Konjungtivitis

OPHTALMOLOGY RECORD

CONJUNCTIVITIS

Examiner :

dr. Gilbert W S Simajuntak Sp.M (K)

Observer :

Filda Sharifah

1161050098

DEPARTMENT OF OPHTALMOLOGY

PERIOD OF JULY 28th – AUGUST 29th 2015

FACULTY OF MEDICINE

CHRISTIAN UNIVERSITY OF INDONESIA

JAKARTA

STATUS OPHTALMOLOGY

Observer : Filda SharifahStudent number : 1161050098Examiner : dr. Gilbert W S Simajuntak Sp.M (K)

I. PATIENT IDENTITY

Name : Mr. S

Age : 42 years old

Address : JL Swadaya I Jakarta Selatan

Occupation : Employee

Gender : Male

Status : Married

Religion : Islam

II. HISTORY

Anamnesis done at August th, 2015

Main complaint : Both eyes are red since 2 days ago

Additional complaint : Burning sensation, itching, and lots of eye discharge in

the morning

History of present illness :

Patient came to Poli Mata RSU UKI complaining both eyes are red since 2 days

ago. Patient also complaint about itching, burning sensation, and lots of eye

discharge in the morning in both eyes. So the patient felt difficult to open his eyes in

the morning after wake up. At first, he felt something came into his eyes, something

like dust in the air,when he ride his motorcycle wihtout helmet. He suffered red eyes

after this, and he has not treat his eyes yet. Fever, cough, and sore throat are denied.

He got dazzled, flare, and decreased in visual acuity denied. He didn’t wear

eyeglasses before. He claimed there’s no one suffering eye disesase like him in his

environment at this time.

History of past illness:

Patient has never experienced a complaint like this before. History of allergy,

eye trauma, diabetes mellitus and hypertension denied.

History of family illness : Denied.

History of social life :

Patient never wore contact lens before and not either consumed both alcohol and

cigarretes.

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 OD OS

The circumstances

surrounding the eyeNormal Normal

General state of the eye Mild Mild

The position of the

eyeballSymmetric Symmetric

Eyeball movement Normal Normal

Eyeball pressure 19 mmHg 19 mmHg

Visual field Wide Wide

B. Systemic examination

Systemic examination OD OS

Acies visus 6/6 6/6

Correction - -

Supercilia Grow evenly Grow evenly

CiliaGrow evenly, good

position

Grow evenly, good

position

Palpebral superior

Normal

Edema (-)

Ptosis (-)

Hyperemic (-)

Normal

Edema (-)

Ptosis (-)

Hyperemic (-)

Palpebral inferior

Normal

Edema (-)

Ptosis (-)

Hyperemic (-)

Normal

Edema (-)

Ptosis (-)

Hyperemic (-)

Conjunctiva tarsalis

superior et inferior

Hyperemic

Follicle (+)

Hyperemic

Follicle (+)

Conjunctiva bulbi Hyperemic Hyperemic

Sclera Normal Normal

Cornea

a. Clarity

b. Infiltrate

c. Ulcers

d. Sikatriks

e. Neovascularization

f. Fluorescein test

g. Sensibility

h. Others

Clear

(-)

(-)

(-)

(-)

Not evaluated

Normal

-

Clear

(-)

(-)

(-)

(-)

Not evaluated

Normal

-

Anterior chamber

a. Depth

b. Hyphema

c. Hypopyon

Deep

(-)

(-)

Deep

(-)

(-)

Iris

Radier

Brown

Sinekia (-)

Radier

Brown

Sinekia (-)

Pupil Round, diameter 3 mm, R.

direct light (+), R. indirect

Round, diameter 3 mm, R.


light (+), isokor light (+), isokor

Lens

a. Clarity

b. Turbidity

(-)

(-)

(-)

(-)

V. RESUME

Patient came to Poli Mata RSU UKI complaining both eyes are red since 2 days

ago. Patient also complaint about itching, burning sensation, and lots of eye

discharge in the morning in both eyes. So the patient felt difficult to open his eyes in

the morning after wake up. At first, he felt something came into his eyes, something

like dust in the air,when he ride his motorcycle wihtout helmet. He suffered red eyes

after this, and he has not treat his eyes yet. Fever, cough, and sore throat are denied.

He got dazzled, flare, and decreased in visual acuity denied. He didn’t wear

eyeglasses before. He claimed there’s no one suffering eye disesase like him in his

environment at this time. Patient has never experienced a complaint like this before.

