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    Rsud Haji - Pterygium

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    pramuliansyah haq
    This document summarizes a patient's morning report from RSUD Haji hospital. A 63-year-old female patient presented with blurry vision in both eyes. She complained of a membrane growing in both eyes. On examination, she was found to have pterygium (a triangular-shaped membrane encroaching on the cornea) in both eyes as well as immature cataracts. She was diagnosed with double-sided pterygium and immature senile cataracts. The treatment plan is to perform pterygium excision with conjunctival grafting for both eyes. Her prognosis for life, function, cosmesis and healing is good.

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    Rsud Haji - Pterygium

    Uploaded by

    pramuliansyah haq
    12 views12 pages
    This document summarizes a patient's morning report from RSUD Haji hospital. A 63-year-old female patient presented with blurry vision in both eyes. She complained of a membrane growing in both eyes. On examination, she was found to have pterygium (a triangular-shaped membrane encroaching on the cornea) in both eyes as well as immature cataracts. She was diagnosed with double-sided pterygium and immature senile cataracts. The treatment plan is to perform pterygium excision with conjunctival grafting for both eyes. Her prognosis for life, function, cosmesis and healing is good.

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    pterygium

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    395865_rsud Haji - Pterygium

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    This document summarizes a patient's morning report from RSUD Haji hospital. A 63-year-old female patient presented with blurry vision in both eyes. She complained of a membrane growing in both eyes. On examination, she was found to have pterygium (a triangular-shaped membrane encroaching on the cornea) in both eyes as well as immature cataracts. She was diagnosed with double-sided pterygium and immature senile cataracts. The treatment plan is to perform pterygium excision with conjunctival grafting for both eyes. Her prognosis for life, function, cosmesis and healing is good.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    12 views12 pages

    Rsud Haji - Pterygium

    Uploaded by

    pramuliansyah haq
    This document summarizes a patient's morning report from RSUD Haji hospital. A 63-year-old female patient presented with blurry vision in both eyes. She complained of a membrane growing in both eyes. On examination, she was found to have pterygium (a triangular-shaped membrane encroaching on the cornea) in both eyes as well as immature cataracts. She was diagnosed with double-sided pterygium and immature senile cataracts. The treatment plan is to perform pterygium excision with conjunctival grafting for both eyes. Her prognosis for life, function, cosmesis and healing is good.

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    © All Rights Reserved
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    MORNING REPORT

    RSUD HAJI
    PTERYGIUM
    Patient Identity

    • Name : Mrs.MP
    • Age : 63 y.o
    • No. RM : 266000
    • Address : Kampung Parang
    • Nation : Indonesia
    • Religion : Islam
    • Work : housewife
    • Date : July 10th 2019
    History Taking

    • Main Complaint : Blur in both eyes

    • Guided History :

    A 63-years old female patient, presented to our Clinic with Blur in both eyes

    experienced for a long time, the patient complains that there is a membrane that initially
    shrinks but eventually grows larger in both eyes. Sandy taste in both eyes (+, red eyes (-),
    headache (-), glare (+), excessive tears (-), excessive eye discharge (-), itching (-), nausea (-),
    vomiting (-). Tight on the neck (-) and the eyes feel tired quickly.

    Family history (+), history of wearing glasses (-) History of eye foreign objects (-), family
    history using eyeglasses denied. Trauma history (-).
    Ophthalmology Examination
    Visual Acuity Examination

    OD Visus OS
    20/100 Uncorrected visual acuity 1/300

    - Correction -
    - Best corrected visual acuity -

    - Near visual acuity -


    - Correction -
    - Best corrected near visual acuity -
    Anterior Segment Examination
    OD OS
    Palpebral Margo Oedema (-) Hyperemia (-), Oedema (-) Hyperemia (-),
    Crust (-) Crust (-)
    Cilia Squama (-), Madarosis (-) Squama (-), Madarosis (-)
    Lacrimal Lacrimation (-) Lacrimation (-)
    Apparatus
    Conjunctiva Hyperemis (+), a triangular-shaped Hyperemis (+), a membrane in the form of a
    membrane in the nasal and temporal triangle in the nasal and temporal regions that
    regions that has passed through the has passed through the limbus that passes throu
    limbus that reaches the pupil gh the pupil
    Cornea Membrane (+) Membrane (+)
    Anterior Chamber Normal Depth Normal Depth
    Iris Brown, Crypt (+) Brown, Crypt (+)
    Pupil Round, Central Round, Central
    Direct/Indirect +/+ +/+
    Light Reflex
    RAPD - -
    Lens cloudy cloudy
    Palpation

    OD OS
    Ocular pressure Tn Tn
    Tumor/Mass (-) (-)
    Pre Auriculer gland Not palpable Not palpable
    DIAGNOSE
    ODS Pterygium Duplex + ODS Katarak Senil Imatur
    Treatment

    - Plan: ODS Pterygium excision + graft conjunctival

    Education
    • encourage patients to use glasses and hats to
    protect their eyes from dust and UV rays.
    Prognosis

    • Quo ad vitam : Bonam


    • Quo ad functionam : Bonam
    • Quo ad Cometicam : Bonam
    • Quo ad sanactionam : Bonam
    Thank you!

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