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PATIENT’S STATUS LIII D K1B3 RSWS 1. IDENTITY Name Sex Birth : Tn.

Mahmuddin : Male : 12 December 1957 : 458768 : :

Vital Sign

: BP : HB : RR : T:

4. DERMATOVENEREOLOGICAL STATUS Location generalisata Effloresence rough scale : Erythema, : Regio

Registered Number Address Marrietal Status

2. HISTORY TAKING Chief Complain : Reddish skin all over the body AT : Reddish on the skin appeared since 2 months ago within

5. ADDITIONAL EXAMINATION
WBC UREUM : 17,82 x 10 : 62 mg/dl

CREATININE : 3,3 mg/dl SGOT SGPT : 38 : 21

exfoliating skin but get worse for these 3 days before get into the hospital. First, his skin showed some flecks then permeated to the whole body and feeling hot, itchy (+). History of the same medical complain (+) two years ago.

(Leukocytosis, taken  2/4/2013)

6. THERAPY IVFD RL 20 dpm Menthol 0,15% Salicil acid 3% LCD 4% Inerson oint 30 gr Fuson cr 10 gr Vaseline album add 60 gr Inerson+fuson cr  for the head Hydrocortisone 20gr  for the
½ upper part of the body – given in the morning ½ lower part of the body – given in the afternoon

History of medication (+), and he treated by hydrocortisone cream, history of fever (+), history of family with the same complain (-), history of HT, DM (-)

3. PRESENT STATUS General appearance Alertness Nutrition Status Hygiene : Moderate : E4M6V5 : Enaugh : Intermediate

face Bathing PK 1/10.000