OPHTALMOLOGY RECORD

Chalazion Palpebra Inferior Oculi Dextra

Examiner :

Dr. Gilbert WS Simanjuntak Sp.M (K)

Observer :

Fitriana Prista

1161050010

DEPARTMENT OF EYE DISEASE

PERIODE OF DECEMBER 12th 2016 21st JANUARY 2017
MEDICAL FACULTY
CHRISTIAN UNIVERSITY OF INDONESIA
JAKARTA

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 OPHTHALMOLOGY RECORD

Name of examine : Fitriana Prista

NIM : 1161050010

Date of examination : January , 20th 2017

Tutor : dr. Gilbert W.S Simanjuntak, Sp.M (K)

I. IDENTITY PATIENT

Name : Mrs. A

Age : 22 years old

Address : Bantulan margokato no. 11 Seyagan, Jogjakarta.

Occupation : Student

Religion : Christian

Status : Single

II. INTERVIEW (October , 16th 2015)

Main complaint : Lump on the lower right eyelid

Additional complaint : Uncomfortable feel with swelling

Course of Disease
Patient come to the hospital RS Mata DR Yap Jogjakarta with lump under the right eye since three
weeks ago. This complaint is slightly change increasingly bigger by the time. At first, she thought
that it was only an usual lump around the eyelid caused by an insect sting, but day by day became
bigger accompanied with an uncomfortable swell. The palpation found theres no tenderness and
the consistency is soft, no visual impairment, watery itching and an excess dirt eyes are denied.
No history of eye trauma, no history of using contact lens. No additional complaint. No complaint
about her left eye.

History of Disease

- The patient had never had any complaint like this before.
- History of diabetes, hypertention, and allergic are denied.

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Family Medical History

None of her family or relatives has the same complaints.

III. GENERAL STATUS

General condition : Mild illnes

Awareness : Compos Mentis

IV. OPTHALMOLOGIST STATUS

A. General investigator

Right Eye Left Eye

Around Eye Appearance Quiet Quiet

General Condition of the Eye Ball Normal Normal

Position of The Eye Ball Symmetric Symmetric

Ocular Mobility Normal Normal

Eye Movement Normal to all directions Normal to all directions

B. Systematic investigator

Right eye Left eye

Visual Acuity 6/6 6/6

Pin Hole - -

Correction No correction No correction

Super cilia Normal growth Normal growth

Cilia Normal, madarosis (-), Normal, madarosis (-),

trichiasis(-) trichiasis(-)

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 Palpebra Superior Edema (-), tenderness (-),
ectropion (-). Entropion (-),
ulcus (-), crust (-)
Palpebra Inferior Edema (+) with soft
consistency, tenderness (-),
ectropion (-). Entropion (-),
ulcus (-), crust (-)
Tarsal Conjunctiva Hyperemic (-), papilar (-),
follicle (-), bleeding (-)
Konjungtiva Forniks Hyperemic (-), papilar (-),
Superior/ inferior follicle (-), bleeding (-)
Bulbar Conjunctiva Ciliary injection (-),
pinguecula (- ), pterigium (-)
Cornea Round, clear, infiltrate (-),
ulcus (-), cicatrix (-),
neovascularization (-)
Anterior chamber Deep
Hipopion (-)
Hyphema (-)
Iris Radier,brown
Sclera Icteric (-)
Pupil isochore, round, in the
middle, 3mm, direct light
reflex (+), indirect light
reflex (+)
Lens Clear
Tonometri Havent been done
V. RESUME
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Edema (-), tenderness (-),
ectropion (-). Entropion (-),
ulcus (-), crust (-)
Edema (-), tenderness (-),
ectropion (-). Entropion (-),
ulcus (-), crust (-)
Hyperemic (-), papilar (-),
follicle (-), bleeding (-)
Hyperemic (-), papilar (-),
follicle (-), bleeding (-)
Ciliary injection(-),
pinguecula(-), pterigium (-)
round , clear, infiltrate (-),
ulcus (-), cicatrix (-),
neovascularization (-)
Deep
Hipopion (-)
Hypema (-)
Radier,brown
Icteric (-)
I
isochore, round, in the middle,
3mm, direct light reflex (+),
indirect light reflex (+)
Clear
Havent been done
 Patient Mrs. A, 22 years old come to the hospital RS Mata DR Yap Jogjakarta with lump
under the right eye since three weeks ago. This complaint is slightly change increasingly bigger
by the time. At first, she thought that it was only an usual lump around the eyelid caused by an
insect sting, but day by day became bigger accompanied with an uncomfortable swell. The
palpation found theres no tenderness and the consistency is soft, no visual impairment, watery
itching and an excess dirt eyes are denied. No history of eye trauma, no history of using contact
lens. No additional complaint. No complaint about her left eye.

General Examination ophthalmologist

Normal

A. Systematic Examination opthalmologist

Right eye Left eye

Visual Acuity 6/6 6/6

Pin Hole - -

Correction No correction No correction

Palpebra Inferior Edema (+) with soft Edema (-), tenderness (-),
consistency, tenderness (-), ectropion (-). Entropion (-),
ectropion (-). Entropion (-), ulcus (-), crust (-)
ulcus (-), crust (-)

Cornea Round, cloudy, infiltrate (+) round , clear, infiltrate (-),

VI. CLINICAL DIAGNOSE

Chalazion Palpebra Inferior Oculi Dextra

VII. Differential diagnose

Hordeolum

VIII. MEDICAL TREATMENT

1. Non medication
- Patient should receive instruction regarding the importance of adequate lid
hygiene and general health measure (rest, time management, proper diet)
- Wash hand before and after touching the eyes
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 - Warm compresses to help melt the viscous lipids
- Use of water diluted baby shampoo, which does not sting if it gets into the eye,
to remove the secretions collecting on the margins of the lids.
- Do not put any make up on around eye area which has bump
- Do not put any contact lense for the prevention of secondary inflamation on to
cornea
2. Medication
- Lencomycyn 3x50 mg
- Cataflam 2x25 mg
- Gentamicyn eye ointment OD 3 times a day

IX. PLANNED EXAMINATION

Slitlamp

VIII. PROGNOSIS

RIGHT EYE LEFT EYE

Dubia ad bonam Dubia ad bonam
Ad Vitam
Dubia ad bonam Dubia ad bonam
Ad Sanationum
Dubia ad bonam Dubia ad bonam
Ad functionum

IX. COMPLICATION

Hordeolum Interna