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Andi Imron

Ifran
Alifia Rahayu AB
Name : Mr. M.A
Gender : Male
Age : 60 years old
Marital status : Marriage
Religion : Moslem
Address : Jl. A.P. Pettarani
No.19 Sidrap
Job :-
Addmission date : 27/02/2012
Medical record no : 072964
Chief Complaint: scaly skin the whole body
Brief anemnesis: since 2 week with itchy.
Beginning only in the form of red spots to fragile
bubbles when rubbed. Initial lesion appeared at
the head and spread to the body ,back until the
limb above. History of fever denied. history of
traditional medicine (+), given coconut oil and
red onion. history of seeing a doctor (+) but no
change.
Consciousness : Compos Mentis
General Condition : Moderate
Hygiene : Moderate
Nutrition : Moderate
Vital sign BP : mmHg
Pulse : x/minutes
RR : /minutes
Temperature: 0C
Anemic (-), icterus (-), cyanoses (-)
Cor/ Pulmonal: Normal
Abdomen: Normal, peristaltic (+)
Extremities: Edema (-)
Lymph nodes: Enlargement (-)
Look : Regio scalp, regio abdomen, regio
trunck.
Eff : hyperkeratosis erythematous plaque,
erythematous base, thick skuama.
Look : Regio ektremitas superior
Eff : thick skuama, ekskoriasi, erythematous
macules.
Look : Regio genitalia, regio axilla D/S
Eff : erythematous plaque, thick skuama,
madidans
Ureum : 31 mg/dl (N= 10 - 50 mg/dL)
Creatine : 0,8 mg/dl (N= 0,6 - 1,1 mg/dL)
GDS : 434 mg/dl (N= 70 -100 mg/dL)
SGOT : 19 U/I (N= 0 37 U/I)
SGPT : 19 U/I (N= 0 42 U/I)
WBC : 12.8 (10 3 /uL) (N = 4000-10000 mm3)
RBC : 4.61 (10 6 /uL)
HB : 13,6 (g/dL)
HCT : 41.5 (%) (N = 37 47 %)
PLT : 290 (10 3 /uL) (N= 150000-400000 mm3)
Albumin : 3,3 mg/dL (N= 3.8 5.1 mg/dL)
Mr. M.A came to hospital with itchy since 2 week ago.
Beginning only in the form of red spots to fragile
bubbles when rubbed. Initial lesion appeared at the
head and spread to the body ,back until the limb above.
History of fever denied. history of traditional medicine
(+), given coconut oil and red onion. history of seeing a
doctor (+) but no change.
His diagnosis is Pemphigoid vulgaris
Physical examination: Moderate
Look : Regio scalp, regio abdomen, regio trunck.
Eff : hyperkeratosis erythematous plaque, erythematous
base, thick skuama.
Look : Regio ektremitas superior
Eff : thick skuama, ekskoriasi, erythematous macules.
Look : Regio genitalia, regio axilla D/S
Eff : erythematous plaque, thick skuama, madidans
Pemphigoid foliaseus
Pemphigoid vulgaris