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PATIENT’S IDENTITY
Name : Mr. SGender : MaleAge : 62 years 7 months oldMarital status : Religion : MuslimAddress : Pao KompalaOccupation : Retired Government ServantDate of admission : 01 August 2015Medical record no : 720854
HISTORY TAKING (autoanamnesis)Chief Complaint:
Redness on some parts of the body
Brief Anamnesis : Redness on some parts of the body for about 2 months before
admitted to the hospital. The redness did not give itch and pain sensation. From the information given by the patient, his daily activity after retired is farming. There are no history of the same disease before. The patients did not have history of Diabetes Mellitus, hypertension but he is allergic to prawn. There are also no other members in the family suffered from the same complaint. The patient does not receive any treatments before come to the hospital.
LABORATORY RESULT : 01/08/2015Test Result Reference value unit
GDS 106 140 Mg/dl
Ureum 18 10-50 Mg/dl
Kreatinin 0,51 <1,3
SGOT 21 <38
SGPT 8 <41 U/L
Albumin 2,8 3,5-5,0 gr/dl
Natrium 138 136-145 mmol/liter
Kalium 4,1 3,5-5,1 mmol/liter
Klorida 104 97-111 mmol/liter
Test RESULT REFERENCE VALUE UNIT
WBC 11,200 4,00-10,00 10^3 uL
RBC 3,80 4,00-6,00 10^6 uL
HGB 10,7 12,0-16,0 gr/dl
HCT 33,6 37,0-48,0 %
MCV 88,4 80,0-97,0 fL
MCH 28,2 26,5-33,5 pg
MCHC 31,8 31,5-35,0 gr/dl
PLT 560 150-400 10^3 uL
PT 10,2 10-14 seconds
INR 0,95
APTT 27,9 22,0-30,0 seconds
LABORATORY RESULT : 01/08/2015
RADIOLOGIC FINDINGS
RESUME
A man 62 years and 7 months old came to the hospital with macula erythematous on some parts of his body since 2 months ago. It started with macula erythema at the trunchus anterior, spread to the trunchus posterior and right axilla. Macula erythema also found at the both inguinal, gluteus and both anterior tibia. The redness did not give itch and pain sensation. From the information given by the patient, his daily activity after retired is farming. There are no history of the same disease before. However, he has allergic to prawn. There are also no other members in the family suffered from the same complaint. The patient does not receive any treatments before admitted to the hospital.
DEFINITION• FUNGAL INFECTIONS = Extensive involvement,
especially groin and feet Thick keratoderma—blennorrhagic-like lesions on feet Proximal subungual onychomycosis
Wolff K, Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ. Fitzpatrick’s : Dermatology in General Medicine. 7th ed. USA: The McGraw-Hill Companies; 2008. p. 349-55
ETIOLOGY• An epidemic of tinea corporis caused by Trichophyton
tonsurans was reported in student wrestlers
Hamzah M. Sindrom Stevens-Johnson In: Djuanda A, editor. Ilmu Penyakit Kulit dan Kelamin. Jakarta: Fakultas Kedokteran Universitas Indonesia; 2007. p.163-165 Wolff K, Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ. Fitzpatrick’s : Dermatology in General Medicine. 7 th ed. USA: The McGraw-Hill Companies; 2008. p. 349-55
RESUME
A man 62 years and 7 months old came to the hospital with macula erythematous on some parts of his body since 2 months ago. It started with macula erythema at the trunchus anterior, spread to the trunchus posterior and right axilla. Macula erythema also found at the both inguinal, gluteus and both anterior tibia. The redness did not give itch and pain sensation. From the information given by the patient, his daily activity after retired is farming. There are no history of the same disease before. However, he has allergic to prawn. There are also no other members in the family suffered from the same complaint. The patient does not receive any treatments before admitted to the hospital.
DIFFERENTIAL DIAGNOSIS
Disease Efflorescence Example
Nummular Eczema Coin shaped plaques form from coalescing papules and papulovesicles.
Dermatitis Seboroic
Yellow colour, mild-severe erythema, mild inflammatory infiltrate and oily, thick scales and crust.
Psoriasis Well-demarcated, raised, red plaque with a white scaly surfaced.
Pruritus, coin shaped (nummular) plaques with erythema and crust on arm
Papulovesicle lesion
Well-demarcated, raised, red plaque with a white scaly surfaced
Erythema lesion and annular yellow scales
PROGNOSIS• Bonam• When the risk factors are diminished, the disease can be healed
completely.