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Case Report: Taufik Rizal, S.Ked Pembimbing
Case Report: Taufik Rizal, S.Ked Pembimbing
Idendity
Anamnesis
Main Complaint : Itching of the right
eyelids.
Disease Of History Now:
Os came to the eye clinic RSPBAH with itching
complaints of the right eyelids since less than
6 months ago. In addition os also admitted
that sometimes the right eyelids side feel
pain, also yellowish color. Bumps on the
eyelids (-), watery eyes (-), can not stand the
light (-) eyes are not red (-), blurred vision (-),
EXAMINATION
PHYSICAL EXAMINATION
76x / min
RR: 20x / min
Head: mesosefal
Thorax: The cast: no abnormality
Lung: no abnormality
Abdomen : No abnormality
Extremity : No abnormality
Status
Ophthalmology
OCULUS DEXTER
OCULUS SINISTER
20/20
VISUS
20/20
uncorrected
CORRECTION
uncorrected
not checked
SENSUS COLORIS
not checked
PARASE/PARALYSE
SUPERCILIA
No abnormalities
Hiperemis (+)
Tenderness (+)
PALPEBRA SUPERIOR
purulent
Edema (-), spasms (-)
PALPEBRA INFERIOR
CONJUNGTIVA
spasms (-)
PALPEBRALIS
CONJUNGTIVA
spasms (-)
Injection (-), secretions (-)
FORNICES
CONJUNGTIVA BULBI
Clear
SCLERA
Clear
Clear
CORNEA
Clear
CAMERA OCULI
hipopion (-)
Kripte (+), sinekia (-)
ANTERIOR
IRIS
(-)
Kripte (+), sinekia (-)
PUPIL
Clear
LENSA
Clear
(+)
FUNDUS REFLEKS
(+)
not checked
TENSIO OCULI
not checked
not checked
SISTEM CANALIS
not checked
LACRIMALIS
RESUME
OCULUS SINISTER
DEXTER
Hiperemis (+)
Tenderness+)
Margo
PALPEBRA
palpebra
SUPERIOR
superior :
yellow
Photo
V.
DIAGNOSIS
Blefritis Anterior OD
VII. TREATMENT
Prognosis
OD
OS
Quo ad Vitam
Dubia Ad bonam Ad bonam
Quo ad sanam
Dubia Ad bonam Ad bonam
Quo ad Vitam
Ad bonam
Quo
ad
ad bonam
Cosmeticam
X.
EDUCATION
Thank You