PRESENTATION CASE

DEPARTMENT OF HEALTH SKIN AND SEX

TK II HOSPITAL MOH. RIDWAN Meuraxa
PERIOD 22 AUGUST - 24 SEPTEMBER 2016

Name: Laila Mayangsari Signature

No. NIM: 1102011139 ............................
Doctor Supervisor: CKM Lt. Col. dr. Dian Andriani RD, Sp.KK,
M.Biomed, MARS

1. Identification of Patients
Name: Ny. E
Age: 53 years
Gender: Female
Address: Cempaka Baru, Jakarta
Islam
Education: High School
Occupation: Housewife
Status: Married
Dates RS: 31Agustus 2016

2. History
Anamnesis done autoanamnesis on Wednesday, August 31, 2016
• Main complaint:
Resilience watering more than one and clustered on the right area of the face to the neck
since 3 days before entering the hospital.

• Supplemental Complaint:
Pain and itching in the area springy, fever

• Disease History Now:

Patients come to the clinic of skin and venereal hospital. Moh. Ridwan Meuraksa with
complaints arising aqueous resilience more than one clustered since three days before
entering the hospital on the facial areas right up to the neck. This complaint with pain and
itching in the area lentingan.
Initially the patient complained of fever, headache and decreased appetite since 6 days before
entering the hospital. Then three days before entering the hospital said the patient appears
redness at the site of pain is accompanied by the emergence of an aqueous resilient clustered.
Patients say lately less rest and eating irregularly. Patients had chicken pox when the age of
20 years. Patients said resilient watery present only on the face and neck just right, do not
exist anywhere else. Patients also said that resilience is not affected by exposure to the
ingredients of various plants such as grasses, flowers and insects and chemicals such as
detergents.

• Past medical history:

o history of similar complaints like this truism.
o history of chicken pox at the age of 20 years.
o history of diabetes is undeniable.
o History of asthma denied.

1
o history of food allergies, medications and chemicals denied.
o History of sneezing in the morning denied.

• Family Disease History:

o A family history of such complaints is denied.
o history of diabetes is undeniable.
o History of asthma denied.
o food and drug allergy history is undeniable.
o History of sneezing in the morning denied.

3. Physical Examination
• Status Generalists
General Situation: Good
Awareness: Compos mentis
Weight: 56 Kg
Height: 155 cm
BMI / BMI: 23.3 (ideal)

• Vital sign
Blood pressure: 110/70 mmHg
Nadi: 85 x / minute
Respiration: 17 x / minute
Temperature: afebrile

• Head: Normocephal
• Eyes: Conjungtiva anemis no, sclera no jaundice
• Ears: Normotia, there are no secretions
• Nose: septum deviation no, not out secretions
• Mouth: Cyanosis none
• Neck: Enlargement KGB does not exist
• Lungs: Symmetrical current dynamic and static, vesicular breath sounds + / +, wheezing - /
-, ronkhi - / -
• Heart: The heart sound I / II regular, murmur (-), and Gallop (-)
• Abdomen: Supple, bowel (+)
• Extremities: Warm Akral

4. Status of Dermatology

1/3 proximal region buccalis

Regio colli dextra

Regio supraclavicula dextra

Location and Distribution
1/3 proximal region buccalis dextra, regio colli dekstra, regio supraclavicula dextra.

Efloresensi
Multiple erythematous vesicles sized miliary demarcated arranged according dermatomes.

5. Investigations
tests Tzanck

6. Resume
Patient 53 year old woman came to the clinic of skin and venereal RS Moh. Ridwan
Meuraksa with complaints arising aqueous resilience more than one clustered since three
days before entering the hospital on the facial areas right up to the neck. This complaint with
pain and itching in the area lentingan. Initially the patient complained of fever, headache and
decreased appetite since six days before entering the hospital. Patients say lately less rest and
eating irregularly. Patients had chicken pox when the age of 20 years. On skin examination
found multiple erythematous vesicles sized miliary demarcated arranged according dermatom
at 1/3 proximal buccalis dextra, regio colli until supraclavicula dextra dextra.

7. Diagnosis
herpes zoster
dermatitis venenata
Irritant contact dermatitis

8. Diagnosis Work
herpes zoster

9. Procedures
Non Medical:
• Do not scratch lentingan and keep them from being broken.
• Increase endurance to rest and eat enough.
• Avoid contact with seniors, people with immunocompromise, pregnant women and people
who have a history of chickenpox until the treatment is completed.

medical:
oral:
5 x 800 mg acyclovir for 7 days
Neurodex 2 x 1
Mefenamic acid 3 x 500 mg
3 x 500 mg paracetamol

topical:
Acyclovir ointment applied in the area lentingan 2 x 1

10. Prognosis
Qua ad Vitam: Ad bonam
Qua ad Functionam: Dubia ad bonam
Qua ad Sanationam: Dubia ad bonam