OPHTALMIC RECORD

EXAMINER : KEITHY DOROTHY SIRAIT - 0861050101 TUTOR : Prof. DR. Dr. JHA Mandang, SpM(K) Medical Faculty Christian University of Indonesia April 2013, Jakarta

PATIENT IDENTITY
Name Sex Age Occupation Address Status : Mr. M : Male : 66 years old : Retired : Purwosari Kwadungan, Ngawi : Married

INTERVIEW
Primary Complaint left eye : Blurred vision in

Additional Complaint : Red eye, difficut to see the left side, headache

Chronology of Disease
A man patient aged 66 years old came to Dr. Yap Eye Hospital with primary complaint blurred vision in his left eye since one week ago. The patient also told that he is difficult to see the left side because the vision get decrease or blurred. He also complaint headache and red eye in his left eye. The patient has taken an eye drop to reduce those symptoms but it didnt getting better and then he decided to go to the hospital to receive better treatment.

Previous Disease and History of Family Disease

The patient denied have minus or plus glasses before. He had never come to the doctor to check up his eyes. Patient denied that he got the other illness like hypertension, diabetic, etc. The patient never had this kind of illness before and no one in his family suffered the same complaint.

GENERAL STATUS
General condition appearance : Mild illness

Complaint related symptoms : Unremarkable

OPHTALMIC STATUS
General Examination Systemic Examination

General Examination
Examination Periocular Appearance General Condition of the Eye Ball Position of The Eye Ball Ocular Mobility Symetric Normal RIGHT EYE Quiet Well LEFT EYE Quiet Mild illness appearance Symetric Normal

Examination Visual acuity Correction Supercillia Cilia Sup/InfMargo Palpebra

RIGHT EYE 6/6 Quiet, Black Quiet, Black Normal 1/60

LEFT EYE

Can not be corrected Quiet, Black Quiet, Black Normal

Sup/Inf Tarsalis Conjunctiva

Sup/Inf Fornices Conjunctiva Bulbar Conjunctiva Cornea

Normal
Normal Normal Clear

Hyperemic
Hyperemic Conjunctiva Injecton, Ciliary Injection Unclear

Camera Oculi Anterior

Iris Pupil

Deep
Radier, Brown Miosis, diametre 3mm, light reflex (+)

Superficial
Radier, Brown Midriasis, diametre 5mm, light reflex (-)

Lens Schiotzs Tonometer

Clear 13 mmHg

Clear 48 mmHg

RESUME
A man patient aged 66 years old came to Dr. Yap Eye Hospital with primary complaint blurred vision in his left eye since one week ago. The patient also told that he is difficult to see the left side because the vision get decrease or blurred. He also complaint headache and red eye in his left eye. The patient has taken an eye drop to reduce those symptoms but it didnt getting better and then he decided to go to the hospital to receive better treatment. The patient denied have minus or plus glasses before. He had never come to the doctor to check up his eyes. Patient denied that he got the other illness like hypertension, diabetic, etc. The patient never had this kind of illness before and no one in his family suffered the same complaint.

Examination Visual acuity Correction Supercillia Cilia Sup/Inf Margo Palpebra

RIGHT EYE 6/6 Quiet, Black Quiet, Black Normal 1/60 Uncorrected Quiet, Black Quiet, Black Normal

LEFT EYE

Sup/Inf Tarsalis Conjunctiva Sup/Inf Fornices Conjunctiva

Bulbar Conjunctiva Cornea Camera Oculi Anterior Pupil

Normal Normal
Normal Clear Deep Miosis, diametre 3mm, light reflex (+)

Hyperemic Hyperemic
Conjunctiva Injecton, Ciliary Injection Unclear Superficial Midriasis, diametre 5mm, light reflex (-)

Lens Schiotzs Tonometer

Clear 13 mmHg

Clear 48 mmHg

DIAGNOSE
CLINICAL DIAGNOSE Primary Acute Glaucoma OS DIFFERENTIAL DIAGNOSE Uveitis Anterior Keratitis

TREATMENT AND EXAMINATION

MEDICAL TREATMENT Medikamentosa : Beta blockers : Timolol 0,5% 1-2 drops/day Carbon anhidrase inhibitors : Asetozolamide 250mg 2 tab once and then 4 x1 tab Osmotik : Manitol 60 drops/mnt Surgery : Iridectomy SUGGESTED EXAMINATION Ofthalmoscopy Gonioscopy

PROGNOSES AND COMPLICATION

PROGNOSES
RIGHT EYE LEFT EYE

Ad Vitam
Ad Sanationum Ad Functionum

Bonam
Bonam Bonam

Bonam
Dubia ad malam Dubia ad malam

COMPLICATION Absolute Glaucoma OS