Morning Report

Sulamsih Sri Budini

IDENTITY

Name Age Sex Status Religion Race Address

: : : : : : :

Hospitalized : Register :

Mrs. SS 33 y.o female Married Moslem Javanese Jl. Krabyakan Rt 5/2 Sumber ngepoh Lawang Agust, 9th, 2010 10916847

HISTORY
Chief complain : scally redness patches all over the body Present History : redness patches has been appeared since 5 days before hospitalization. Firstly, it was appeared on the chest after that spreading to back,scalp, face, arm, thigh and leg and then followed by peel off of the skin. She felt itchy accompanied by that lesion.

HISTORY

Past History :

She had suffered for these complains since 5 days before hospitalization 4 days before patient was partus and she taken some medicine ( yellow and green tablets, and inj (?) from mantri. 4 days after that she complain appeared redness patches with itchy and spread to face Patient use herocyn talk on all over of her body to release from itchy But the lesion and itchy more severe History of often felt itchy on neck, face and scalp (-) No complain about same disease in her family Atopic history (-) History of taken some tradisional medicine (-) History of taken some medicine (+) from mantri History of application chemical liquid to coloring hair (-) History of drug allergy (-) History of hair loss and recurent dendruff (-) History of fever (-)

Physical examination
Dermatological examination L : face, trunk, back, arm,thigh E : there were erythematous plaque, irreguler shape, not sharply marginated covered by white & yellow scales that were attached on base, erosion (+), excoriation (+)

Physical examination

Dermatological examination
L : face E : erythematous plaque, irreguler shape, not sharply marginated covered by white & brown scales, attached on base, erosion (+), excoriation (+)

Physical examination
Dermatological examination, 10-8-2010

PHYSICAL EXAMINATION
General state
CM BP: 150/100 PR: 84x/i RR: 20x/i t: 37C Head/Neck : A (-/-), I (-/-), edema palpebra (+/+), angioedema (+) ENL (-) Thorax : cor/pulmo WnL Abdomen : hepar/lien not palpable Extremities : oedem (-)

 Assessment:

Erythroderma ec. DDx. 1. Seborrheic dermatitis 2. Sezary syndrome DKA

 Planning

: Dx : - Blood, Glucose,LFT, RFT, electrolyte, sezary cell, - Biopsy PA Tx : - IVFD NS 20 drops/m - CTM 3X1 tab - Inerson oint/ Biocream ue - High calories & protein diet Mx : VS, skin lesions

RESULT OF LABORATORY EXAMINATION

August,9th ,2010 Electrolyte : Na : 137 mmol/L K : 3,54 mmol/L Cl : 120 mmol/L

Hb Leucocyte LED Trombocyte

: 12,8 gr/dl : 16.000 / m3 : 5 mm/h : 288000 /mm3

Follow Up August, 10th ,2010

S Itchy(+), O General state: CM, VS : BP: 130/80,PR: 110, RR:24 x/m, t 36,8 C A Dx : Tx : -IVFD NS 20 drops/m -CTM 3X1 tab -Inerson oint/ biocream ue -High calories &protein diet P Erythroderma ec. DDx : 1. Seborrheic Dermatitis 2. Sezary Derm.examination : Syndrome L : face, trunk, back, DKA arm,thigh E: erythematous plaque, irreguler shape, not sharply marginated covered by white&brown scales that were attached on base, erosion (+),

Follow Up
August,11th ,2010 S O
Itchy(+)

August,12th , 2010
Itchy(+), disuria(+)

General state: CM, VS : BP: 130/80,PR: 88, RR:24 x/m, t 36,9 C

General state: CM, VS : BP: 110/80,PR: 84, RR:20 x/m, t 37 C

Derm.examination : L : face, trunk, back, arm,thigh E: erythematous plaque, irreguler shape, not sharply marginated covered by white& brown scales that were attached on base, erosion (+)

Derm.examination : L : face, trunk, back, arm,thigh E: erythematous plaque, irreguler shape, not sharply marginated covered by white&brown scales that were attached on base, erosion (+)

Erythroderma ec. DDx : 1. Sezary Syndrome 2. Seborrheic Dermatitis DKA Dx : Tx : -IVFD NS 20 drops/m -ctm 3X1 TAB -Inerson oint/ biocream ue -High calories & protein diet

Erythroderma ec. DDx : 1. Sezary Syndrome 2. Seborrheic Dermatitis DKA Dx : Tx : -IVFD NS 20 drops/m -ctm 3X1 TAB -Inerson oint/ biocream ue -High calories & protein diet

Dermatological examination

Dermatological examination

..Thank you..