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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

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