OPTHALMIC RECORD

Examiner NIM Date of Exam Tutor

: : : :

Bartolomeus Rusman 94-072 Dec, 15th 2006 Prof. DR. Dr. JHA Mandang, Sp.M(K)

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

II. Interview (Dec, 15th 2006) Main Complain Additional complain : : Red eye on the left eye since a week ago. 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
: : Well Unremarkable

General Condition Complain Related Symptom IV. Ophthalmic Status 1. General Examination Around Eye Appearance

Right Eye Quiet Quiet Symmetric Normal Right Eye 6/6 Quiet Quiet Quiet Quiet Quiet Quiet Clear (-) (-) Normal Radier Round,

Left Eye Quiet Mild illness appearances Symmetric Normal Left Eye 5/6 Cant be corrected Quiet Quiet Oedema Hyperemic Follicular Conjunctiva injection Clear Sub epithelial (-) Normal Radier Round,

General Condition of the Eye Eye Ball Position Eye Ball Movement 2. Systemic Examination Visual Acuity Correction Supercilia Cilia Sup/inf margo palpebra Tarsalis conjunctiva Inferior tarsalis conjunctiva Bulbar conjunctiva Cornea : Clearness Infiltrate Ulcer Anterior Chamber Iris Pupil

Light Reflex (+) Lens V. Resume Clear

Light Reflex (+) Clear

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 : Visual acuity Sup/inf margo palpebra Tarsalis conjunctiva Inferior tarsalis conjungtiva Bulbar conjucntiva Cornea : Clearness Infiltrate VI. Clinical Diagnose Epidemic Kerato conjunctivitis OS. VII. Differential Diagnose Clear (-) Clear Sub epithelial Right Eye 6/6 Quiet Quiet Quiet Quiet Left Eye 5/6 Oedema Hyperemic Follicular Conjunctiva Injection

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 ad vitam ad sanationum ad functionum Right Eye Bonam Bonam Bonam Left Eye Bonam Dubia at 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