CASE REPORTS
A. Patient identity
Name : Mrs. M
Age : 63 Years
Gender : Female
Occupation : Retired Teacher
Marital Status : Married
Address : (not shown)
Check Date : 19 April 2022
B. Anamnesis
1. Main
The patient came with complaints of red right eye and a feeling of lump.
2. History of Present Disease
A 63-year-old female patient came to the eye policlinic at the hospital with
complaints that her right eye was red and felt lumpy since 2 days before coming to the eye
clinic. Complaints accompanied by watery right eye, right eye cannot see at all, right eye
feels sore. Complaints are not accompanied by itching, no discharge. The patient's left eye
can still see but within limits and the patient's left eye does not experience redness, does
not runny, does not feel lumpy, does not itch or discharge.
The patient underwent glaucoma surgery on the left eye in February 2022 and
underwent cataract surgery on the left eye in March 2022. At first the patient said he could
not see at all in his left eye but after glaucoma and cataract surgery the patient could see
within certain distance limitations.
The patient said it was routine to use routine medicine from eye poly. The patient
came to the hospital's eye clinic with out of medicine.
3. Past medical history
History of the same complaint: Red, watery, lumpy eyes when not taking
routine medication and experienced similar complaints in the left eye before
surgery
History of other eye diseases : Chronic Glaucoma, Cataracts
, • History of trauma to the eye : Exposed to a papaya tree trunk +- 6 years
ago in the area around the eye
Heart disease : Denied
Allergic history : Denied
History of asthma : Denied
• Eye surgery history : Glaucoma surgery February 2021 and cataract
surgery March 2021
History of using angcoagulant drugs : Denied
4. Family Disease History
Same complaint : Denied
History of hypertension : Denied
History of diabetes mellitus : Denied
History of heart disease : Denied
Allergic history : Denied
History of asthma : Denied
5. Social Personal History
The patient is a retired teacher and in the patient's environment no one smokes
or consumes alcohol.
6. System history
Cardiovascular System : no complaints
Respiratory System : no complaints
Gastroentertestinal system : no complaints
Urogenital system : no complaints
Integumentary System : no complaints
Musculoskeletal System : no complaints
C. Physical examination
1. General Condition & Vital Signs
a. General Condition : Good
A. Patient identity
Name : Mrs. M
Age : 63 Years
Gender : Female
Occupation : Retired Teacher
Marital Status : Married
Address : (not shown)
Check Date : 19 April 2022
B. Anamnesis
1. Main
The patient came with complaints of red right eye and a feeling of lump.
2. History of Present Disease
A 63-year-old female patient came to the eye policlinic at the hospital with
complaints that her right eye was red and felt lumpy since 2 days before coming to the eye
clinic. Complaints accompanied by watery right eye, right eye cannot see at all, right eye
feels sore. Complaints are not accompanied by itching, no discharge. The patient's left eye
can still see but within limits and the patient's left eye does not experience redness, does
not runny, does not feel lumpy, does not itch or discharge.
The patient underwent glaucoma surgery on the left eye in February 2022 and
underwent cataract surgery on the left eye in March 2022. At first the patient said he could
not see at all in his left eye but after glaucoma and cataract surgery the patient could see
within certain distance limitations.
The patient said it was routine to use routine medicine from eye poly. The patient
came to the hospital's eye clinic with out of medicine.
3. Past medical history
History of the same complaint: Red, watery, lumpy eyes when not taking
routine medication and experienced similar complaints in the left eye before
surgery
History of other eye diseases : Chronic Glaucoma, Cataracts
, • History of trauma to the eye : Exposed to a papaya tree trunk +- 6 years
ago in the area around the eye
Heart disease : Denied
Allergic history : Denied
History of asthma : Denied
• Eye surgery history : Glaucoma surgery February 2021 and cataract
surgery March 2021
History of using angcoagulant drugs : Denied
4. Family Disease History
Same complaint : Denied
History of hypertension : Denied
History of diabetes mellitus : Denied
History of heart disease : Denied
Allergic history : Denied
History of asthma : Denied
5. Social Personal History
The patient is a retired teacher and in the patient's environment no one smokes
or consumes alcohol.
6. System history
Cardiovascular System : no complaints
Respiratory System : no complaints
Gastroentertestinal system : no complaints
Urogenital system : no complaints
Integumentary System : no complaints
Musculoskeletal System : no complaints
C. Physical examination
1. General Condition & Vital Signs
a. General Condition : Good
