I.

PATIENT’S STATUS

Name :Tn B
Age : 17 years old
Profession : Student
Religion : Islam
Address : Cibinong
Tribe : Jawa
Mariatal Status : no Marriage
Last Education : Senior High School
Room : Polyclinic Dermatology
Date of Entry in Hospital : 20th December 2017

II. ANAMNESIS

Anamnesis be held on 20th December 2017 at 10.30 0’clock in Polyclinic

Dermatology ‘s TK.II. Ridwan Meuraksa Hospital
Anamnesis : autoanamnesis
Main Complaint : Itching between thighs since 1,5 months
Before he came to Hospital, itching constantly
when sweating.

III. HISTORY OF PRESENT ILLNESS

Since 1.5 months of SMRS, patients was begin to feel an itching with red rash on
thights . He feel very itching when he sweating. He said no complaint if he took a
rest. Patients said there is no other part besides thights .Patients said its first time got
illness. Patients Also had to go to the health care provider but there’s no healed.
Patient forgot the drug that gave by doctor. Patients said the disease was constantly
not disappeared. Patients said there’s no history of drug allergy or food allergy in
himself or his family. A history of insect bites, or contact with irritant substances is

also refuted. Patients are also not taking routine medications.

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 Patient lives in the house together with his mother, his father and sister.
There’s no one has a similar complaint like as the patient. His home is approximately
50 m2 in size. The floors are ceramic, and do not wear carpets, and have ventilation
and also get enough sun exposure. Patients said they haven’t habit of changing

clothes or towels with neighbors or their families. The Patient has get exercise
routine so, the patient often feel sweating all the day. Although feel sweating, the
patients said he only once to take a bath in one day. He also lazy to changed his
clothes after exercise because he feel tired.so, he was only sat at front proch for
drying out. Patients took a bath by using water sourced from an electric pump, and
then using liquid soap, shampoo. All of his family washed their clothes in the same
bucket and washed their clothes with powder detergents.

IV. HISTORY OF PAST ILLNESS

Patient said never has this disease before. Patient also denied has hypertension

disease, DM, asthma disease and any allergies. There’s no atopic history

V. FAMILY HISTORY

In his family no one get this disease like as patient. History of DM (+), history of high
blood pressure (-) , asthma and allergies (-)

VI. PHYSICAL EXAMINATION

1. Generalized Status

General Appearance : well, mild ilness

Consciousness : Compos mentis, Cooperative

Vital Sign :
Blood Pressure : 120/70 mmHg
Heart Rate : 77 x/minutes
Temperature : Afebris (36,5 C)
Respiratory Rate : 20x/minutes
Weight :70 kg

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 Height : 175 cm
Status of Nutrition : 24,23 kg/m2 healthy weight.
Head : Normocephal
Eye : eyebrow symmetrical, not easily revoked, conjugtiva pale-/-, sclera
jaundiced -/-, pupil round, isokor, diameter 3 mm, light reflex direct
and indirect +/+, secret-/-.
Neck : no lymphadenopathy and thyroid Gland is not palpable
Thoraks : Cor : S1-S2 reguler (+), murmur (-), gallop (-)
Pulmo : vesikular Breathing (+/+), ronchi -/- , wheezing -/-
Abdomen : Supel (+) , tenderness (-), Bowel Sounds (+)Normal
Ekstremitas : warm extremity, no oedema , CRT< 2 second

2. DERMATOLOGICAL STATUS

The inguinal region of dextra and sinistra of plaque hyperpigmentation bordered with
polycyclic edges with little erosion and skuama

VII. ADJUVANT EXAMINATION

No Adjuvant performed in this patient

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VIII. RESUME
Since 1.5 months of SMRS, patients was begin to feel an itching with red rash on
thights . He feel very itching when he sweating. He said no complaint if he took a
rest. Patients said there is no other part besides thights .Patients said its first time got
illness. There no family history like as the patient. Patients denied the history of
allergy. Generalized status ‘s patient normally. In Dermatological status , on
The inguinal region of dextra and sinistra of plaque hyperpigmentation bordered with
polycyclic edges with little erosion and skuama. No adjuvant perfomed in this patient.

IX. WORKING DIAGNOSIS

 TINEA CRURIS

X. DIFFERENTIAL DIAGNOSIS
 Psoariasis
 Aritrasma

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  Dermatitis Seboroik
 Neurodermatitis

XI. THERAPY

1. Non Medicamentosa
 Explain to the patient to take a bath at least 2 times daily using water and soap
 Explain to patients to always wash his hand while working
 Ask the patient to often change his clothes after get much of sweating

2. Medicamentosa
a. Systemic Drugs
Ketokonazol 2 x 200 mg. twice a day for 5 days. It depends on type
and size of Dermatomycosis
Loratadin 1 x 10 mg if itching

b. Topical Drugs
Ketokonazol 2% cream ue is a topical drug . Applied thin and evenly
twice a day to the infected area and surrounding for 2-3 weeks.

XII. PROGNOSIS
a. Quo ad vitam : ad bonam
b. Quo ad functionam : ad bonam
c. Quo ad sanationam : dubia ad bonam
d. Quo ad cosmeticum : ad bonam