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OPTHALMIC RECORD - Prof. Mandang
OPTHALMIC RECORD - Prof. Mandang
Tutor:
Examinee :
Ledya Lusi Crista Simanjuntak
07- 021
DEPARTMENT OF OPHTHALMOLOGIC
MEDICAL FACULTY
CHRISTIAN UNIVERSITY OF INDONESIA
JAKARTA 2011
OPHTHALMIC RECORD
Name of Examiner
NIM
07-021
Date of examination
Tutor
Name
Mrs. S
Age
68 years old
Sex
Female
Address
Occupation
housewife
Religion
Moslem
Nation
Indonesian
Tribe
Java
Status
Married
I. PATIENT IDENTITY
II.
INTERVIEW
Main complaint
Pain in the left eye
Additional complain
Reddish and blurred vision on the left eye, headace, nauseous,
vomitting, see a rainbow colored halo around the light
Chronology of disease
Mrs. S age 68 years old came to dr. Yap eyes hospital with
sudden pain in the left eye since 1 day ago as a main complain. She
GENERAL STATUS
General condition
OPHTHALMIC STATUS
a. General Examination
OD
OS
Quiet
Quiet
Quiet
Mild illness
Symmetric
Symmetric
Normal
Normal
OD
OS
Eyeball position
Eyeball movement
b. Systematic Examination
Visual acuity
6/6
1/300
uncorected
Cilia
Quiet
Quiet
Quiet
Quiet
Quiet
Quiet
Quiet
Quiet
Bulbar conjunctiva
Quiet
injection
Cornea
Clear
Edematous
Normal in depth
shallow
Radier, Brown
Radier, Brown
Pupil
Round,
Light reflex: positive
Round
Light reflex: negative
midriasis
Lens
Clear
Clear
Palpable improvement
spasm
Correction
Anterior chamber
Iris
IOP ( palpation )
V.
RESUME
Mrs. S age 68 years old came to dr. Yap eyes hospital with sudden
pain in the left eye since 1 day ago as a main complain. She also feel a
severe headache, nauseous, vomitting, reddish and blurred vision on the left
eye and see a rainbow colored halo around the light
Patient take panadol, but there is no change in her condition. The
headache and pain in the eye is stay still.
General Condition
Visual acuity
1/300
bulbar conjunctiva
Cornea
Edematous
Anterior Chamber
VI.
injection
Shallow
CLINICAL DIAGNOSE
Primary Acute Closure Angle Glaucoma OS
VII.
DIFFERENTIAL DIAGNOSE
Acute iritis
VIII.
MEDICAL TREATMENT
Education
Medicamentosa
1.
2.
3.
Surgical Treatment :
1. Laser
2. Peripheral iridectomy
3. Trabeculectomy
IX.
SUGGESTIVE EXAMINATION
Tonometry
Perimetry
X.
PROGNOSIS
Ad Vitam
Dubia ad Bonam
Ad Sanationum
Dubia ad malam
Ad Functionum
Dubia ad malam
COMPLICATIONS
Absolute Glaucoma OS