Skin anamnesis social history (living, background, tobacco/alcohol, sexual history,

occupational hazard/environmental exposure).

- Chief complaint
- History of present illness (HPI)
- Past medical history (PMH)
- Medication Growth
- Allergy
HPI
- Family history
- Health-related behavior -How long has the lesion been present?
- Social history -Has it changed? (in size, shape, color, itch, bleeding?)
- Review of system
PMH
Rash
-Ever had skin cancer? Type? When? (most common basal cell &
HPI: (OLDCARTS) squamous cell ca)
-Onset  when was the first episode? -If melanoma, remember the Breslow tumor depth (in mm)? any
-Location  where on the body did it start? other detail? LN involved?
-Duration  continuous?
Family history of skin ca, biopsy confirmed melanoma.
-Characteristic  itch/burn/hurt?
-Associated symptoms Medication, cosmetic, travel history
-Aggravating & Relieving factor
-Radiation has it spread, pattern of spread?
-Timing
Itchy Rash
-Severity have lesion changed (evolution)?
Onset:
PMH:
-Acute: insect bite, acute urticaria.
Allergy/atopy, medication, past illness, last oral intake/last
-Chronic: fungal infection, chronic irritant contact dermatitis,
menstrual cycle,, cancer, HT, MI, PE/DVT, stroke, DM, Obgyn (GPA,
scabies.
mens, sexual history), hospital.
Affecting factor: atopy, bath, timing (diurnal, seasonal), medication,
Other: family history (similar, chronic dz), travel history, cosmetic,
environment.
exposure (occupation, toxin), associated symptoms, febrile dz
(mucosal involvement, sick contact), fever (fever or rash first?), Dermatologic history:
-Medication (new cream, cosmetic: allergic contact dermatitis,
urticaria, photodermatitis; new drugs: urticaria/fixed drug eruption)
-Travel (new food: urticaria; sunlight: photodermatitis; infestation:
scabies/lice)
-Hobby (solvent & topical agent: contact dermatitis; new pet: flea
infestation, allergic, urticaria)
-Occupational (chronic exposure to solvent: xerosis, atopic
dermatitis/eczema)
-Systemic (renal pruritus, cholestatic pruritus, hematologic pruritus,
endocrine (thyroid, DM) pruritus, malignancy (lymphoma),
chronic/generalized pruritus, older age, abnormal PF)
 1. Scabies
-Incubation: 3-6weeks after infestation
-Intense pruritus at night, burning sensation
Site: wrists (flexor surface), Medial aspect of fingers, Interdigital
folds
History: crowded living condition, direct contact.
-Kelompok/keluarga serupa?
2. Tinea cruris
Erythema, pruritus and rash in the groin, spread to upper thigh.
recently visiting a tropical climate, wearing tight-fitting clothes
(including bathing suits) for extended periods, sharing clothing with
others, participating in sports, or coexisting diabetes mellitus or
obesity. Prison inmates, members of the armed forces, members of
athletic teams, and people who wear tight clothing may be subject
to independent or additional risk for dermatophytosis.
Contaminated towels or hotel bedroom sheets, or by
autoinoculation from a reservoir on the hands or feet
3. Irritant contact dermatitis
acute: lesi terbatas pd tpt kontak kulit, perih, panas, rasa
terbakar, lesi eritematosa, batas tegas, asimetris, edema,
bula/ nekrosis. Slow acute: 8-24h/+ after contact, awal
berupa eritema, besoknya jadi vesikel/necrosis.
Kumulatif/kronis: kulit kering dgn lesi eritem & skuama,
hyperkeratosis, likenifikasi dgn batas tdk tegas, gatal/nyeri,
berhub dgn pekerjaan shg byk di tgn.
4. Urticaria et causa food allergy
Trigger allergy (peanut, egg, shrimp, shellfish), can appear
on any area of the body (face, lips, tongue, throat, or ears);
they may change shape, move around, disappear and
reappear over short periods of time. The bumps – red or
skin-colored “wheals” with clear edges – usually appear
suddenly and go away just as quickly.
5. Pityriasis rosea
flu-like symptom (1-2 weeks). Sebagian penderita
mengeluh gatal ringan-sedang. Penyakit
dimulai dengan timbulnya lesi kulit berupa macula eritem
dengan skuama
halus (pitiriasiformis) yang melekat pada tepi lesi (skuama
kolaret). Lesi sering soliter berbentuk lonjong atau anular
dengan diameter kira-kira 3cm, terletak di badan. Lesi
pertama ini disebut sebagai herald patch. 4-10 hr kemudian
timbul lesi-lesi sama yang lebih kecil secara serentak, garis
panjang lesi tersusun mengikuti garis kulit. Pada punggung
lesi sejajar costa sehingga memberikan gambaran seperti
pohon
cemara. Setelah 3-8 minggu kelainan kulitakan menghilang
secara spontan dan hampir tidak pernah diderita untuk
kedua kalinya.
Predileksi: badan, lengan atas, paha atas (daerah yang
tertutup).
Tinea cruris -Intro, inform consent, identity, chief complaint (itch)
Intro, inform consent, identity
-Onset (acute)
Complain: itch on groin
-Location (groin)
HPI: (OLDCARTS)
-Duration (continuous)
-Onset  when was the first episode?
-Location  usually groin -Characteristic (itch, burn)
-Duration  continuous?
-Characteristic  itch, red, ring shape -Associated symptoms (fever?)
-Associated symptoms
-Relieving/exacerbating factor (memburuk saat aktivitas)
-Aggravating & Relieving factor
-Radiation usually spread to upper thigh -Radiating (upper thigh)
-Timing
-Severity -Timing (pagi only/malam lbh parah, sebelumnya?)
-have lesion changed?
-Severity
PMH:
-Allergy/atopy (buang dd dka), medication (skin ttx, medication),
Allergy/atopy, medication, past illness (DM), last oral intake past illness (DM comorbid), last oral intake

