OPHTALMOLOGY RECORD

CONJUNCTIVITIS

Examiner:
Dr. Gilbert WS SimajuntakSp.M (K)

Observer:
Citra Pratiwi
1061050017

DEPARTMENT OF EYE DISEASE

PERIODE OF SEPTEMBER 1st– OCTOBER 3rd , 2015
MEDICAL FACULTY
CHRISTIAN UNIVERSITY OF INDONESIA
JAKARTA
STATUS OPHTALMOLOGY
The Examine : Citra Pratiwi
Student number : 1061050017
Examiner : dr. Gilbert WS SimajuntakSp.M (K)

I. PATIENT IDENTITY
Name : Mr. W
Age : 31 years old
Address : Ks TubunNgampilan, Yogyakarta
Occupation : Employee
Gender : Man
Religion : Moeslim
Status : Married

II. HISTORY
Anamnesis done atSeptember 10th, 2015
Main complaint : Redness in both eyes since 5 days ago.
Additional complaint : Itching,tearing, burning sensation, eye discharge in the
morning

History of present illness :

Patient came to YAP’sEyes Hospital complainingredness in both eyes since 5
days ago and constant tearing in both eyes.First in left eye.followed by the right eye
one day later.Patient also complaint about itching, burning sensation, and eye
discharge in the morning
These eyes tearing complaint is not accompanied by decreased in visual acuity
of usual vision, ocular pain, swelling.
Patient has fever, and sore throat since 5 days ago.
The pasien didn’t use any medication yet. he also has not beento the doctor to
treat the complaint.

History of past illness:

Patient never felt the same symptoms before. Patients never wore contact lenses. Or
eyeglasses. Patient’s denied the presence of a high blood pressure , allergy, or
diabetes mellitus.
 History of family illness:
Denied

History of social life:

Patient not consumed alcohol and cigarrets..

III. GENERALIST STATUS

General state : mild
Awareness : composmentis
A Disease/ clinical symptom that has to do with complaints: denied

IV. OPHTHALMOLOGY STATUS

A. General examination
General examination OD OS
The circumstances
Normal Normal
surrounding the eye
General state of the eye Mild Mild
The position of the
Symmetric Symmetric
eyeball
Eyeball movement Normal Normal
Eyeball pressure 14 mmhg 14 mmhg
Visual field Wide Wide

B. Systemic examination
Systemic examination OD OS
Aciesvisus 6/6 6/6
Correction - -
After correction - -
Near correction -
Super cilia Grow evenly Grow evenly
Cilia Grow evenly, good Grow evenly, good
position position
Palpebral superior edema (+), pseudoptosis edema (+), pseudoptosis
(+), hyperemic (-) (+), hyperemic (-)
Palpebral inferior Normal, edema (-), ptosis Normal, edema (-), ptosis
(-), hyperemic (-) (-), hyperemic (-)
Conjunctivatarsalis Hyperemic, follicle (-) Hyperemic, follicle (-)
superior et inferior
Conjunctiva bulbi Hyperemic Hyperemic
Sclera Normal Normal
Cornea
a. Clarity Clear Clear
b. Infiltrate (-) (-)
c. Ulcers (-) (-)
d.Sikatriks (-) (-)
e. Neovascularization (-) (-)
f. Fluorescein test Not evaluated Not evaluated
g. Sensibility Not evaluated Not evaluated
h. Others - -
Anterior chamber
a. Depth Deep Deep
b. Hyphema (-) (-)
c. Hypopyon (-) (-)
Iris Radier, brown, sinekia (-) Radier, brown, sinekia (-)
Pupil Round, diameter 3 mm, R. Round, diameter 3 mm, R.
direct light (+), R. indirect direct light (+), R. indirect
light (+), isokor light (+), isokor
Lens Clear Clear
V. RESUME
Patient came to YAP’s Eyes Hospital complainingredness in both eyes since 5
days ago and constant tearing in both eyes.First in left eye.followed by the right eye
one day later.Patient also complaint about itching, burning sensation, and eye
discharge in the morning
These eyes tearing complaint is not accompanied by decreased in visual acuity
of usual vision, ocular pain, swelling..
Patient has fever, and sore throat since 5 days ago.
The pasien didn’t use any medication yet. he also has not beento the doctor to
treat the complaint.
Patient never felt the same symptoms before. Patients never wore contact
lenses. Or eyeglasses. Patient’s denied the presence of a high blood pressure , allergy,
or diabetes mellitus.

GENERALIST STATUS
General state : Mild
Awareness : Composmentis
Systemic examination OD OS
Aciesvisus 6/6 6/6
Correction - -
After correction - -
Near correction -
Super cilia Grow evenly Grow evenly
Cilia Grow evenly, good Grow evenly, good
position position
Palpebral superior Normal, edema (+), Normal, edema (+),
pseudoptosis (+), pseudoptosis (+),
hyperemic (-) hyperemic (-)
 Palpebral inferior Normal, edema (-), ptosis Normal, edema (-), ptosis
(-), hyperemic (-) (-), hyperemic (-)
Conjunctiva tarsalis Hyperemic, follicle (-) Hyperemic, follicle (-)
superior et inferior
Conjunctiva bulbi Hyperemic Hyperemic
Sclera Normal Normal
Cornea
a. Clarity Clear Clear
b. Infiltrate (-) (-)
c. Ulcers (-) (-)
d. Sikatriks (-) (-)
e. Neovascularization (-) (-)
f. Fluorescein test Not evaluated Not evaluated
g. Sensibility Not evaluated Not evaluated
h. Others - -
Anterior chamber
a. Depth Deep Deep
b. Hyphema (-) (-)
c. Hypopyon (-) (-)
Iris Radier, brown, sinekia (-) Radier, brown, sinekia (-)
Pupil Round, diameter 3 mm, R. Round, diameter 3 mm, R.
direct light (+), R. indirect direct light (+), R. indirect
light (+), isokor light (+), isokor
Lens Clear Clear

VI. DIFFERENTIAL DIAGNOSIS

ODS :conjunctivitiset causa allergic
Conjungtivitis et causa bacterial infection
VII. DIAGNOSIS
OD : acute conjunctivitis et causa viral
OS :acuteconjunctivitis et causa viral

VIII. WORKUP
 Complete blood count
 Cultureeye secret
 Anel test

IX. MANAGEMENT
Medication:
 Anti-inflammation : CendoXytrol (Dexamethasone) 1% 2gtt/ 8 hour
 Antibiotic/Antiviral : CendoFenicol (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

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. COMPLICATION
 Keratoconjunctivitis
 Keratitis
 Uveitis
XI. 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