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    Ophtalmology Record Corneal Ulcer: Anggi Lewis R P Aruan 1161050113

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    Lewishoppus
    The document summarizes an ophthalmology record for a patient presenting with a corneal ulcer in the left eye. The patient reported decreased vision, redness, sensitivity to light, watery discharge, discomfort and a white spot in the left eye. Examination findings included visual acuity of 1/300 in the left eye with a central corneal ulcer. The clinical diagnosis was a corneal ulcer in the left eye suspected to be of bacterial origin. Treatment prescribed included topical broad spectrum antibiotics and further planned examinations.

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    Ophtalmology Record Corneal Ulcer: Anggi Lewis R P Aruan 1161050113

    Uploaded by

    Lewishoppus
    33 views7 pages
    The document summarizes an ophthalmology record for a patient presenting with a corneal ulcer in the left eye. The patient reported decreased vision, redness, sensitivity to light, watery discharge, discomfort and a white spot in the left eye. Examination findings included visual acuity of 1/300 in the left eye with a central corneal ulcer. The clinical diagnosis was a corneal ulcer in the left eye suspected to be of bacterial origin. Treatment prescribed included topical broad spectrum antibiotics and further planned examinations.

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    Ophtalmology Record

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    The document summarizes an ophthalmology record for a patient presenting with a corneal ulcer in the left eye. The patient reported decreased vision, redness, sensitivity to light, watery discharge, discomfort and a white spot in the left eye. Examination findings included visual acuity of 1/300 in the left eye with a central corneal ulcer. The clinical diagnosis was a corneal ulcer in the left eye suspected to be of bacterial origin. Treatment prescribed included topical broad spectrum antibiotics and further planned examinations.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    33 views7 pages

    Ophtalmology Record Corneal Ulcer: Anggi Lewis R P Aruan 1161050113

    Uploaded by

    Lewishoppus
    The document summarizes an ophthalmology record for a patient presenting with a corneal ulcer in the left eye. The patient reported decreased vision, redness, sensitivity to light, watery discharge, discomfort and a white spot in the left eye. Examination findings included visual acuity of 1/300 in the left eye with a central corneal ulcer. The clinical diagnosis was a corneal ulcer in the left eye suspected to be of bacterial origin. Treatment prescribed included topical broad spectrum antibiotics and further planned examinations.

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    of 7

    OPHTALMOLOGY RECORD

    CORNEAL ULCER

    Anggi Lewis R P Aruan

    1161050113

    Examiner:

    Dr. dr. Gilbert W. S. Simanjuntak, Sp. M (K)

    DEPARTMENT OF OPHTALMOLOGY

    PERIOD OF 12 JUNE 22 JULY 2017

    FACULTY OF MEDICINE

    CHRISTIAN UNIVERSITY OF INDONESIA

    JAKARTA
    OPHTALMOLOGY RECORD

    Name : Anggi Lewis R P Aruan


    NIM : 1161050113
    Date of Examination : Thursday, 20 July 2017
    Examiner : Dr. dr. Gilbert W. S. Simanjuntak, Sp.M (K)

    I. PATIENT IDENTITY
    Name : Mr. D
    Age : 45 years old
    Address : Cawang III, Gg. Sawo, RT/RW 01 / 011, East Jakarta
    Job : Merchant
    Religion : Moslem

    II. INTERVIEW ( 8 July 2017)


    Main complaint : Decreasing of vision in the left eye
    Additional complaint : redness, sensitive to light, and watery,discomfor, in the
    left eye, white-ish spot in the left eye

    Course of Disease
    Patient came to UKI Hospital with chief complaint suddenly decreasing of
    vision in the left eye since 3 weeks ago. It felt progressive day by days, according to
    the patient, 3 weeks earlier, his left eye poked by her colleague when he was working
    as a merchant, the patient said he was poked right to the left eye ball, 2 days after that
    when he woke up in the morning, patient felt pain, redness in his left eye, sensitive to
    light, watery, feel discomfort in his left eye, and decreasing in vision. Then 2 weeks
    earlier the patient went to the puskesmas and he got eye drops from there, but the
    patient didnt know about his eye drops, and the patient stop using the eye drops, both
    because the complaints gets better after the medicine and he went to garut for ied., 1

    1
    week ago according to the patient, he felt the complaints like redness, sensitive to
    light, and watery, discomfort, in the left eye come back again, and got worse than
    before. And know he saw white spot in the left eye, so he came to the puskesmas and
    referred to UKI Hospital to met an ophtamologist.
    Patient never using glasses or soft lenses, history of eye infection earlier
    denied, history of both hypertension and diabetes mellitus denied. History of allergics
    denied, There are no complaints about headache and feeling nauseous. There are no
    complaints about his right eye.

    History of Disease
    - Patient had never had any complaint like this before
    - History of having red and itch eyes denied
    - History of diabetes and hypertension denied.

    Family Medical History


    None of his family or relatives had complaints like this before.

