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RECENT HISTORY OF PATIENT

2 days before the patient inwarded at the hospital:

Patient post inward at the hospital for 2 weeks with dx: psoriatic erythroderma given therapy:
MP 20mg 1x1, MTX 5mg / week, 1x0.5ml ketotifen, cetirizine 1x0.5ml, 1x1 folate. Topical
medicine: Cetaphil 2d ue on whole body, cendo lyters 6 dd gtt 1, and gentamycin ointment 2dd
ue at inferior conjunctiva.

Red and scaly skin formerly complaints were getting better and improved so that the patient is
allowed to go home.

Outpatient therapy: dexametasone 2.5 mg / 48h, MTX 5mg / week, ketotifen 1x0.5ml, cetirizine
1x0.5ml, 1x1 folate.

Topical medicine: Cetaphil 2 dd ue on whole body, cedmdo lyters 6 dd gtt 1, and gentamycin
ointment 2 dd ue at inferior conjunctiva.

2 days before the patient inwarded at the hospital:

Red skin complaint reemerge. It comes from the back and spreads throughout the body. Skin complaints
are exfoliation and scaly (-). Patient checked himself to the polyclinics of DV RSS given therapy:
dexametasone 2.5 mg / 48jam, MTX 5mg / week, ketotifen 1x0.5ml, cetirizine 1x0.5ml, folic acid 1x1.
Topical medicine: Cetaphil 2 dd ue on whole body, cendo lyters 6 dd gtt 1, and gentamycin ointment 2 dd
ue at inferior conjunctiva.

7 days after the patient treated at the hospital:

Complaints remain. The skin is getting more reddish and exfoliation on the whole body. Itchy (+), pain (-),
fever (-)

(?) days after the patient treated at the hospital:

Complaints of red skin and exfoliation skin remain. The patient checked himself to polyclinics of DV RSS
inwarded at the hospital

FORMER/ PREVIOUS HISTORY OF PATIENT

September 2016: Red and scaly skin appears on the arms, head and legs extending to almost the entire
body. Checked into Banyumas hospital. The patient then refered to RSS. Recommended to do biopsy.
Result: psoriasis. Was given once light therapy, followed by light therapy at Banyumas hospital, 3 times a
week. Red and scaly skin is getting wider all over the body.

November 2016: Scaly red skin complaints are getting worse. Patient inwarded at RSS. Was given therapy
of Sandamun 2.5 mg, metilprednisolon 4 mg / 24 hours. Complaints persist.
December 2016: Patient checked to Banyumas hospital, given 5 mg sandimun therapy and 16 mg
methylprednisolone. Skin redness and scalp complaints are reduced. 2 days later the complaints is
getting worse.

February 2017: Patient fell, was done wound skin suture, tx: Cefadroxil, 1 week later appears red spots
-- polyclinics of DV at RSS, dx: maculopapular eruptions ec susp Cefadroxil inwarded at the hospital

April 2017: Patient was inwarded for five days at the hospital and stayed in the DV ward with, Dx:
erythroderma psoriatika, home therapy: MP 20mg / day, MTX tab 5mg / week, 1x1 mg ketotifen, 1x1 mg
folic acid (when the patient does not use MTX) and topical : Olive oil 2dd ue skin exfoliation improves
and not red