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    Status Ujian Afif

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    afifberlian
    A 65-year-old male presented with a membrane in his right eye that had developed over the past 3 weeks. On examination, his right eye showed a fibrovascular growth in triangular shape on the cornea, consistent with a grade II pterygium. His left eye was normal. He was diagnosed with a grade II pterygium in the right eye and referred to an eye specialist for excision of the pterygium. Potential complications included recurrent pterygium or dry eye syndrome.

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    Status Ujian Afif

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    afifberlian
    39 views7 pages
    A 65-year-old male presented with a membrane in his right eye that had developed over the past 3 weeks. On examination, his right eye showed a fibrovascular growth in triangular shape on the cornea, consistent with a grade II pterygium. His left eye was normal. He was diagnosed with a grade II pterygium in the right eye and referred to an eye specialist for excision of the pterygium. Potential complications included recurrent pterygium or dry eye syndrome.

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    A 65-year-old male presented with a membrane in his right eye that had developed over the past 3 weeks. On examination, his right eye showed a fibrovascular growth in triangular shape on the cornea, consistent with a grade II pterygium. His left eye was normal. He was diagnosed with a grade II pterygium in the right eye and referred to an eye specialist for excision of the pterygium. Potential complications included recurrent pterygium or dry eye syndrome.

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    © All Rights Reserved
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    Download as docx, pdf, or txt
    39 views7 pages

    Status Ujian Afif

    Uploaded by

    afifberlian
    A 65-year-old male presented with a membrane in his right eye that had developed over the past 3 weeks. On examination, his right eye showed a fibrovascular growth in triangular shape on the cornea, consistent with a grade II pterygium. His left eye was normal. He was diagnosed with a grade II pterygium in the right eye and referred to an eye specialist for excision of the pterygium. Potential complications included recurrent pterygium or dry eye syndrome.

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    of 7

    OPHTALMOLOGY RECORD

    PTERYGIUM

    Examiner :

    dr. Gilbert. W. Simanjuntak, SpM

    Observer :

    Faras Afif Berlian


    (1261050089)

    DEPARTMENT OF EYE DISEASE


    PERIOD OF DECEMBER 11st 2017 – JANUARY 20th 2018
    MEDICAL FACULTY
    CHRISTIAN UNIVERSITY OF INDONESIA
    JAKARTA
    2018
    OPHTALMOLOGY RECORD

    Examiner : Faras Afif Berlian

    NIM : 1261050089

    Tutor : dr. Gilbert. W. Simanjuntak, SpM

    I. PATIENT IDENTITY
    Name : Mr. S
    Age : 65 years old
    Sex : Male
    Religion : Moslem
    Address : Karang Sambung Rt 04/ Rw 02. Kebumen, Middle Java
    Occupation : Farmers
    Status : Married

    II. ANAMNESIS
    Anamnesis done at January 10th, 2018

    Main complaint :
    There is a membrane in the right eye

    Additonal complaint :
    Right eye feels blocked, watery and itchy

    Chronology of disease :

    A 65 years old male came to Dr. YAP hospital eye care with there is a
    membrane in the right eye since 3 weeks ago. The patient said initially there was a
    protrusion of fat folded on his right eye, it was small and thin and gradually thickened
    and wide, covering some of his right eye, causing the patient has difficulties to see with
    his right eye. The patient also said his right eye felt blocked while blinking and often
    watery. sometimes his right eye also feels itchy so he often rubbed his right eye. Patient
    admitted that blocked and sprinkled eye complaints increased if the patient goes outside
    from his house for a quite time. To reduce the complaints, the patient dripped insto to his
    right eye but it doesn’t have any improvement so that patient go to the hospital, and
    referred to Dr. YAP eye hospital. Watery eyes are denied, red eyes are denied, excessive
    eye excrement was denied, or injured eyes before a complaint arises, or history of allergy
    were denied by the patient.

    Previous disease :
    The patient never felt the same symptoms before. Patient never wore any contact
    lenses or eyeglasses. Patient’s denied the presence of high blood pressure, allergy and
    diabetes mellitus.

    History of family disease :


    In families of the patient has never suffered like him.

