8/18/2019 case dr. endang DKI - revisi WIDYA A.docx

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Laporan kasus perorangan

Pembimbing: Dr. dr. Endang Herlianti Darmani, Sp.KK 

STATUS PASIENBAGIAN ILMU KESEHATAN KULIT DAN KELAMIN

FAKULTAS KEDOKTERAN UNIVERSITAS RIAUPEKANBARU

 NAMA DOKTER MUDA :M.ARIF KURNIAWAN NIM : 1008120616

 NAMA PASIEN : Ny. E PENDIDIKAN : SMA

UMUR/TGL LAHIR : 27 T!"# AGAMA : I$%&

'ENIS KELAMIN : P()(&*"# SUKU : M+##,

PEKER'AAN : W+)$-$ NO RM : 272768ALAMAT : K"%+& TANGGAL : 0/11/201

STATUS PERNIKAHAN : S"! M(#+!

ANAMNESIS  3 ALLO/ AUTO 4 : A"5#($+$

KELUHAN UTAMA  : G% + )+)+ (" +

RIWAYAT PENYAKIT SEKARANG :

P$+(# &(#,(%"!# ,%,% + $(% $(% )+ (" + $( 1 &+#,," y#, %%".

K(%"!# ,% +)$# ()"$ &(#()"$ # + ()")#,. K(%"!# + ()&!*+% ()()+#,. P$+(# ", &(#,(%"!# *()+! + )+)+ (" +#y. K(%"!# +#+

+)$# $( 1 &+#,," y#, %%".P()+! +)$# ()"$ &(#()"$ # + ()")#,..

P$+(# ", &(#,(%"!# "%+#y ()+#, # ()* ##!. P$+(# + &()$#(&&. S((%"y 2 &+#,," y#, %%"9 -%#y *$+(# &(#,(%"!# +&"% (#5%#(#5%#

 ()+$+ +) + )+)+ (" +. B(#5%# ()$ ,% $(!+#,, *$+(# $()+#, &(#,,)"#y

+#y (#5%# + *(!. B(()* !)+ (&"+# "%+ &(#+ ()+#, # ()##!.

P$+(# + )+-y ()5 $((%"y. T()* )+-y 5# (#,# !# +)+# y+"((),(# )(# *$+(# &(&" $ %"#)y + )"&!. P$+(# &(#," + &(#,,"##

% *(%+#"#, $(*()+ $)"#, #,#.

RIWAYAT PENYAKIT DAHULU :

*$+(# *()#! &(#,(%"!# (%"!# y#, $& $(+) "%# y#, %%"9 *$+(# ()5

( P5%+%+#+ RSUD A)+;+# A!& %%" $(&"!. )+-y %(),+ 34 $& 34 )!+#++$ %(),+ 34

RIWAYAT PENYAKIT KELUARGA : T+ #,,5 (%"), *$+(# y#, &(#()+ *(#y+ y#, $&

8/18/2019 case dr. endang DKI - revisi WIDYA A.docx

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STATUS GENERALIS

K(# U&"& : B+ 

K($)# : K5&*5$&(#+$

K(# ,+ S"!" 4

TES LAIN : T+ +%"#

KELAINAN SELAPUT / MUKOSA : T+ KELAINAN KUKU  : T+

KELAINAN RAMBUT : T+

KELAINAN KELENJER LYMFE  : T+ *(&($)# KGB

( REGIONAL )

8/18/2019 case dr. endang DKI - revisi WIDYA A.docx

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PEMERIKSAAN LABORATORIUM :

DARAH: R"+# : H???. L("5??? E)+............... LED.................

D+;????..

K!"$"$ : T+ +%"#

URINE : R"+# : T+ +%"#  K!"$"$ : T+ +%"#

FAE@ES : R"+# : T+ +%"#

  K!"$"$ : T+ +%"#

PEMERIKSAAN MIKROBIOLOGI :

P(&()+$# S(+# B$!/L#,$"#, :T+ +%"#

P(-)## (#,# KOH 10 : T+ +(&"# !+; # $*5)

P(-)## GRAM : T++%"#

P(-)## GIEMSA : T+ +%"#

P(-)## +(!% N((%$(# : T+ +%"#

PEMERIKSAAN SEROLOGIK   :T($ S()5%5,+ VDRL : K"%++; :T+ +%"#  K"#++; :T+ +%"#

T($ S()5%5,+ TPHA : K"%++; :T+ +%"#  K"#++; :T+ +%"#

T($ S()5%5,+ L+# :T+ +%"#

PEMERIKSAAN HISTOPATOLOGI  : T+ +%"#

PEMERIKSAAN LAIN : T+

PEMERIKSAAN ANJURAN :

- "+ (&*(%

- P(&()+$# !+"#, (#+$ %("5$+

RESUME :

P$+(# Ny E 27 !"# #, ( *5%+%+#+ RSUD AA (#,# ,%,% # *()+! + $(%

$(% )+ (" + $( 1 &+#,," y#, %%". K(%"!# ,% +)$# ()"$ &(#()"$ # + 

()")#,. K(%"!# + ()&! *+% ()()+#,.. P$+(# ", &(#,(%"!# "%+#y

()+#, # ()* ##!. P$+(# + &()$# (&&. S((%"y 2 &+#,," y#, %%"9

-%#y *$+(# &(#,(%"!# +&"% (#5%#(#5%# ()+$+ +) + )+)+ (" +. P$+(#

+ )+-y ()5 $((%"y. T()* )+-y 5# (#,# !# +)+# y+"

((),(# )(# *$+(# &(&" $ %"#)y + )"&!. P$+(# + &(&+%++ )+-y 5*+ # *()#! &(#,%&+ !% +#+ $((%"y "%# y#, %%". D)+ *(&()+$# ;+$+ +(&"#

&"% ()+(& 3=49 *"$"%( 3=49 %+(#+;+$+ 3=49 )"$ 3=49 ($5)+$+ 3=4 + )(,+5 +,++ *(+$

($) # $+#+$) (#,# *(#y()# )(,+5#%.

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DIAGNOSIS BANDING :

D()&++$ 5# %(),+

D()&++$ 5# +)+#

T+#( *(+$

DIAGNOSIS : Derma!!" K#$a% A&er'! e$'a$ I$e%"! Se%*$er

TERAPI

• UMUM :

M(#,,"## $)"#, #,# + &(#"+ *+#

K5#)5% "%#,

• KHUSUS :

• SISTEMIK:

M(+%*)(#+$5%5#( C &,/!)+ @(+)+

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RESEP :

D5() : ). M.A)+; K")#+-#SIP/STR: 01/II/201

A%& : '%. K)+#+ N5. 0

H* : 082712611

P(#)"9 0 N5(&() 201

R / M(!y%*)(#+$5%5#( &, #5. V  S  1 *.

R /  @(+)+