Other: family history (similar, DM), travel history, cosmetic,
exposure (occupation, toxin), associated symptoms, fever, social
history (usually wearing tight-fitting clothes for extended periods,
sharing clothing with others, participating in sports).
-Family history (same symptoms, chronic dz)
-Social history (living situation: alone?, hygiene)
-Personal background (travel, wear tight cloth, direct contact
similar, sharing cloth, sering keringat)

-Tobacco/alcohol, sexual history

-Occupational hazard/environmental exposure (animal, soil contact)

-Review of system (penyakit hati, ginjal?)

-Summarizing, closing
Lesion on 2 week old baby, on her back, keep crying especially on
warm night.

-Intro, inform consent & procedure, identity, wash hand

-Observe general (asymmetry by stroke, obese, pallor, fatigue,

jaundice)

-Observe lesion head-toe skin (hand, feet, elbow (xanthoma?), knee,

axilla, genital, cubiti, hair follicle, dermatome, face, scalp
(dandruff?), nail (onycholysis?), hair (hair loss, excess?))

-Move patient (sit to lie)

-Close inspection lesion by magnifier (size, shape, border, lesi

tunggal/gabungan, color, morfologi)

-Palpation (texture (rough/flat/raised/depressed), consistency

(hard/solid, firm/fluctuant), mobility, tenderness)

