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    RS Bhayangkara (Hordeolum)

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    marindada
    This document contains a morning report from an ophthalmology department regarding a patient named Mr. U, age 31, who presented with swelling in his left eye and pain upon pressing. He reported a history of the same complaint 10 months ago treated with eye ointment. On examination, edema and hyperemia were present in the left eye. The diagnosis was left eye hordeolum externus. The treatment plan included warm compresses, oral antibiotics, eye drops, and educating the patient on hygiene to prevent relapse. The prognosis was generally good except for some uncertainty regarding complete resolution.

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    RS Bhayangkara (Hordeolum)

    Uploaded by

    marindada
    10 views12 pages
    This document contains a morning report from an ophthalmology department regarding a patient named Mr. U, age 31, who presented with swelling in his left eye and pain upon pressing. He reported a history of the same complaint 10 months ago treated with eye ointment. On examination, edema and hyperemia were present in the left eye. The diagnosis was left eye hordeolum externus. The treatment plan included warm compresses, oral antibiotics, eye drops, and educating the patient on hygiene to prevent relapse. The prognosis was generally good except for some uncertainty regarding complete resolution.

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    This document contains a morning report from an ophthalmology department regarding a patient named Mr. U, age 31, who presented with swelling in his left eye and pain upon pressing. He reported a history of the same complaint 10 months ago treated with eye ointment. On examination, edema and hyperemia were present in the left eye. The diagnosis was left eye hordeolum externus. The treatment plan included warm compresses, oral antibiotics, eye drops, and educating the patient on hygiene to prevent relapse. The prognosis was generally good except for some uncertainty regarding complete resolution.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
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    Download as pptx, pdf, or txt
    10 views12 pages

    RS Bhayangkara (Hordeolum)

    Uploaded by

    marindada
    This document contains a morning report from an ophthalmology department regarding a patient named Mr. U, age 31, who presented with swelling in his left eye and pain upon pressing. He reported a history of the same complaint 10 months ago treated with eye ointment. On examination, edema and hyperemia were present in the left eye. The diagnosis was left eye hordeolum externus. The treatment plan included warm compresses, oral antibiotics, eye drops, and educating the patient on hygiene to prevent relapse. The prognosis was generally good except for some uncertainty regarding complete resolution.

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    of 12

    MORNING

    REPORT
    Opthalmology department
    RS Bhayangkara
    Hordeolum
    Patient identity
    • Name : Mr. U

    • Age : 31Years Old

    • No. RM : 278150

    • Address : Jl. Dg tata 1 blok 4

    • Nation : Indonesia

    • Religion : Islam

    • Date : 09 September 2019

    • Anamnesis : Autoanamnesis
    History Taking
    Main Complaint : swollen in left eyes
    Guided History :
    A Patient cames to Bhayangkara Hospital complaining of swelling in the
    left eye and sensation of pain when pressed. The Complaints were felt since 3 da
    ys ago. The complaints also accompanied by watery in eye. The patient doesn’t
    complain of any itchy and eye discharge. There is no history of foreign objects, al
    lergy and trauma. There was history of the same complaint in the 10 month’s ag
    o and was treated with eye oinment . There’s no family history of the same comp
    laint.
    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 Ocular pressure Tn

    - Tumor/ Mass -

    Not palpable Pre Auricular Gland Not palpable


    Diagnose
    OS Hordeolum Eksternum

    Differential Diagnose
    Kalazion
    Treatment Insert the title of your subtitle Here

    • Compress with warm water 3-4 times a day for 10-15 minutes
    • Cefadroxil 2x500mg
    • Bralifex plus eye drops (Tobramycin, Dexamethasone) 6 dd 1
    gtt ODS
    Education :
    Patient instructed to :
    Don’t rub his eyes
    Give some advice to the patient about Improve personal hygine
    of his body especially his eyes, because the hordeolum disease
    can be relaps.
    Prognosis

    Quo ad Quo ad Quo ad Quo ad


    Vitam Functionam Cosmetican Sanationam

    Bonam Bonam Bonam Dubia


    Thank you

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