[go: up one dir, main page]
Scribd
Upload
79 views12 pages

Bali Mandara Eye Hospital Eye Policlinic Case Report

This medical case report summarizes a patient visit to an eye hospital for blurred vision. The patient is a 52-year-old Indonesian woman who complained of worsening blurred vision outdoors and seeing double with one eye closed. Her examination found cloudy lenses and iris shadows in both eyes. The assessment is immature senile cataracts in both eyes. The planned treatment is phacoemulsification surgery with intraocular lens implantation.

Uploaded by

Hananya Manroe
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
79 views12 pages

Bali Mandara Eye Hospital Eye Policlinic Case Report

This medical case report summarizes a patient visit to an eye hospital for blurred vision. The patient is a 52-year-old Indonesian woman who complained of worsening blurred vision outdoors and seeing double with one eye closed. Her examination found cloudy lenses and iris shadows in both eyes. The assessment is immature senile cataracts in both eyes. The planned treatment is phacoemulsification surgery with intraocular lens implantation.

Uploaded by

Hananya Manroe
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
You are on page 1/ 12

BALI MANDARA EYE

HOSPITAL
EYE POLICLINIC
CASE REPORT
Patient’s Identity

Name WA
Sex Female
Date of Birth 19/05/1968
Religion Moeslim
Race/Nationality Indonesian
Address Dusun Semboro

MRN 157646
ANAMNESIS

Chief Complaint: Blurred vision


 Patient came complaining of blurred vision on both eyes since 2
months ago. Complaints are felt to worsen when the patient is
outdoors (feels glare). Complaints did not improve even after the
patient rested, but the patient claimed to be more comfortable
seeing inside rooms and more comfortable reading at close range.
Patient also complaint of seeing two images when one eye’s
closed (monocular diplopia). Patients never use glasses, other
complaints such as red eyes, pain, watery eyes and itching are
denied.
ANAMNESIS

Past History:

No history of similar condition before. No previous eye


disease. Patient denied any systemic disease DM (-),
Hypertension (-) Asthma (-). No history of trauma and known
allergy

Medication History :

No previous medication
ANAMNESIS

Family History :
Patients sister known to have cataracts, denied any systemic
disease in family . DM (-), Hypertension (-) Asthma (-)

Social History:

Patient is a housewife, with no history of smoking and alcohol


consumption. Patient often use gadget on daily life
General Examination
Status Present:

 Compos Mentis (E4V5M6)


 BP : 110/70 mmHg
 HR : 76 x/minute
 RR : 18 x/minute
 Temp: 36 oC
Ophthalmology Status
RE LE
6/60 PH 6/15 Visual Acuity 6/30 PH 6/15

Normal Palpebra
Normal

Calm Conjungtiva Calm

Clear. Cornea Clear

Anterior
Deep Deep
Chamber
Ophthalmology Examination

Round, reguler Iris Round, reguler

Pupil reflex (+) Pupil Pupil reflex (+)


Cloudy Cloudy
Lens
Iris shadow (+) Iris shadow (+)
Clear Vitreous Clear
Fundus reflex Fundus reflex
Funduscopy
(+) (+)
Intra Ocular
15 Pressure
16
RE LE
Assessment and Planning
 Assessment :
 ODS Immature Senile Cataract

 Planning :
 Surgical : Phaco + IOL
THANK YOU

You might also like