-Summarizing (lesi superfisial vesikel subkorneal jernih di back, 1-

2mm miliaria crystalina), closing, wash hand
STD
Intro, inform consent, identity, chief complaint (lesi vesicular &/
ulcerative in genital, discharge)
Onset (bbrp hr lalu); Location (genital); Characteristic (itch, pain)
Duration (continuous); Associated symptoms (fever); Radiating
(anus); Relieving/exacerbating factor (memburuk saat aktivitas)
Timing (pagi only/malam lbh parah, sebelumnya?); Severity
Allergy/atopy
Family history (same symptoms, chronic dz)
Personal background (travel, wear tight cloth, direct contact similar,
sharing cloth, sering keringat)
Social history (hygiene, tobacco/alcohol)
Sex history
Saya akan menanyakan hal tentang keadaan sex anda. Saya
mengerti kalo ini sgt bersifat pribadi, tetapi saya tanyakan kepada
semua pasien tanpa terkecuali utk kepentingan kesehatan,
informasi ini juga pasti dirahasiakan. Apakah bisa kita mulai?
-Partner (number over last 1y & gender)
Apakah anda aktif berhubungan belakangan ini? kl ga, kpn terakhir?
Dalam 1 thn trakhir, ada brp pasangan seks? Jenis kelamin? (If 1=
ask partner RF current/past sex partner, drug use, If >1= ask
condom usage?
-Practice (if >1: genital, oral, anal, condom)
Saya akan menanyakan yg lbh sensitif lagi utk mengetahui lebih
lanjut apakah anda beresiko untuk terkena IMS. Anda pernah sex
contact dengan cara gimana saja? Genital (penis in the vagina)?
Anal (penis in the anus)? Oral (mouth on penis, vagina, or anus)?
-Protection from STD
Apakah anda dan pasangan menggunakan proteksi? If not, why? If
so, pakai apa? Seberapa sering pake? Kalau kadang, pas kpn aja
pke/sama siapa pke? Apakah ada pertanyaan/ bahas proteksi yg
lain?
-Past history of STD
Sebelumnya perna kena ims? Kpn? Kok bs kena? Perna ada gejala
berulang? Pernah dites hiv/ims lain? Mau dites?
Pasangan/ mantan perna kena ims? Kl iya, apa anda sama ims nya. If
yes, kpn tu? diagnosis? How was it treated?
-Prevention of pregnancy
Apa lagi mau punya anak? Apakah anda khawatir? Ada pke
contrasepsi kb? Mau bahas info kb?
-Medication history (medication)
-Past medical history (DM, HT, kidney liver dz, nyeri perut bwh, hari
terakhir haid, keluhan menjelang/sesdh haid)
-Contraception? (apa, mulai kpn)
-Completing history
Apa ada hal lain yang ingin anda bahas ttg kehidupan sex anda demi
kesehatan anda? Apa ada yg ingin didiskusikan mengenai kesehatan
sex anda?
For patients at risk for STDs, be certain to encourage testing and
offer praise for protective practices.
Explain STD prevention methods: abstinence, monogamy, i.e.,
being faithful to a single sex partner, or using condoms consistently
and correctly.
-Praise, closing
Discharge swap woman
-Intro, inform consent & procedure (+ditemani suster), identity
(married woman only, kl blm: only urethra & vagina), wash hand,
wear handscoon
-Underwear off, lithotomy
-Bersihkan genital externa dengan kain kasa + NaCl
-Siapkan bahan (speculum steril, swab/sengkelit steril)
-Buka lampu, pasang speculum
-Cervix: bersihkan endoservix, lalu ambil specimen dgn swab utk
sediaan hapus & sediaan biakan.
Fornix posterior: dgn swab utk sediaan basah dan tes amin.
Dinding vagina: dgn sengkelit utk sediaan apus.
Urethra: dgn sengkelit steril utk sediaan apus.
-Lepas speculum, closing
Eye (1)
-Intro, inform consent, procedure, identity, wash hand, bk kcmata
-Visus: tutup 1 mata, cek mata skt dulu,
Snellen chart (normal: 6/6, stop di baris salah 2 huruf, kl plg atas gbs
ljt hitung jari),
hitung jari (normal 60/60, jarak 1m dulu, br mundur, min3x bnr
sampe 6m, kl gbs ljt lambai tgn),
waving hand (normal 300/300, jarak 1m dulu, arah tgn keatasbwh
atau kiri kanan, kl gbs ljt light perception),
light perception (normal unlimited, apa ada cahaya, arah drmn)
-lapang pandang/confrontation test: pemeriksa dan pasien tutup 1
mata, jarak 1m, 4 sisi. (apa ada keterbatasan lapang pandang,
bagian mana)
-gerakan bola mata: Gerakan arah mata angina
-closing, wash hand
Eye (2)
-Intro, inform consent, procedure, identity, wash hand
-IOP: tes sndiri dulu, pasien ttp mata liat bwh, palpasi 1 jari telunjuk
tekan mata, 1 Jri rasa undulasi (keras naik, lembek turun)
-Reflex cornea (Hirschberg): pasien liat lurus, penlight ke glabella,
jarak ½ m, liat pantulan cahaya di mata (kedudukan bola mata:
ortoforia/esotropia/eksotropia/hypertropia/hypotropia)
-Segmen anterior (kelopak, conjunctiva, cornea, CoA depth): pke
