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STATUS PASIEN BAGIAN ILMU PENYAKIT MATA RUMAH SAKIT ATMA JAYA
1. IDENTIFIKASI
Nama : ……………………………………. Agama : ………………………........Jenis Kelamin: ……………………………………. Pendidikan : ………………………........Umur : ……………………………………. Pekerjaan: ………………………........Bangsa / suku : ……………………………………. Alamat : ………………………........
II. ANAMNESAKeluhan Utama :
Keluhan Tambahan :
Riwayat Penyakit Sekarang :
Riwayat Penyakit Dahulu :
Riwayat Penyakit Keluarga :
III. STATUS GENERALISKeadaan Umum : ………………………….. Tensi : ………………… Nadi : …………..
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STATUS ILMU PENYAKIT MATABAGIAN ILMU KESEHATAN MATA
FAKULTAS KEDOKTERANUNIVERSITAS MUHAMMADIYAH
JAKARTA
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Kesadaran : ………………………….. Suhu : ………………… RR : …………..Thorax : Pulmo : …………………………..
Cor : …………………………..Abdomen : ………………………….. THT: …………………….Extremitas : ………………………….. Gigi: …………………….
IV. STATUS OFTALMOLOGIKUSA. Asies Visus
AVOD :AVOS :P.D. :
Pemeriksaan di kamar terang OD OS
1. Supersilia:Lengkap …………………
…………………Alopesia …………………
…………………Sikatriks …………………
…………………2. Eksoftalmus …………………………………….
Enoftalmus …………………………………….3. Palpebra superior :
Bengkak …………………………………….
Hiperemis …………………………………….
Benjolan …………………………………….
Blefarokalasis …………………………………….
Ptosis …………………………………….
Lain-lain …………………………………….4. Palpebra Inferior :
Bengkak …………………………………….
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Hiperemis …………………………………….
Benjolan …………………………………….
Lain-lain …………………………………….5. Area Lakrimal :
Bengkak …………………………………….
Hiperemis …………………………………….
Fistel …………………………………….6. Margo palpebra superior & silia :
Bengkak …………………………………….
Hiperemis …………………………………….
Sekret …………………………………….
Ulkus …………………………………….
Skuama …………………………………….
Menebal …………………………………….
Trikiasis …………………………………….
Madarosis …………………………………….
Ektropion …………………………………….
Entropion …………………………………….
Benjolan …………………………………….
Lain-lain …………………………………….7. Margo palpera superior & Cilia :
Bengkak …………………………………….
Hiperemis …………………………………….
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Sekret …………………………………….
Ulkus …………………………………….
Skuama …………………………………….
Menebal …………………………………….
Trikiasis …………………………………….
Madarosis …………………………………….
Ektropion …………………………………….
Entropion …………………………………….
Benjolan …………………………………….
Lain-lain …………………………………….
8. Punktum Lakrimalis :
Normal …………………………………….
Sekret …………………………………….
9. Epikantus : …………………………………….
10. Konjungtiva tarsalis superior :
Bengkak …………………………………….
Hiperemis …………………………………….
Anemia …………………………………….
Prefolikel …………………………………….
Folikel …………………………………….
Papil …………………………………….
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Kalazion …………………………………….
Litiasis …………………………………….
Simblefaron ……………………………………
Lain-lain …………………………………….
11. Konjungtiva tarsalis inferior :
Bengkak …………………………………….
Hiperemis …………………………………….
Anemia …………………………………….
Prefolikel …………………………………….
Folikel …………………………………….
Kalazion …………………………………….
Litiasis …………………………………….
Lain-lain / simblefaron …………………………………….
12. Konjungtiva forniks superior :
Bengkak …………………………………….
Hiperemis …………………………………….
Folikel …………………………………….
Simblefaron …………………………………….
Lain-lain …………………………………….
13. Konjungtiva forniks interior :
Bengkak …………………………………….
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Hiperemis …………………………………….
Folikel …………………………………….
Simblefaron …………………………………….
14. Konjungtiva :
Kemosis ……………………………………. Hiperemia …………………
…………………. Pterigium………………… ………………….Pinguicula ………………… ………………….
Flikten ……………………………………. Nevi pigmentosus………………… ………………….Melanokarsinoma ………………… ………………….
Perdarahan Subkonjungtiva …………………………………….
Injeksi konjungtiva …………………………………….
Injeksi siliar …………………………………….
Injeksi episklera …………………………………….
Simblefaron …………………………………….
Lain-lain …………………………………….
15. Kornea :
Kejernihan …………………………………….
Edema …………………………………….
Infiltrat …………………………………….
Ulkus …………………………………….
Nebula …………………………………….
Makula …………………………………….
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Leukoma …………………………………….
Neovaskularisasi …………………………………….
Tes Plasido …………………………………….
Tes Fluoresen …………………………………….
Tes Sensibilitas …………………………………….
Lain-lain ( pannus ) …………………………………….
16. Limbus kornea :
Arkus senilis …………………………………….
17. Pergerakan bola mata …………………………………….
18. Tonometri :
Digital …………………………………….
Schiots …………………………………….
Aplanasi ……………………………………
Pneumo ……………………………………
19. Kampimetri (bjerum): …………………………………….
B. Pemeriksaan di kamar gelap / obligue illumination :1. Kornea :
Kejernihan …………………………………….
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Infiltrat …………………………………….
Ulkus …………………………………….
Nebula ……………………………………
Makula …………………………………….
Leukoma …………………………………….
Keratis presipitat …………………………………….
Neovaskularisasi …………………………………….
Lain-lain ( pannus ) …………………………………….
2. Kamera okuli anterior :Kedalaman …………………
………………….Kejernihan …………………
………………….Flare …………………
………………….Hipopion …………………
………………….Hifema …………………
………………….
3. Iris :Warna …………………
………………….Gambar radier …………………
………………….Eksudat …………………
………………….Atrofi …………………
………………….Sinekia anterior …………………
………………….Sinekia posterior …………………
………………….Oklusi pupil …………………
………………….
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Iris bombe (bomwans) …………………………………….
Iridodialisis ( iridodonesis ) …………………………………….
Lain-lain …………………………………….
4. Pupil :Bentuk …………………………………….Regularitas …………………………………….Isokor …………………………………….Reaksi cahaya langsung …………………………………….Reaksi cahaya tak langsung …………………………………….Besar ( N : 4mm ) …………………………………….Reaksi akomodasi …………………………………….
5. Lensa : Kejernihan …………………
………………….Shadow test …………………
………………….Lain-lain …………………
………………….
6. Vitreous Humor:Kejernihan ………………..………………….Perdarahan …………………
………………….
7. Oftalmoskopi :
Papil : batas …………………………………….
warna …………………………………….
Eskavasi (C/D r) …………………………………….
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lamina kribrosa …………………………………….
pembuluh darah …………………………………….
Retina : arteri …………………………………….
vena …………………………………….
bercak/eksudat …………………………………….
perdarahan …………………………………….
Makula lutea : fovea sentralis …………………………………….
warna …………………………………….
lain-lain …………………………………….
V. Ringkasan1. Anamnesis :
2. Pemeriksaan fisik :
Status oftalmologikus :
VI. Diagnosa Kerja :
VII. Diagnosa Banding :
VIII. Terapi :
IX. Anjuran :
X. Prognosis :
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