    III. GENERAL STATUS


    General condition : Mild illness appearance
    Conciousness : Compos mentis

    IV. STATUS OFTALMOLOGI


    A. General examination
    Parameter OD OS
    Periocular Appearance Quiet Quiet
    General Condition of The Mild Normal
    eye
    Eyeball position Simetric Simetric
    Eyeball movement All direction All direction
    Visual field Wide Wide

    B. Sistematic Examination
    Parameter OD OS
    Visual Acuity 6/6 6/6
    Supersilia Grow evenly Grow evenly
    Silia Grow evenly, good Grow evenly, good
    position position
    Palpebra Normal Normal
    Superior/inferior Color matches the color Color matches the color
    of the skin of the skin
    edema (-) edema (-)
    tumor (-) tumor (-)
    Tarsal conjungtiva Hyperemic (-) Hyperemic (-)
    Superior/inferior Cicatrical (-) Cicatrical (-)

    Papilar (-) Papilar (-)

    Forniks conjungtiva Hyperemic (-) Hyperemic (-)


    Superior/inferior
    Bulbi conjungtiva Hyperemic (-) Hyperemic (-)

    Injection conjungtiva (-) Injection conjungtiva (-)

    Injection ciliar (-) Injection ciliar (-)

    Fibrovascular in Fibrovascular (-)


    triangular shape (+)

    Cornea
     Clarity Fibrovascular (+) Fibrovascular (-)
     Infiltrate (-) (-)
     Ulcus (-) (-)

     Erosion (-) (-)

     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 Round, isokor, diameter
    3 mm, Direct light 3 mm, Direct light
    refleks(+), Indirect light refleks(+), Indirect light
    refleks (+) refleks (+)

    Lens Clear Clear

    V. RESUME

    A 65 years old male came to Dr. YAP hospital eye care with there is a
    membrane in the right eye since 3 weeks ago. The patient said initially there was a
    protrusion of fat folded on his right eye, it was small and thin and gradually thickened
    and wide, covering some of his right eye, causing the patient has difficulties to see with
    his right eye. The patient also said his right eye felt blocked while blinking and often
    watery, sometimes his right eye also feels itchy so he often rubbed his right eye. Patient
    admitted that blocked and sprinkled eye complaints increased if the patient goes outside
    from his house for a quite time. To reduce the complaints, the patient dripped insto to his
    right eye but it doesn’t have any improvement so that patient go to the hospital, and
    referred to Dr. YAP eye hospital. Watery eyes are denied, red eyes are denied, excessive
    eye excrement was denied, or injured eyes before a complaint arises, or history of
    allergy, previous disease and history of family disease were denied by the patient.

    GENERAL STATUS
    General condition : Mild illness appearance
    Conciousness : Compos mentis

    From the ophtalmologic examination on both eyes founded


    Parameter OD OS
    Visual Acuity 6/6 6/6
    Cornea
     Clarity Fibrovascular (+) Fibrovascular (-)
     Infiltrate (-) (-)
     Ulcus (-) (-)

     Erosion (-) (-)

     Cicatrix (-) (-)


    Bulbi conjungtiva Hyperemic (-) Hyperemic (-)

    Injection conjungtiva (-) Injection conjungtiva (-)

    Injection ciliar (-) Injection ciliar (-)

    Fibrovascular in Fibrovascular (-)


    triangular shape (+)

    Pupil Round, isokor, diameter Round, isokor, diameter


    3 mm, Direct light 3 mm, Direct light
    refleks(+), Indirect light refleks(+), Indirect light
    refleks (+) refleks (+)

    Lens Clear Clear

    VI. CLINICAL DIAGNOSE


    OD : Pterygium grade II
    OS : Normal eye

    VII. DIFFERENTIAL DIAGNOSE


    - Pinguecula
    - Pseudopterygium

    VIII. MEDICAL TREATMENT


    - Non medicamentosa : Use sunglasses to protect the eyes from ultraviolet rays
    - Medicamentosa :-
    - Operation : Referral to eye specialist to get pterygium excision

    IX. RECOMMENDED EXAMINATION


    - Sonde test

    X. PROGNOSE
    OD OS
    Ad Vitam Bonam Bonam

    Ad Sanasionum Bonam Bonam

    Ad Fungsionum Bonam Bonam


    XI. COMPLICATION
    - Recurrent pterygium
    - Dry eye syndrome

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