RESPONSI

Oleh:

Pramudana Ekaputra 011011099

Pembimbing :

Prof. Dr. Indropo A. dr SpKK(K)

FAKULTAS KEDOKTERAN UNIVERSITAS AIRLANGGA

LAB / SMF ILMU KESEHATAN KULIT
RSU DR. SOETOMO SUR ABAYA
2015

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IDENTITY
Name : Mrs. A 12.38.83.34
Gender : Female
Age : 51 years old
Status : Married
Ethnic : Javanese
Religion : Islam
Address : Tulungagung
Occupation : Farmers
No. MR : 12.38.83.34
Date of examination : 28 January 2015

BASIC DATA
History Taking
Chief Complain
Itchy red patches all over the body

Present Medical History

Patient complained appearing red patches on the body. Red patches
appeared in last 6 months. First patches appeared in the patient chest. In that
time, the patient already go to the doctor and use some ointment, but she forget
the name. The patient also use herbs to cure the patch, but the patches
increasingly numerous and larger in the whole body. The patches increasingly
just after the patient using herbs to cure the patches in the chest. The patient said
that these patches were not so itchy but sore and hot. After 2 weeks, the skin is
scalling, at this time, the skin is very itchy. Patient has no history of allergies.

Past Medical History

Patient’s first symptom, in march 2014, was vesicle in her wrist and chest, not
itchy but painful. Patient didn’t know the trigger, but it occured after the patient
farming. Then she go to the doctor, about 1 week hospitalized, the lesions in

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 wrist is recovered but not in the chest. Patient had history of using herbs and
”sirih” leaf to help the medication, she bought it in the market. After that, at
august 2014, the lession spreading all over the body and then scaling.
The patient had no history of allergy
The patient has type 2 Diabetes Mellitus 1 years and have treated with Insulin

Family History
There were no other family members who has the same disease as patient.

Social History
There were no friends or neighbours who has the same disease as the patient.

PHYSICAL EXAMINATION
PHYSICAL EXAMINATION WAS DONE AT 28 January 2015 (Admitted at Dr.
Soetomo Hospital at 13 January 2015)
General Status
General behaviour : Well
Level of consciousness: Compos mentis, GCS 4-5-6
Blood pressure : 140/70 mmHg
Pulse rate : 80 x/minute
Respiratory Rate : 18 x/minute
Temperature : 36.5°C

Head and Neck

Anemia -, Icterus -, Cyanosis -, Dyspnea –

Thorax
General

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 Shape : No abnormalities, no deformities
Skin : Normal

Lungs
Inspection : Symmetry, no retraction
Palpation : Symmetry, normal right and left fremitus
Percussion : sonor/sonor
Auscultation : vesikuler/vesikuler, ronchi -/-, wheezing -/-

Heart
Inspection : No abnormalities
Palpation : Pulsation of the apex on the left 5th intercostal space
Percussion : No abnormalities
Auscultation : Normal S1 S2, no murmur, no gallop

Abdomen
Inspection : Not distended
Auscultation : Normal peristalsis
Percussion : Timpany
Palpation : Liver and spleen enlargement (-)

Extremities
Red ,warm and dry, CRT<2 seconds, no edema

Dermatological Status
Location : Generalized
Efflorescence : Erythematous macula, unclear edge, thick squama, minimal erosion
Additional Examination : -

PROBLEM LIST
- Red patches almost the entire body and scaly

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 - Patches feel a little itchy
- History of Diabetes Mellitus for the last 1 years
- Erythematous macula, unclear edge, thick squama, minimal erosion

SUMMARY
A 51 year old female patient came with a chief complain red patches on the body in last
6 months. First patches appeared in the patient chest The patches increasingly just after
the patient using herbs to cure the patches in the chest. The patient said that these
patches were not so itchy but sore and hot. After 2 weeks, the skin is scalling, at this
time, the skin is very itchy. Patient has no history of allergies. She has never had a
complain like this before. He has type 2 Diabetes Mellitus. According to the patient,
there were no family members, frineds or neighbours who has the same complain or any
diseases that is similar as his complain.
Based on the physical examination, the blood presssure is 140/70
mmHg, pulse rate 80x/min, respiratory rate 18x/m with a temperature of 36.5 oC. There
were no abnormalities found on head, neck, thorax, abdomen and extremities. For the
local status, on thorax and abdomen, we found that there are Erythematous macula,
unclear edge, thick squama, minimal erosion.

DIAGNOSIS : Eritroderma e.c. Drug eruption

DIFFERENTIAL DIAGNOSIS : Psoriasis Vulgaris, Dermatitis Seborrhoic

PLANNING
Diagnosis :-
Therapy :
 Metylprednisolone 125 mg injection
 Loratadine 10 mg twice a day for oral use
 Vaselin album for emolient
 Oleum coccos for emolient

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Surabaya, 1st December 2014
R/ Inj. Metylprednisolone 125 mg No. I
ᶘ S imm

R/ Tab. Loratadine 10mg No. VII

ᶘ2 dd Tab 1

R/ Vaselin album No. I

ᶘ S ue

R/ Oleum coccos No. I

ᶘ S ue

Pro: Mrs. A. /51 yo/ Tulungagung

Monitoring : Vital signs

Complains
Lesion
Effectiveness of the treatments given

Education :
Educate the patient about the disease
 Patients should discontinue any medications that are often used to relieve itching
in his body and only use drugs given by doctors
 Explain how to use external medicine
 Avoid bathing with warm water and replace soap with liquid soap baby
 Use emolient in the skin to prevent skin dry

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  This disease is not infectious
DOCUMENTATION

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