headloop magnifier, pasien liat lurus, inspeksi palpasi (nyeri/mass)
palpebra superior & inferior, conjunctiva (anemis/folikel/secret),
eversi palpebra, CoA sinari dr temporal lurus (normal terlihat
terang, sudut dangkal ada bgn gelap)
-Pupil reflex (direct indirect, normal constrict kena cahaya, kl rusak
dilatasi)
-Shadow test: pke magnifier sinari 45’ dr temporal (negative: lensa
normal/keruh smua, positive: blm keruh/katarak imatur, matur)
-Closing, wash hand
Nose
-Intro, inform consent, procedure, identity, wash hand, silahkan
duduk, pake lampu kepala, fiksasi
-Inspeksi: dorsum nasi (perubahan warna btk edema hematom),
vestibulum nasi apa ada secret, krusta? wajah hiperemis, allergic
shiner, rease, pendarahan epistaxis, secret, trauma, deformitas,
trauma, simetris, maxilla, mandibula, palpebra edema?secret?
hiperemis?
-Palpasi: pegang aja jgn trlalu tekan di dorsum nasi ada
fraktur/nyeri? maxilla, frontal ada nyeri?
-Speculum rhinoscopy anterior: pegang speculum telunjuk sejajar
ujung buat fiksasi, buka lampu arah ke hidung, jgn kena mata silau,
masukin trtutup, lalu dibuka diangkat telunjuk fiksasi di tip hidung
(warna mucosa (merah muda/merah/pucat) cavum nasi lapang?
Secret (kl ada warna kekentalan letak) Concha inferior
eutrophic/atrofi/hipertrofi? Septum deviasi? Meatus media
terbuka? Concha media eutrophic/atrofi/hipertrofi) keluarin posisi
stgh, lalu sisi lain
-Closing, wash hand
Head throat
-Intro, inform consent, procedure, identity, wash hand, silahkan
duduk, pake lampu kepala, arahkan ke mulut
-Inspeksi faring: rongga mulut (sariawan, plak), lihat gigi
(lubang/karies), lihat lidah (normoglosi/makro/mikro, tip marking),
pke tang spatula pd 2/3 anterior lidah lihat uvula (tengah? edema?
hiperemis? Memanjang?) dinding arkus (simetris), dinding faring
posterior (mucosa hiperemis? permukaan licin/granul? Post nasal
drip?), tonsil (ukuran? Pembesaran? Simetris?)
-Inspeksi leher: ada massa? Benjolan? Trauma? Bekas luka? Jejas?
Laserasi? Edema? Julurin lidah apa ada krista ductus tiriglossus (kl
ada, ada massa naik)
-Palpasi: periksa kgb ada nyeri? (submental, submandibular,
cervical, supraclavicula), tiroid (menelan, apa ada massa?)
-Closing, wash hand
Ear (1)
-Intro, inform consent, procedure, identity, wash hand, silahkan
duduk
-Inspeksi: bentuk auricula simetris/tidak, mastoid hiperemis,
pendarahan/secret,
ulkus/furuncle/fistula/trauma/laserasi/ekskoriasi
-Palpasi: nyeri tekan mastoid (nyeri Otitis media supuratif kronik) /
tragus (otitis externa nyeri), tarik auricula
-Otoskopi: jempol jari tengah Tarik ke superoposterior, telunjuk
Tarik ke anterior auricula, pegang otoskop spserti pensil kelingking
fiksasi ke pipi, lihat liang telinga lapang, tidak ada secret serumen,
membrane timpani intact tidak cembung/cekung, transparansi,
reflex cahaya (jam 5=kanan, 7=kiri), bayangan tulang maleus
-Closing, wash hand
Ear (2)
-Intro, inform consent, procedure, identity, wash hand, silahkan
duduk, ambil garpu tala 512 Hz
-Rinne: getar, letak di mastoid, setelah tidak terdengar, penala
dipegang di depan telinga sektar 2,5cm. Terdengar: (+), tidak
terdengar (-) [ (+) normal/tuli sensori (-) tuli konduktif ]
-Weber: getar, letak di garis vertex, dahi, pangkal hidung, tengah
gigi seri/dagu. Terdengar lebih keras di salah satu telinga:
lateralisasi ke telinga itu, tidak dapat dibedakan: lateralisasi (-)
[ lateralisasi ke sehat: sensorineural, ke sakit: konduktif]
-Schwabach: getarkan, letak di pros mastoid sampai tak bunyi.
Pindahkan ke pros mastoid pemeriksa. Pemeriksa masih dengar=
Schwabach memendek (sensorineural), pemeriksa tidak dengar=
ulang taruh penala di pros mastoid pemeriksa baru ke pasien,
pasien dengar=schwabach memanjang (konduktif), pasien dan
pemeriksa sama mendengar: schwabach = pemeriksa
-Bing (oklusi): tragus telinga diperiksa ditekan sampai menutup
liang telinga (tuli konduktif sekitar 30 dB). Getarkan penala dan
letak di vertex. Lateralisasi ke telinga yg ditutup=normal; tidak
lateralisasi= tuli konduktif
-Stenger (prinsip masking): pura-pura tuli telinga kiri. 2 buah penala
getarkan dan letak di depan telinga kiri kanan (tidak terlihat).
Getarkan penala 1, taruh depan telinga kanan (N) jelas terdengar.
Penala 2 getar lebih keras, taruh depan telinga kiri (pura-pura). Efek
masking: hanya telinga kiri dengar, telinga kanan tidak. Bukan efek
masking (organik): telinga kiri tuli, telinga kanan tetap dengar.
-Closing, wash hand