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OPTHALMIC RECORD
Tutor:
Dr. Gilbert WS Simanjuntak S!M "#$
E%aminer :
Daniel D&ia'(i Wibo&o
)*+,)-))*
DEPARTME/T O0 OPHTHALMOLOGIC
0AC1LT2 O0 MEDICI/ECHRISTIA/ 1/I3ERSIT2 O0 I/DO/ESIA
4A#ARTA 5),6
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OPHTHALMIC RECORD
Name of Examiner : Daniel Dwiadhi Wibowo
NIM : 0961050049
Date of examination : 17thOtober !01"
#$tor : Dr %ilbert W& &iman'$nta() &*M +,-
PATIE/T IDE/TIT2
Name : M./ &
e : 20 3ear. old
ddre.. : ,aran Malan) o'a(arta
O$*ation : o$.ewife
A/AM/ESIS ",5t(O7tober 5),6$
Main 7om!lain
ed e3e on left e3e .ine " wee(. ao/
A''itional 7om!lain
Water3 e3e) felt li(e .omethin *ro**in her e3e
Hi8tor9 o 'i8ea8e
20 3ear. old female ame to Dr/ a* o.*ital with red e3e on left e3e .ine "
wee(. ao/ &he felt it re*eatedl3 and .he alwa3. .$ffered it on her left e3e/
&he .$ffered a little *ain e8er3 time .he blin(ed her e3e/ &he al.o told that her
e3e beame water3) felt li(e .omethin *ro**in her e3e) and it al.o di.r$*ted
her 8i.ion/ atient denied the o$rrene of lare of the liht) .eretion on her
e3e) or e8en an ith/ atient .aid that .he had one ome to dotor and .he
.aid that .he had a minor .$rer3 ta(e to o8erome hi. e3e *roblem/ #here are
no other *eo*le. in her famil3 whih ha8e .ame .3m*tom. li(e her/
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Pre;iou8 'i8ea8e
i.tor3 of *h3.ial tra$ma denied) hi.tor3 of $.in lonterm dr$ denied)
allerie. denied) h3*erten.ion and diabete. mellit$. hi.tor3 denied
I. GE/ERAL STAT1S
%eneral ondition : Well
&3m*tom or illne.. related to the om*laint : ;nremar(able
II. OPHTHALMIC STAT1S
A. General E%amination
Ri
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#ar.al on'$nti8a
.$bAinf 3*eremi +-) Bleddin +-) 3*eremi +@-) Bleddin +-
Cornixe. on'$nti8a
.$*Ainf 3*eremi +- 3*eremi +@-
B$lbar on'$nti8a 3*eremi +-) *in$e$la+-) *terii$m +-) .eretion
+-
h3*eremi+@-)*in$e$la +-) *terii$m
+-) .eretion +@-
?ornea ?learInfiltrate +- ;l$. +-
r$. &enilli. +-
?learInfiltrate +- ;l$. +-
r$. &enilli. +-
nterior hamber Normal
Dee*
Bleddin +-
Normal
Dee*
Bleddin +-Iri. adiant
?olor : Brown
adiant
?olor : Brown
$*il o$nd) i.ohori
"mm
iht eflex. : +@-
o$nd) i.ohori
"mm
iht eflex. : +@-
en. ?lear ?lear
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III. RES1ME
20 3ear. old female ame to ho.*ital with red e3e on left e3e .ine " wee(.
ao/ &he al.o .aid that her e3e beame water3) felt li(e .omethin *ro**in
her e3e) and di.r$*ted her 8i.ion/ hoto*hobia +-) ith +-) .eret +-
O*hthalmi Examination
Rii.$al a$it3 0)7 0)5
Maro al*ebra
.$*Ainf E(tro*ion +-) Entro*ion +-);l$. +-) ?r$.ta +-
E(tro*ion +-) Entro*ion+@-) ;l$. +-) ?r$.ta +-
#ar.al on'$nti8a
.$bAinf 3*eremi +@-) Bleddin +-) 3*eremi +@-) Bleddin +-
Cornixe. on'$nti8a
.$*Ainf 3*eremi +@- 3*eremi +@-
B$lbar on'$nti8a in$e$la +-) *terii$m +-)
.eretion +-
in$e$la +-) *terii$m
+-) .eretion +-
I3. CLI/ICAL DIAG/OSE
3. Dierential Dia
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Eletrol3.i.
E*ilation
PROG/OSES
Ri
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