    III. GENERAL STATUS


    General condition : Moderate illness
    Awareness : Compos mentis

    IV. OPHTALMOLOGIST STATUS

    A. General investigator
    Right Eye Left Eye
    Around eye appearance Quiet Quiet
    General Condition of the Normal Hyperemic
    Eye Ball
    Position of the Eye Ball Symmetric Symmetric
    Eye movement Normal to all directions Normal to all directions
    Donders Confrontation Wide Couldnt be examined

    2
    Test

    B. Systemic investigator

    Right Eye Left Eye


    Visual Acuity 6/6 1/300
    Pin Hole - -
    Correction No correction No correction
    Super Cilia Normal growth, madarosis (-) Normal growth, madarosis (-)
    Cilia Normal, madarosis (-), trichiasis (-) Normal, madarosis (-), trichiasis
    (-)
    Palpebra Normal skin colour, edema (-), Normal skin colour, edema (-),
    Superior/inferior tenderness (-), ectropion (-), tenderness -, ectropion (-),
    entropion (-), ulcer (-), crust (-) entropion (-), crust (-)
    Tarsal Conjungtiva Hyperemic (-), papilar (-), follicle (-), Hyperemic (-), papilar (-),
    Superior/inferior bleeding (-) follicle (-), bleeding (-)
    Bulbar Conjungtiva Ciliar injection (-), Conjungtiva Ciliar injection (+), Conjungtiva
    injection (-), pinguekula (-), injection (-), Pinguekula (-),
    pterigium (-) Pterigium (-)
    Sclera Icteric (-) Icteric (-)
    Cornea Round, clear, infiltrate (-), ulcer (-), Foggy, ulcer (+) sentral ,
    cicatrix (-), neovascularization (-), cicatrix, neovascularization,
    reflex (+) reflex (+)
    Anterior Chamber Normal deep, hipopion (-), hyphema Couldnt be examined
    (-)
    Iris Radier, dark brown, sinekia (-) Couldnt be examined
    Pupil Round, in the middle, 3 mm, direct Couldnt be examined
    light reflex (+), indirect light reflex
    (+)
    Lens Clear, afakia (-), luksasi (-), Couldnt be examined
    subluksasi (-)

    3
    V. RESUME
    Patient came to UKI Hospital with chief complaint suddenly decreasing of
    vision in the left eye since 3 weeks ago. It felt progressive day by days, according to
    the patient, 3 weeks earlier, his left eye poked by her colleague when he was working
    as a merchant, the patient said he was poked right to the eye ball, 2 days after that
    when he woke up in the morning, patient felt pain, redness in his left eye, sensitive to
    light, watery, feel discomfort in his left eye, and decreasing in vision. Then 2 weeks
    earlier the patient went to the puskesmas and he got eye drops from there, but the
    patient didnt know about his eye drops, and the patient stop using the eye drops,
    because he went to garut for ied. So he stopped his medicine, because the complaints
    gets better after the medicine too , 1 week ago according to the patient, he felt the
    complains like redness, sensitive to light, and watery,discomfor, in the left eye come
    back again, and got worse than before. And know he saw white spot in the left eye, so
    he came to the puskesmas and referred to UKI Hospital to met an ophtamologist.

    GENERAL EXAMINATION

    OS : Acies Visus 1 / 300, PH (-), Cilliare Injection (+), foggy kornea and ulcer in
    sentral.

    SYSTEMIC EXAMINATION OPHTAMOLOGIST

    Right Eye Left Eye


    Visual Acuity 6/6 1/300
    Pin Hole - -

    4
    Cornea Round, clear, infiltrate (-), ulcer (-), Tear, infiltrate (-), ulcer (+)
    cicatrix (-), neovascularization (-), sentral, cicatrix -,
    reflex (+) neovascularization -, reflex (+)

    Lens Clear Couldnt be examined

    VI. CLINICAL DIAGNOSE


    Corneal Ulcer OS ec susp bacterial

    VII. DIFFERENTIAL DIAGNOSE

    - Corneal Ulcer OS ec susp fungal


    - Corneal Ulcer OS ec susp virus
    - Keratitis bacterialis OS

    VIII. MEDICAL TREATMENT


    1. Non medication
    - Dont rub both eyes
    - Wash hand before and after touching the eyes
    - Do not using eye pad or bandage on the affected eye except when going
    out
    -
    2. Medication
    - Topical Broad spectrum antibiotic
    Levofloxacin every 2 hour, 1 drop for OS

    IX. PLANNED EXAMINATION


    a. Slit lamp with fluorescent test
    b. Microbiology culture (cornea scraping)

    X. COMPLICATIONS
    - Corneal Perforation
    - Endoftalmitis

    XI. PROGNOSIS

    RIGHT EYE LEFT EYE

    5
    Ad Vitam Bonam Dubia ad Bonam
    Ad Sanationum Bonam Dubia ad bonam
    Ad Fuctionum Bonam Malam

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