyes. Complaints felt increasingly become heavy until the patient feels bothered to move.
Therefore, the patient went to the UKI Hospital.
Patients using the glasses, the patient had never had a complaint like this before.
Hypertension history denied, denied a history of diabetes mellitus, cholesterol denied. A
history of trauma to the eye and a history of longterm drug use is denied.
GENERALIST STATUS
General state : Mild
Awareness
: Composmentis
Systemic examination
Aciesvisus
Correction
After correction
Near correction
Super cilia
Cilia
OD
6/30
6/12
Grow evenly
Grow evenly, good
Grow evenly
Grow evenly, good
Palpebral superior
position
edema (-), pseudoptosis
position
edema (-), pseudoptosis
Palpebral inferior
hyperemic (-)
Hyperemic, follicle (-)
hyperemic (-)
Hyperemic, follicle (-)
Hyperemic
Clear, sclera hyperemic
Hyperemic
Clear, sclera hyperemic (-),
Clear
(-)
(-)
(-)
(-)
Not evaluated
Not evaluated
-
Clear
(-)
(-)
(-)
(-)
Not evaluated
Not evaluated
-
Deep
(-)
(-)
Radier, brown, sinekia (-)
Round, diameter 3 mm, R.
Deep
(-)
(-)
Radier, brown, sinekia (-)
Round, diameter 3 mm, R.
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
VI.
OS
5/12
6/9
-
WORKING DIAGNOSIS
VII.
DIFFRENTIAL DIAGNOSIS
ODS Mature Senile Cataract
ODS Hipermature Senile Cataract
VIII.
WORKUP
Pre-operation inspection
a. Eye examination: keratometri, tonometry, ultrasound biometry.
b. Systemic examination: vital signs
IX. MANAGEMENT
Consul to the ophthalmologist for ODS plan extra capsular cataract extraction and
installation of Intra Ocular Lens (IOL).
Patient education:
1. Explain to patients that the views of both eyes were blurred due to cataracts in both
eyes lens.
2. Explain to patients that cataract can not be treated with medication, but can be
cured with surgery and administration of planting the lens of the eye.
3. Describe the complications that will occur if no surgery, the possibility of the lens
will melt, the content of the lens will come out, cause inflammatory reactions and
increased eye pressure.
4. Describe the possible complications during surgery and postoperatively.
X.
COMPLICATION
Glaucoma
XI.
PROGNOSIS
Ad. Vitam
Ad. Fungsionum
Ad. Sanationum
OD
Dubia ad Bonam
Dubia ad Bonam
Dubia ad Bonam
OS
Dubia ad Bonam
Dubia ad Bonam
Dubia ad Bonam