This document summarizes an ophthalmology record for a 55-year-old male patient presenting with a lump in his right eyelid. On examination, there was edema of the right eyelids and a 0.5x0.5x0.3 cm soft lump. The clinical diagnosis was a chalazion of the right eye. The patient underwent a chalazion excision procedure and was prescribed eye ointment for post-operative care. The prognosis for the right eye was good for life, healing, and function with the potential complication of recurrent chalazion.
This document summarizes an ophthalmology record for a 55-year-old male patient presenting with a lump in his right eyelid. On examination, there was edema of the right eyelids and a 0.5x0.5x0.3 cm soft lump. The clinical diagnosis was a chalazion of the right eye. The patient underwent a chalazion excision procedure and was prescribed eye ointment for post-operative care. The prognosis for the right eye was good for life, healing, and function with the potential complication of recurrent chalazion.
This document summarizes an ophthalmology record for a 55-year-old male patient presenting with a lump in his right eyelid. On examination, there was edema of the right eyelids and a 0.5x0.5x0.3 cm soft lump. The clinical diagnosis was a chalazion of the right eye. The patient underwent a chalazion excision procedure and was prescribed eye ointment for post-operative care. The prognosis for the right eye was good for life, healing, and function with the potential complication of recurrent chalazion.
This document summarizes an ophthalmology record for a 55-year-old male patient presenting with a lump in his right eyelid. On examination, there was edema of the right eyelids and a 0.5x0.5x0.3 cm soft lump. The clinical diagnosis was a chalazion of the right eye. The patient underwent a chalazion excision procedure and was prescribed eye ointment for post-operative care. The prognosis for the right eye was good for life, healing, and function with the potential complication of recurrent chalazion.
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OPHTALMOLOGY RECORD
CHALAZION
Examiner :
DR. dr. Gilbert. W. Simanjuntak, SpM (K)
Observer :
Yoga Rahmat Witular
(1161050136)
DEPARTMENT OF EYE DISEASE
PERIOD OF FEBRUARY 27rd APRIL 1th , 2017 MEDICAL FACULTY CHRISTIAN UNIVERSITY OF INDONESIA JAKARTA 2017 OPHTALMOLOGY RECORD
Examiner : Yoga Rahmat Witular
NIM : 1161050136
Tutor : Dr. dr. Gilbert. W. Simanjuntak, SpM (K)
I. PATIENT IDENTITY
Name : Mr. S
Age : 55 years old
Sex : Male
Religion : Islam
Address : Kampung Rawa Bugel, RT. 01 RW. 010, Bekasi
Occupation : PNS
Status : Married II. ANAMNESIS
Anamnesis done at March 25th, 2017
Main complaint : Patients present with a lump in the right eyelid.
Additonal complaint : Cause feel prop in the right eyes
Chronology of disease :
A 55 years old male come to eyes Polis UKI Hospital with
complaints of a lump in the lower lids right eye since 7 days ago. Initially a small-sized lumps, but slowly growing lump is felt. Currently lump like as green beans. Lump causes a lump in the right eye patient's, but the lump does not feel pain, itching, and heat. Patients already compress with ice cubes to reduce complaints. Bumps do not produce the pus. No red eye before. Patient admitted, his sight is still good and there is no vision problems at all.
There are no white spots like dandruff or dry wound along the edge of the eyelid. Complaints blurred vision, double vision denied. Patients are often exposed to dust. Diabetes and history taking regular drug treatment since 3 months ago. History of hypertension denied. Surgical history denied. History of wearing glasses positive. Previous disease :
The patient never felt the same symptoms before. Patients never wore contact lenses or eyeglasses. Patients denied the presence of a high blood pressure, allergy and positive diabetes mellitus.
History of family disease :
In families of patient has never suffered like him.
III. GENERAL STATUS
General condition : Mild illness appearance
Conciousness : Composmentis
IV. STATUS OFTALMOLOGI
A. General examination
Parameter OD OS Periocular Appearance Quiet Quiet General Condition of The eye Mild Mild Eyeball position Simetric Simetric Eyeball movement All direction All direction Visual field Wide Wide B. Sistematic Examination
Parameter OD OS Visual Acuity 6/9 6/15 Supersilia Grow evenly Grow evenly Silia Grow evenly, good Grow evenly, good position position Palpebra Color not matches the Normal Superior/inferior color of the skin Color matches the color of Edema inferior (+) the skin
(-) (-) Cicatrix Sclera White White Cicatrix (-) Cicatrix (-) Anterior Chamber Medium in depth Medium in depth Hypopyon (-) Hypopyon (-) Hyphema (-) Hyphema (-) Iris Radier Radier Brown Brown Synechia (-) Synechia (-) Pupil Round, isokor, diameter 3 Round, isokor, diameter 3 mm, Direct light refleks mm, Direct light refleks (+), Indirect light refleks (+), Indirect light refleks (+) (+)
Lens Clear Clear
V. RESUME
A 55 years old male come to eyes Polis UKI Hospital with
complaints of a lump in the lower lids right eye since 7 days ago. Initially a small-sized lumps, but slowly growing lump is felt. Currently lump like as green beans. Lump causes a lump in the right eye patient's. On examination found edema of the eyelids are right outside and inside and reddish. Lump size of 0.5 x 0.5 x 0.3 cm with a soft consistency and a flat surface. Patients already compress with ice cubes to reduce complaints. Bumps do not produce the pus. No pain, itching, heat and red eye before. Patient admitted, his sight is still good and there is no vision problems at all. Patients are often exposed to dust. Positive diabetes and history taking regular drug treatment since 3 months ago. History wear glasses positive.
GENERAL STATUS
General condition : Mild illness appearance
Conciousness : Composmentis From the ophtalmologic examination on both eyes founded
Parameter OD OS Visual Acuity 6/9 6/15 Palpebra Color not matches the Normal Superior/inferior color of the skin Color matches the color of Edema inferior (+) the skin
