CASE REPORT

I. PATIENT’S IDENTITY
Name : An. F
Gender : Girl
Age : 7 years old
Occupation : Student
Religion : Islam
Address : Bambu apus
No. RM : 39.03.43

II. ANAMNESIS
Anamnesis was done by autoanamnesis on 13th July 2018 at 11.50 WIB in
DermatoVenerology Department Ridwan Meuraksa Hospital.

Main Complaint:
White scaly patch that itch on the right ear since three months before being
admitted to the hospital.

Additional Complaint:
Blisters on the itcy area.

History of Patient’s Illness:

Ms. F, 7 years old, came to Ridwan Meuraksa Hospital,
Dermatovenorology Department with complaints there are white scaly patches on
her right ear since three months ago. The white scaly patches were very itchy. At
first, the patient complained to her mother that her right ear was itchy and after a
few days, red spottings the size of a pin needle were seen which the mother
thought was ‘biang keringat’. The patches felt very itchy all day, but not painful.
She often scratched the itchy area and the itching reduced. The presence of fever
is denied and the patient is not admitted for treatment.
 Around two months ago, the patient complained to her mother that the
itching was getting worse on her right ear. The patches seemed spreaded and the
surface felt watery when touched. The patches also seemed getting bigger from
the size of a pin needle to the size of corn seed, and there were thin white scales
layering the surface of the patches. Since the patient kept scratching the itchy
area, the patches became blisters. The mother decided to bring her daughter to the
puskesmas and were given Ketokonazol cream and CTM for her oral medication,
however there was no improvement.
Around three weeks ago, the scaly patches have gotten even thicker and
more itchy, until finally the patient was taken to Ridwan Meuraksa Hospital with
her mother.
Riwayat asma pada pasien disangkal. Pasien mandi 2x sehari dan tidak
menggunakan handuknya bergantian dengan orang lain.
The patient’s history of Asthma is denied and she bathes twice a day and
does not use the towel alternately with other people.

Past Medical History:

- Diabetes Mellitus denied

- Hypertension denied
- Asthma denied
- Rhinitis denied

Family Medical History:

- The patient stated that neither the family at the house experienced the
same symptoms.

- Riwayat DM (-), Hipertensi (-), Rinitis (-)

- The patient’s grandfather has asthma

III. Physical Examination

1. General Status
General : The patient appears alert, oriented and cooperative
 Nutrition status : Enough

Vital sign

Blood Pressures: 120/80 mmHg

Pulse : 90 x/minute

Respiration : 20 x/minute

Temprature : 36,5o

Height : 135 cm

Weight : 25 kg

BMI : 13,7 kg/m2

HEENT : Head appears normochepal

Eyes : Negative scleral icterus and conjunctival pallor

Neck : No thyroid nodules and lymph nodes enlargement

Thorax

Cor : S1-S2 reguler (+), murmur (-), gallop (-)

Pulmo : Vesicular breathing (+/+), ronchi -/- ,

wheezing -/-

Abdomen : Nyeri tekan (-), bowel sounds (+) normal

Genital : not performed

Extremities : feels warm, oedema (-)

2. Dermatological Status
 On regio of auricular dextra was found a multiple patch with
hipopigemented base, grouped with lenticular size and ancircumscribe
edges, discrete and confluence, which are covered with thin white scaly
squama.

IV. Supporting Diagnostic Test

Any supporting diagnostic test was not performed in the patient.

V. Resume
Ms. F, 7 years old, came with her mother to Dermatovenorology
Department Ridwan Meuraksa Hospital with main complaints of white
scaly patches on her right ear since three months before being admitted to
the hospital. The white patches were itchy. At first, the patches were red in
a size of a pin needle and very itchy. At that time, the patient explained
how the itching was reduced when she scratched the itchy area. However,
the patches seemed worse when she realized sometimes it got watery and
the patches were also spreaded around. On around the second month, thin
and white scale were also formed on the surface of the patches. The
patient’s mother decided to take her daughter to the puskesmas and was
given Ketokonazole cream and CTM as her oral medication. The
symptoms had no improvement and the scales on the patches were getting
thicker and they have gottten more itchy all day, until finally the patient
went to the hospital for treatment. Physical examination remains normal.
The dermatological status was on regio of auricular dextra was found a
multiple patch with hipopigemented base, grouped with lenticular size and
ancircumscribe edges, discrete and confluence, which are covered with
thin white scaly squama.

VI. Working Diagnosis

- Dermatitis seboroik
VII. Differential Diagnosis
- Dermatitis atopic
- Dermatitis kontak iritan
- Dermatofitosis

VIII. Plan
Non Medic

1. Explaining to the patient about the disease that related to increased of

sebum production.
2. Telling the patient to maintain self-hygiene, example: by taking a
shower twice a day with clean water.
3. Telling the patient to maintain skin moisture, example: by applying
body lotion three times a day.
4. Avoiding any scratching when it feels itchy, as secondary infection
may develop.
Medical

Systemic:

1. Antibiotic: Cetirizine Syrup 1x1 cth

Topical:

1. Corticosteroid: Hydrocortisone cream

IX. Prognosis
Quo ad vitam : ad bonam

Quo ad functionam : ad bonam

Quo ad sanationam : ad bonam