CASE REPORT

DEPARTMENT OF DERMATOVENEROLOGY
MOH. RIDWAN MEURAKSA LEVEL II HOSPITAL
PERIOD 13 JUNI 16 JULI 2016
NamE

: Sahid Adi Kusumo Negoro

No. SID

: 1102011252

Adviser doctor

: Letkol CKM dr. Dian Andriani RD, SP.KK,

Sign
............................

M.Biomed, MARS

1. Patient Identity
Name
: Mrs. K
Age
: 35 years old
Gender
: Women
Address
: Cempaka baru 2 street
Religion
: Moeslem
Education
: Senior High School
Occupation
: Private Employees
Status
: Married
Date of hospital admission : 22 June 2016
2. Anamnesis
autoanamnesis conducted on Tuesday, June 22 2016
Main Complaint:
Red patches with thick white scales on the skin throughout the body since 8 months
before hospital admission.
Additional Complaint:
Itchy red patches on the red patches area.
Riwayat Penyakit Sekarang:
Patient come to the clinic of skin and venereal Moh. Ridwan Meuraksa
Hospital with raised red patches accompanied by white thick scales that feels itchy
since 8 months ago before entering the hospital, on the skin throughout the body.
Initially raised red spots with itching sized bumps caused by the bite of mosquitoes
found on left forearm. Then patients say that the red spots grew in size, dries into a
thick white scales, and spread to other body parts within 3 months. Patient decides to
see the doctor and get drugs that are consumed namely CTM 1 a day, Ketoconazole 1
a day, and Mefenamic acid if there is pain in the red spots, but there is no change after
patients taking these drugs for two months. Patients feel complaints worsen, then the
patient decides to go to a dermatologist, and then treated with the topical ointment
called topcort applied to the red spot every day for one month, but patients also feel
no changes with these drugs. Patients discontinued treatment without control back to
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the doctor and the complaint get worse until the patient went to the dermatology clinic
of Moh. Ridwan Meuraksa Hospital. Patient often scratching these spots because of
the itchiness, so at times bleed. Itching arise when patient perform activities that made
her feel tired like doing housework in the morning. Patient routinely take a bath twice
a day and wash her hair once a day. Complaints are not accompanied by a fever and
isnt affected by contact with an object, food, drug, or air.

Past medical history :

o Patient have experienced a complaint like this two times, the first one 12 years
ago, and 8 years ago treated with phototherapy. The results are completely
healed.
o History of diabetic denied.
o History of asthma denied.
o History of food and drugs allergy denied.
o History of sneezing in the morning denied.

Family medical history :

o The patients grandfather has a history the complaint like this on the scalp,
uncontrolled.
o The patient's father has a history of diabetic, controlled.
o History of asthma denied.
o History of food and drugs allergy denied.
o History of sneezing in the morning denied.

3. Physical Examination
Generalist Status
General State
: Well
Awarness
: Compos Mentis
Weight
: 62 Kg
Height
: 160 cm
BMI
: 24,2 (ideal)

Vital Sign
Blood Preassure
Pulse
Respiration
Temperature

: 110/70 mmHg
: 76 x/menit
: 16 x/menit
: Afebris

Head
Eye
Ear
Nose
Mouth
Leher
Paru
+/+,

: Normocephal
: Conjungtiva anemis (-), jaundice sclera (-)
: Normotia, cerumen (-)
: Septum deviation (-), secret (-)
: Sianosis (-)
: Lymphadenopathy (-)
: Symmetrical while dynamic dan static, vesikuler breath sound
wheezing -/-, ronkhi -/2

Jantung
Abdomen
Ekstremitas

: Heart sound I/II regular, murmur (-) dan gallop (-)

: Suppel, bowel sound (+) normally
: Warm

4. Dermatology Status

Regio Abdominis

Regio Cruris Sinistra

Regio Antebrachialis Dextra

Location and Distribution

Regio capitis, colli, thorax, deltoid to digiti anterior and posterior (dextra and sinistra),
femoralis to digiti anterior and posterior (dextra and sinistra)
Efloresensi
Multiple erythematous plaques lentikuler size until placards firmly bounded groups
distribution, the composition partly discrete and partly confluent accompanied by scaly
thick white layers like mica.
5. Supporting examine
Not carried.
6. Resume
Patient 35 year old woman came to the clinic of skin and venereal RS Moh. Ridwan
Meuraksa with the complaint raised red patches accompanied by thick white scales that
feels itchy on the skin all over the body. Itching is felt especially when the patient feels
tired after the activity. Patient have felt the same complaint of 12 years and 8 years ago
also on the skin of the whole body. On examination of the skin throughout the body
region there are multiple erythematous plaques, size lentikuler until placards, demarcated,
groups distribution, the composition partly discrete and partly confluent accompanied by
thick white scales layers like mica.
7. Working Diagnosis
Psoriasis
8. Differential Diagnosis
Tinea corporis
Dermatitis Seboroik
9. Therapy
Non-medikamentosa:
Avoid precipitating factors of chemical, mechanical and thermal as scratching.
Avoid emotional factors.
Keeping the body's immunity.
Educate the patient, therapy will only control doesnt cure psoriasis.
Medikamentosa:
Ointment :
Keratolitik (Salisilat Acid) 3%
Coal Ter (Karbonis detergent liquor) 5%
Systemic :
Antihistamines (Loratadin) tablet 1x 10 mg
Corticosteroid (Prednison) tablet 6x 5 mg
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10. Prognosis
Qua ad Vitam
Qua ad Functionam
Qua ad Sanactionam

: Ad bonam
: Ad bonam
: Dubia ad malam