MORNING

REPORT
Opthalmology department
RS Bhayangkara
KALAZION
Patient identity
• Name : Miss A

• Age : 9 Years Old

• No. RM : 024821

• Address : Jl. Dg tata

• Nation : Indonesia

• Religion : Islam

• Date : 14 Oktober 2019

• Anamnesis : Autoanamnesis
 History Taking
Main Complaint : Swollen in right eye
Guided History :
A Patient cames to Bhayangkara Hospital complaining of swelling in the right eye with
a complaint were felt since eye since ± 1 month ago. Initially the lump was small, but slowly the
lump felt increasingly enlarged. Currently a lump as big as a mung bean seed. The lump causes
a lump in the patient's right eye, but the lump is not painful, itchy, or sore. The lump does not
discharge pus. There were no red eyes before. There are no white spots such as dandruff or dry
sores along the edges of the eyelids. Complaints of blurry vision, double vision is denied.
Visual Acuity Examination
OD Visual OS

5/5 Uncorrected visual acuity 5/5

- Correction -

- Best corrected visual acuity -

- Near visual acuity -

- Correction -

- Best corrected near visual acuity -

 Anterior Segment Examination
OD OS

Oedema (+) Hyperemia (-), Oedema (-) Hyperemia (-),

Palpebral
Crust (-) Crust (-)
Cilia Squama (-), Madarosis (-) Squama (-), Madarosis (-)
Lacrimal Apparatus
Lacrimation (-) Lacrimation (-)

Conjunctiva Hyperemis (-) Hyperemis (-)

Cornea Clear Clear

Anterior Chamber
Normal Depth Normal Depth

Iris Brown, Crypt (+) Brown, Crypt (+)

Pupil Round, Central Round, Central
Direct/Indirect Light
Reflex +/+ +/+

RAPD - -
Lens clear clear
 Palpation

OD OS

Tn Tn
Ocular pressure

- -
Tumor/ Mass

Not palpable Not palpable

Pre Auricular Gland
 Diagnose

OD KALAZION

Differential Diagnose

Hordeolum

Blefaritis

Karsinoma
Treatment
• Ciprofloxacin tab 2 x 500 mg
• Natrium Diclofenac tab 2 x 500 mg
• Methylprednisolon tab 3 x 4 mg
• Becom C tab 3 dd 1
• Polidemisian ED eye zalf 3 dd 1 qs OD
 Prognosis

Quo ad Quo ad Quo ad Quo ad

Vitam Functionam Cosmetican Sanationam

Bonam Bonam Bonam Dubia

Thank You