PATIENT

S
CLINIC

GENERAL

AGE:

60

FEMALE 23RD PX

APRIL 2012

WAS REFERRED TO NDH FROM THE ARTHRITIS CLINIC AT UNIVERSITAS HOSPITAL

 CC:

INTERMITTENT BLURRY VX @ PAINFUL EYES

PAIN SITAUTED AROUND EYES LONG TIME

VERY SHE

USES DROPS ( PX COULD NOT SPECIFY

OR KNEW WHAT ITS FOR)

 LEE: OH

NEVER BEFORE

& FOH: NOTHING SIGNIFICANT HBP (SHE USES MX, CANT

REMEMBER NAME)

MH:

RHEUMATOID ARTHRITIS
(USES MX, CANT REMEMBER NAME),

ASTHMA (HAS A PUMP)

2 DEGREE SJOGRENS SYNDROME

(DROPS TDS, CANT REMEMBER NAME)

FMH:

GRANDMOTHER HAD ASTHMA MOTHER HAVE HBP

OTHER:

EXTERNAL OBSERVATIONS EPIPHORIA

 PAINFUL

EYES ARTHRITIS

RHEUMATOID HBP SJOGRENS

SYNDROME

HBP 172/ 95 10:09AM

VA
(SC)

(77)

SEATED, LEFT ARM AT

DISTANCE
6/6

NEAR OD
6/60

6/6
6/6

OS
OU

6/60
6/30

 CT

D:

ORTHO

N:
PHI:
NPC

ORTHO
ORTHO
(DISTANCE)

9/11 OBJ.

(WOOLF BALL )

CVF

RESTRICTED TEMPORAL QUADRANTS (OU)

 PUPILS

PERRL -RAPD

OU: 5MM/4MM

EOM

PURSUITS:

SAFE; VERY SORE

SACCADES: +3
PD

65/62

*At this stage patient confessed that she did not know what the medication is for and that she has not been using the drops for a while*

 OBJECTIVE

REFRACTION
(6/7.5) (6/7.5) REFRACTION (6/6) (6/6)

OD: -0.25DS OS: -0.50DS

SUBJECTIVE

OD:+0.25DS OS: +0.25DS

 HIC

OD: -0.25DS OS: -0.25DS

FCC

(6/4.5) (6/4.5)

OU: +2.50DS (6/6)

ADD

REFINEMENT: +2.50DS

RANGE: 23 39 CM

 VON

GRAEFE

DLP: ORTHO DVP: ORTHO NLP: 1 EXOPHORIA NVP: ORTHO

IOP (REICHART AT 555) AT 10:34AM

OD: 11/11/12 OS: 11/11/11

AVG. 11.3 MMHG AVG. 11.0 MMHG

 SLIT

LAMP

CLINICAL ERROR, SHOULD HAVE DONE THIS, PX WAS IN A HURRY.

DIAGNOSIS
OU: PRESBYOPIA OU: SM OD: SEVERE PTERYGIUM

MANAGEMENT
INFORMATION

DOCUMENT

 MX

PURPOSE AND IMPORTANCE OF REGULAR USE EDUCATION ON HBP MX

PATIENT

PATIENT

WAS ALSO EDUCATED ON THE IMPORTANCE OF THE DROPS TO BUY +2.50DS READERS @ PHARMACY

PX

 CHRONIC

CONDITION INFLAMMATORY DISORDER

SYSTEMIC ATTACK

FLEXIBLE SYNOVIAL JOINTS

PATHOLOGY:

DESTRUCTION OF ARTICULAR CARTILAGE

 1%

OF THE WORLDS POPULATION HAS RA = 3:1 40-50

F:M

COMMONLY AGES

DRY EYE
UVEITIS

EPISCLERITIS
SCLERITIS
GLAUCOMA
CATARACTS