OPTHALMIC RECORD

Examiner : Bartolomeus Rusman

NIM : 94-072
Date of Exam : Dec, 15th 2006
Tutor : Prof. DR. Dr. JHA Mandang, Sp.M(K)

I. Patient Identity
Name : Mr. T
Sex : Male
Age : 29 years old
Occupation : Unemployed
Address : Semarang

II. Interview (Dec, 15th 2006)

Main Complain : Red eye on the left eye since a week ago.
Additional complain : Watery, felt something like entrance of sand,
photosensitive, pain and itch

Chronology of Disease
The patient come to dr. YAP Hospital with the main complaint red eye his
left eye since a week ago. He also told that he felt watery, photosensitive,
felt something like entrance of sand in his left eye accompanied with pain
and itch. Initially patient complain his left eye always have watery and
itch, progressively day felt pain, bloated eye, very having watery and felt
to sprag like entrance of sand. Patient tell, when its eye nighttime felt ill
progressively and have water. Patient feel degradation of eyesight.
He didnt visit the doctor to check up his illness and he doesnt take some
cure his illness. He never felt the same symptoms before.
 Previous Disease
Unremarkable

III. General Status

General Condition : Well
Complain Related Symptom : Unremarkable

IV. Ophthalmic Status

1. General Examination
Right Eye Left Eye
Around Eye Appearance Quiet Quiet
General Condition of the Eye Quiet Mild illness appearances
Eye Ball Position Symmetric Symmetric
Eye Ball Movement Normal Normal
2. Systemic Examination
Right Eye Left Eye
Visual Acuity 6/6 5/6
Correction - Cant be corrected
Supercilia Quiet Quiet
Cilia Quiet Quiet
Sup/inf margo palpebra Quiet Oedema
Tarsalis conjunctiva Quiet Hyperemic
Inferior tarsalis conjunctiva Quiet Follicular
Bulbar conjunctiva Quiet Conjunctiva injection
Cornea :
Clearness Clear Clear
Infiltrate (-) Sub epithelial
Ulcer (-) (-)
Anterior Chamber Normal Normal
Iris Radier Radier
Pupil Round, Round,
 Light Reflex (+) Light Reflex (+)
Lens Clear Clear

V. Resume
The patient, male, 29 years old came to YAP Hospital with the main
complaint red eye his left since a week ago. He also told that he felt
watery, photosensitive, felt something like entrance of sand in his left eye
accompanied with paint and itch. Patient tells, when its eye nighttime felt
ill progressively and have watery. Patients feel degradation of eyesight. He
didnt visit the doctor to check up his illness and he doesnt take some cure
his illness. He never felt the same symptoms before

From the ophthalmology examination, founded :

Right Eye Left Eye
Visual acuity 6/6 5/6
Sup/inf margo palpebra Quiet Oedema
Tarsalis conjunctiva Quiet Hyperemic
Inferior tarsalis conjungtiva Quiet Follicular
Bulbar conjucntiva Quiet Conjunctiva Injection
Cornea :
Clearness Clear Clear
Infiltrate (-) Sub epithelial

VI. Clinical Diagnose

Epidemic Kerato conjunctivitis OS.

VII. Differential Diagnose

Pharyngo conjunctivitis fever
Acute hemorrhagic Conjunctivitis

VIII. Medical Treatment

 Cendo Xitrol,1 drops, 6 times daily

IX. Suggested Examination

Virus Isolation

X. Complication
Scarring
Symblepharon OS.

XI. Prognose
Right Eye Left Eye
ad vitam Bonam Bonam
ad sanationum Bonam Dubia at bonam
ad functionum Bonam Bonam
 OPHTAMOLOGY RECORD

Tutor:
Prof. DR. Dr. JHA Mandang, Sp.M(K)

Presented by:
Bartolomeus Rusman
( 94 72 )

DEPARTEMENT OF OPHTAMOLOGY
MEDICINE FACULTY
CHRISTIAN UNIVERSITY OF INDONESIA
JAKARTA 2006