8/18/2019 Glaukoma Tn. z

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Problem Oriented Medical Record

Poli Mata RSUD Jombang, 17 Februari 2016 12.00 WIB

onita Pra!ta "gu!tia

201# 10$0 1011 0%&

DM Mata RSUD Jombang '(2$

8/18/2019 Glaukoma Tn. z

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DATA BASE

CLUE AND

CUE

PROBLEM

LIST

INITIAL DX PLANNING

DIAGNOSIS THERAP MONITORING EDUCATION

Identita! Pa!ien "

 )ama * +n. Umur * #7 ta-un

J * /ai(lai

"lamat * Mooarno Jombang

Peeraan * Wira!a!taPen3i3ian tera-ir * SM4"

 )o. RM * &0 21 0&

Anamne!a#el$%an $tama" Mata anan abur 

RPS "

( Mata anan abur !ea 1 ta-un 5ang lalu

( mata anan ti3a 3aat meli-at

( +era!a emeng, tebel, n5eri, berat, 3an

!ilau. )roo- 89:(;( mata mera- 8(;, gatal 8(;, mblobo 8(;,

eot(eot 8(;, mata men5emit 8(;,

 an3angan gan3a 8(;

− RPD* DM 8(;, '+ 8(;, trauma 8(;

RP# "eluarga ti3a a3a 5ang men3erita!ait !eerti ini

RPSo! * (

Pemeri&!aan 'i!i&

U * Bai 0 mm'g

 )a3i *%$?:menit

RR * 1%?:menit

Pemeri&!aan (eneral"

Dbn

Stat$! lo&ali!

@i!u! *

( AD * /P 8(;

( AS * $:60 -9 $:10

+AD #:10

+AS * 17

Segmen "nterior 

(/elai, #7 t-n

( Mata abur!ea 1 ta-un

5ang lalu

( Mata anan

ti3a 3aatmeli-at

( 4iora 9:(( Fotoobia 9:(

( @AD /P 8(;( @AS $:60 -9

$:10

( +AD #:10

( +AS 17

Segmen

anterior 

AD *

( =A"3angal

( Puil bulat

ani!oormi3(

mi3ria!i! C #

mm

( Iri3etomi8(;

( Iri! !-a3o

8(;

( Rubeo!i!

iri3i! 8(;

1.