KASUS I

Tn. / Ny. / Sdr. / Nn. / An., th / bln

Pekerjaan:
Alamat:
No. RM:

Keluhan utama:
Bintil2/plenthing isi air/lepuh/penebalan
kulit/mati rasa/kebas/
 Riwayat Penyakit Sekarang
History of skin lesions. Seven key questions:
• When? Onset
• Where? Site of onset
• Does it itch or hurt? Symptoms
• How has it spread (pattern of spread)?
Evolution
• How have individual lesions changed?
Evolution
• Provocative factors? Heat, cold, sun, exercise,
travel history, drug ingestion, pregnancy,
season
• Previous treatment(s)? Topical and systemic,
Constitutional symptoms
• “Acute illness” syndrome: headaches, chills,
feverishness, weakness
• “Chronic illness” syndrome: fatigue, weakness,
anorexia, weight loss, malaise

Sexual history: history of risk factors of

HIV: blood transfusions, IV drugs, sexually
active, multiple partners, sexually transmitted
disease?
Riwayat Penyakit Dahulu
Riwayat asma (-), riwayat ekzema (-),
Riwayat bersin2 bila kena debu (+)

Riwayat Bahan Kontak

Bahan
Sabun cuci tangan Detol cuci tangan tanpa air

Sabun mandi Detol, JF sulfur, fresh,lux

Hand body Marina, viva, citra
Deterjen pakaian Surf, Daia,So klin
Pelembut pakaian Softener so klin
Cairan pembersih lantai So klin
Lotio anti nyamuk Sofel jeruk

Riwayat Penyakit Keluarga :

sakit serupa (-), Riw.atopi (-)
Keadaan Umum :
Status gizi :
Vital sign:
Tekanan Darah :
Respirasi :
Nadi :

Pembesaran limfonodi:
(+) pada inguinal/aksila, dekstra/sinistra, teraba
lunakl/keras, berbenjol-benjol, mobil/nonmobil,
soliter/mulitpel
Lokasi:
terdapat UKK. warna. batas. bentuk.
perabaan; konsistensi (lunak, keras, kenyal, fluktuasi, seperti
papan); suhu (hangat, dingin); mobilitas; perhatikan adanya rasa
nyeri/tidak nyaman; perkirakan kedalaman lesi (dermis / subkutis)

jumlah lesi (tunggal, multipel). susunan; mengelompok

(herpetiformis, bulan sabit, anular, seperti jaring/jala, linear,
serpiginosa); tersebar. konfluensi (ya / tidak). distribusi;
perhatikan perluasan (terisolasi / lesi tunggal, terlokalisir,
regional, generalisata, universal); pola (simetris, daerah
terbuka/exposed, daerah tekanan, intertriginosa, folikular, acak,
sesuai dermatom / garis Blaschko)
Dermatitis numularis
Patch test:
Dermatitis Numularis
Topikal :
-
-

Sistemik:
-
-

Edukasi :
-
-
-