History of allergy, eye trauma, diabetes mellitus and hypertension denied. Patient

never wore contact lens before and not either consumed both alcohol and cigarretes.

GENERALIST STATUS

General state : Mild

Awareness : Compos mentis


Acies visus 6/6 6/6

Correction - -

Supercilia Grow evenly Grow evenly

CiliaGrow evenly, good

position

Grow evenly, good

position

Palpebral superior

Normal

Edema (-)

Ptosis (-)

Hyperemic (-)

Normal

Edema (-)

Ptosis (-)

Hyperemic (-)

Palpebral inferior Normal

Edema (-)

Normal

Edema (-)

Ptosis (-)

Hyperemic (-)

Ptosis (-)

Hyperemic (-)



Hyperemic

Follicle (+)

Hyperemic

Follicle (+)



Cornea

a. Clarity

b. Infiltrate

c. Ulcers

d. Sikatriks


f. Fluorescein test

g. Sensibility

h. Others

Clear

(-)

(-)

(-)

(-)

Not evaluated

Normal

-

Clear

(-)

(-)

(-)

(-)

Not evaluated

Normal

-

Anterior chamber

a. Depth

b. Hyphema

c. Hypopyon

Deep

(-)

(-)

Deep

(-)

(-)

Iris

Radier

Brown

Sinekia (-)

Radier

Brown

Sinekia (-)

Pupil



light (+), isokor



light (+), isokor

Lens

a. Clarity

b. Turbidity

(-)

(-)

(-)

(-)


Acies visus 0,8 pin hole 1,0 0,8 pin hole 1,0

Correction - -

After correction - -

Near correction -

Super cilia Grow evenly Grow evenly

Cilia Grow evenly, good

position

Grow evenly, good

position

Palpebral superior Normal, edema (-), ptosis

(-), hyperemic (-)

Normal, edema (-), ptosis

(-), hyperemic (-)

Palpebral inferior Normal, edema (-), ptosis

(-), hyperemic (-)

Normal, edema (-), ptosis

(-), hyperemic (-)



Hyperemic, follicle (+) Hyperemic, follicle (+)



Cornea

a. Clarity

b. Infiltrate

c. Ulcers

d. Sikatriks


f. Fluorescein test

g. Sensibility

h. Others

Clear

(-)

(-)

(-)

(-)

Not evaluated

Not evaluated

Arcus senile

Clear

(-)

(-)

(-)

(-)

Not evaluated

Not evaluated

Arcus senile

Anterior chamber

a. Depth

b. Hyphema

c. Hypopyon

Deep

(-)

(-)

Deep

(-)

(-)

Iris Radier, brown, sinekia (-) Radier, brown, sinekia (-)

Pupil Round, diameter 3 mm, R.


light (+), isokor



light (+), isokor

Lens

a. Clarity

b. Turbidity

(-)

(-)

(-)

(-)

VI. DIFFERENTIAL DIAGNOSIS

a. Conjungtivitis et causa allergic ODS

b. Conjungtivitis et causa viral ODS

c. Conjungtivitis et causa chlamydia ODS

VII. DIAGNOSIS

Conjungtivitis et causa bacterial infection ODS

VIII. WORKUP

a. Complete blood count

b. Culture eye secret

c. Anel test

IX. MANAGEMENT

Medication:

Anti-inflammation : Cendo Xytrol (Dexamethasone) 1% 2gtt/ 8 hour

Antibiotic/Antiviral : Cendo Fenicol (Chloramphenicol) 0,5% 2gtt/ 6 hour

for 14 days/ Trifluridine (viropic) 1gtt/ 2 hour for 7 days then continued 1 gtt/

4 hour for 7 days

Anti-histamine : Livostin (Levocabastine hydrochloride)

0,05% / Emedastine (Emadine) 0,05% 1 gtt/ 6 hour

Patient education:

o Patient should avoid touching their eyes, shaking hands, sharing towel

o Proper isolation of the eye (using glasses) to prevent epidemics

o Patient who wear contact lenses should discontinue lens wear until

symptoms have resolved

o Take care of hand and eyes hygiene

o Patient should return in 1-3 weeks or sooner if the condition worsen

X. PROGNOSIS

OD OS

Ad. Vitam Dubia ad Bonam Dubia ad Bonam

Ad. Fungsionum Dubia ad Bonam Dubia ad Bonam

Ad. Sanationum Dubia ad Bonam Dubia ad Bonam

XI. COMPLICATION

a. Keratoconjunctivitis

b. Keratitis

c. Uveitis

Konjungtivitis

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