The examinee : Vidi Posdo Ahapta Simarmata, Sked

NIM : 99 148
Date of examination : February 9th, 2006
The examiner : dr. Gilbert Simanjuntak, SpM

I. PATIENT IDENTITY
Name : Mrs. NK
Age : 28 Years old
Address : Kampung kasihan Gamping, Yogyakarta
Occupation : Farmer

II. ANAMNESIS (January 27th, 2006)

Main complains : Red eye, smarting, and blurred vision
on the left eye.
Additional complains : Cant stand on the light and watering.

History of Disease
Patient came to Dr. Yap Eyes Hospital Yogyakarta with main
complains red eye, smarting, and blurred vision on her left
eye since 15 days ago. She also complained that she couldnt
stand on the light while outdoor and her left eye was
watering too. She said that 15 days before she came to the
hospital, she had an accident at her farm. While she plows
the field, suddenly the cows tail threw her left eye. Patient
never tried any medication to heal her illness. Patient only
wash her eyes with warm water twice a day, and it didnt
make her eye feel better. She never had the same symptoms
like this before and there are no other peoples in her family
which have same symptoms like her.

Previous Diseases
Unremarkable

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III. GENERAL STATUS
General condition : Appearance of mild illness
Complains-related symptoms : Unremarkable

IV. OPHTALMIC STATUS

A. General Examination
Right Eye Left Eye
Around Eye Appearance Quiet Quiet
General Condition of Normal Mild illness
The Eye Ball
Position of The Eye Ball Symmetric Symmetric
Eye ball movement Normal Normal

B. Systematic Examination
Right Eye Left Eye
Visual acuity 6/6 6/18
Correction - -
Super cilia Quiet Quiet
Cilia Quiet Quiet
Palpebra Quiet Quiet
superior/Inferior
Tarsal conjunctiva Quiet Hyperemic
Fornices conjunctiva Quiet Hyperemic
Bulbar conjunctiva Quiet Ciliarys
injection
Cornea Clear Nummular
infiltrate
Anterior chamber Normal in depth Normal in depth
Iris Radier Radier
Pupil Round, central, Round, central,
light reflex light reflex
Lens Clear Clear

V. RESUME
Patient Mrs. NK, age 28 Years old, came to Dr. Yap Eyes
Hospital Yogyakarta with main complains red eye, smarting,
and blurred vision on her left eye since 15 days ago. She also
complained that she couldnt stand on the light while
outdoor and her left eye was watering too. She said that 15

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 days before she came to the hospital, she had an accident at
her farm. While she plows the field, suddenly the cows tail
threw her left eye.

From General Examination on The Left Eye Founded :

General condition of eye ball : Appearance of mild illness

From Systematic Examination on The Left Eye Founded :

Visual acuity : 6/18
Tarsal conjunctiva : Hyperemic
Fornices conjunctiva : Hyperemic
Bulbar conjunctiva : Ciliarys injection
Cornea : Nummular infiltrate

VI. CLINICAL DIAGNOSE

Right Eye Left Eye
Normal Nummular ceratitis

VII. DIFFERENTIAL DIAGNOSE

Right Eye Left Eye
- Disiform ceratitis

VIII. MEDICAL TREATMENT

Topical : - Cendo citrol, 1drop, 6 times/day
- Cendo tropin, 1 drop, 3 times/day
Systemic : Vitamin A, 6000 iu, once daily

IX. PROGNOSES
Right Eye Left Eye
Ad vitam Bonam Bonam
Ad sanationum Bonam Dubia ad bonam
Ad functionum Bonam Dubia ad bonam

X. COMPLICATION
Right Eye Left Eye
- Cornea ulcer

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