STATUS OPHTALMOLOGY

Name of examiner
Student number
Date of examination
Examiner

I.

PATIENT IDENTITY
Name
Gender
Age
Address
Occupation
Status
Religion

II.

: Nidyawati Zebadiah
: 1161050095
: August 19th, 2015
: dr. Gilbert W S Simajuntak Sp.M (K)

: Ny.TDR
: Woman
: 42 years old
: Anggur street No. 36 A, East Jakarta
: Teacher
: Married
: Christian

HISTORY
Anamnesis done at August 19th, 2015
Main complaint
: Red eyes 1 week.
Additional complaint : Pain when seeing the light, few watery eye discharge.
History of present illness
:
Patient came to Poli Mata RSU UKI complaining redness in both eyes for 1
week. This complaint occurs continuously and progressively. Patient also complaint
about pain when seeing the light so she prefers to avoid seeing the light and few
watery eye discharge in both eyes. Patient has been used cendo xytrol to improve the
eye redness but the complaint has not been resolved.
These complaint is not accompanied by decreasing in visual acuity, double
vision, and itchy. Headache and respiratory infection are denied by the patient. The
patient doesnt have a habit to rub her eyes. Patient doesnt use contact lenses but the
patient uses glasses to correct near sight vision with size +1,25 OD and +1,00 OS.
History of past illness:
Patient has never experienced a complaint like this before. History of allergy,
eye trauma, hypertension, diabetes mellitus, and consumption of drugs regularly are
denied.
History of family illness:
Denied.
History of social life:

STATUS UJIAN ILMU PENYAKIT MATA RS UKI 2015

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Patient doesnt use contact lenses but the patient uses glasses to correct near
sight vision with size +1,25 OD and +1,00 OS. patient doesnt have a habit to rub her
eyes.

III.

GENERALIST STATUS
General state : mild
Awareness
: compos mentis
A Disease/ clinical symptom that has to do with complaints: denied

IV.

OPHTHALMOLOGY STATUS
A. General examination
General examination
The circumstances
surrounding the eye
General state of the eye
The position of the
eyeball
Eyeball movement
Eyeball pressure
Visual field

OD

OS

Normal

Normal

Mild

Mild

Symmetric

Symmetric

Normal
Wide

Normal
Wide

B. Systemic examination
Systemic examination
Acies visus
Correction
After correction
Near correction
Super cilia
Cilia

OD
0,8 pinhole 1,0
-

OS
0,8 pinhole 1,0
-

Palpebral superior

Grow evenly
Grow evenly,
good position
Normal, edema (-), ptosis

Grow evenly
Grow evenly,
good position
Normal, edema (-), ptosis

Palpebral inferior

(-), hyperemic (-)

Normal, edema (-), ptosis

(-), hyperemic (-)

Normal, edema (-), ptosis

(-), hyperemic (-)

Hyperemic, follicle (+)

(-), hyperemic (-)

Hyperemic, follicle (+)

Hyperemic
Normal

Hyperemic
Normal

Slightly cloudy
(-)
(-)
(-)
(-)

Slightly cloudy
(-)
(-)
(-)
(-)

Conjunctiva tarsalis
superior et inferior
Conjunctiva bulbi
Sclera
Cornea
a. Clarity
b. Infiltrate
c. Ulcers
d. Sikatriks
e. Neovascularization

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f. Fluorescein test
g. Sensibility
h. Others
Anterior chamber
a. Depth
b. Hyphema
c. Hypopyon
Iris
Pupil

Not evaluated
Not evaluated
Arcus senile (-)

Not evaluated
Not evaluated
Arcus senile (-)

Deep
(-)
(-)
Radier, brown, sinekia (-)
Round, diameter 3 mm, R.

Deep
(-)
(-)
Radier, brown, sinekia (-)
Round, diameter 3 mm, R.

direct light (+), R. indirect

direct light (+), R. indirect

light (+), isokor

light (+), isokor

(-)
(-)

(-)
(-)

Lens
a. Clarity
b. Turbidity

V.

RESUME
A woman, 42 years old, came to Poli Mata RSU UKI complaining redness in
both eyes for 1 week. This complaint occurs continuously and progressively. Patient
also complaint about pain when seeing the light so she prefers to avoid seeing the
light and few watery eye discharge in both eyes. Patient has been used cendo xytrol to
improve the eye redness but the complaint has not been resolved. Patient uses glasses
to correct near sight vision with size +1,25 OD and +1,00 OS.
GENERALIST STATUS
General state : Mild
Awareness
: Compos mentis
Systemic examination
Acies visus
Correction
After correction
Near correction
Super cilia
Cilia

OD
0,8 pinhole 1,0
-

OS
0,8 pinhole 1,0
-

Grow evenly
Grow evenly, good

Grow evenly
Grow evenly, good

Palpebral superior

position
Normal, edema (-), ptosis

position
Normal, edema (-), ptosis

Palpebral inferior

(-), hyperemic (-)

Normal, edema (-), ptosis

(-), hyperemic (-)

Normal, edema (-), ptosis

(-), hyperemic (-)

Hyperemic, follicle (+)

(-), hyperemic (-)

Hyperemic, follicle (+)

Conjunctiva tarsalis

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superior et inferior
Conjunctiva bulbi
Sclera
Cornea
a. Clarity
b. Infiltrate
c. Ulcers
d. Sikatriks
e. Neovascularization
f. Fluorescein test
g. Sensibility
h. Others
Anterior chamber
a. Depth
b. Hyphema
c. Hypopyon
Iris
Pupil

Hyperemic
Normal

Hyperemic
Normal

Slightly cloudy
(-)
(-)
(-)
(-)
Not evaluated
Not evaluated
Arcus senile (-)

Slighty cloudy
(-)
(-)
(-)
(-)
Not evaluated
Not evaluated
Arcus senile (-)

Deep
(-)
(-)
Radier, brown, sinekia (-)
Round, diameter 3 mm, R.

Deep
(-)
(-)
Radier, brown, sinekia (-)
Round, diameter 3 mm, R.

direct light (+), R. indirect

direct light (+), R. indirect

light (+), isokor

light (+), isokor

Clear
(-)

Clear
(-)

Lens
a. Clarity
b. Turbidity

VI.

DIAGNOSIS
ODS

VII.

DIFFERENTIAL DIAGNOSIS
ODS

VIII.

: Bacterial keratoconjunctivitis, keratitis.

WORKUP

IX.

: Keratoconjunctivitis et causa viral infection

Slit lamp
Fluorescein test
Conjunctival cytology with CGiemsa and Gram stain
Culture eye secrete

MANAGEMENT
Medication:
Cold compresses

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Antibiotic/Antiviral

: Cendo LFX (Levofloxacin) 6x1gtt/day for 14

days/Trifluridine (Viroptic) 1% 6x1gtt/day.

Patient education:

X.

COMPLICATION

XI.

Take care of hand and eyes hygiene

Patient should avoid touching and rubbing her eyes
Patient should avoid sharing towels, tissues, or handkerchiefs
Patient should throw tissue has been used immediately.
Proper isolation of the eye (using glasses) to prevent epidemics
Patient should return if the condition worsen

Keratitis
Uveitis

PROGNOSIS
Ad. Vitam
Ad. Fungsionum
Ad. Sanationum

OD
Dubia ad Bonam
Dubia ad Bonam
Dubia ad Bonam

STATUS UJIAN ILMU PENYAKIT MATA RS UKI 2015

OS
Dubia ad Bonam
Dubia ad Bonam
Dubia ad Bonam

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