case dr sh liken

7/21/2019 Case Dr SH Liken

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Laporan Kasus Perorangan

Pembimbing : dr. Sukasihati, Sp. KK

STATUS PASIENBAGIAN ILMU KESEHATAN KULIT DAN KELAMIN

FAKULTAS KEDOKTERAN UNIVERSITAS RIAU

PEKANBARU

NAMA DOKTER MUDA : Rena Irta Yulis NIM : 09101048

NAMA PASIEN : Tn.S PENDIDIKAN : SMA

UMURT!" "A#IR : 4$ ta%un A!AMA : Isla&

'ENIS KE"AMIN : "a(i)la(i SUKU : Mela*u

PEKER'AAN : Pe(er+a ,an-unan NO RM RSAA : 8$$08

A"AMAT : 'l. Sant/sa TAN!!A" : 1)1)01$

!-. Se(untu& N/. 1

STATUS PERNIKA#AN : Sua% &eni(a%

ANAMNESIS : aut/ana&nesis

KELUHAN UTAMA :

!atal)-atal i 2un--un- (a(i.

RIWAYAT PENYAKIT SEKARANG :

) Se+a( ta%un *an- lalu 2asien &en-elu%(an -atal)-atal i 2un--un- (a(i. !atal ,ersi3at

%ilan- ti&,ul. !atal serin- i2iu /le% stres an irasa(an teruta&a ,ila tia( sean-

,era(ti5itas.

) Paa a6aln*a ,era( (e&era%an an sei(it ,en-(a( *an- isertai rasa -atal7 la&a)

(ela&aan ,era( &en+ai &ene,al an ,e6arna (e/(latan7 ,atas te-as7 ,eru(uran 4

&7 en-an sisi( *ante,al. A6aln*a sisi( terse,ut ti2is7 se&a(in serin- i-aru( sisi(

se&a(in te,al an tia( tera2at ,intil),intil. 'i(a i-aru( tia( tera2at ara% i ,a6a%

sisi( an +i(a i-aru( ,a-ian tu,u% *an- lain tia( &unul -a&,aran *an- seru2a.

) Pasien 2erna% ,er/,at seniri7 teta2i tia( aa 2eru,a%an.

RIWAYAT PENYAKIT DAHULU :Pasien ,elu& 2erna% &enerita 2en*a(it (ulit se2erti ini.

RIWAYAT PENYAKIT KELUARGA :

Tia( aa an--/ta (eluar-a *an- &enerita 2en*a(it *an- sa&a.

STATUS GENERALIS

Keaaan U&u& : Ta&2a( sa(it rin-an

Kesaaran : K/&2/s&entis

Keaaan -ii : ai(

Pe&eri(saan T%/ra( : Tia( aa (elainan

Pe&eri(saan A,/&en : Tia( aa (elainan

1



STATUS DERMATOLOGIS

( Lokasi- Efo!"s"#si-P"#$"%a!a# &

Lokasi : /rsu& 2eis

Efo!"s"#si : &a(ula erite& ;<= 2la( %i2er2i-&entasi ;<= 7 ,atas te-as7 s(ua&a (asar ante,al;<=7 li(eni3i(asi;<=7 u(uran 4 & i /rsu& 2eis7 2a2ul ;)=

P"#$"%a!a# : re-i/nal

PEMERIKSAAN SARAF TEPI : tia( ila(u(an

TES SENSIBILITAS KULIT : tia( ila(u(an

( Ra%a- N$"!i ' S) &

TES LAIN : 3en/&ena tetesan lilin ;)= an 3en/&ena Aus2it ;)=

3en/&ena K/e,ner ;)=

KELAINAN SELAPUT * MUKOSA: tia( aa (elainan

KELAINAN KUKU : tia( aa (elainan

KELAINAN RAMBUT : tia( aa (elainan

KELAINAN KELEN+ER LYMFE : tia( aa 2e&,esaran K!

( REGIONAL &

PEMERIKSAAN LABORATORIUM :

DARAH: - R,i# : #,>>>. "eu(/>>> Eri............... "ED............. Di3t>>>..

) K)ss : tia( ila(u(an

URINE : - R,i# : tia( ila(u(an

) K)ss : tia( ila(u(an

FAEES : - R,i# : tia( ila(u(an - K)ss : tia( ila(u(an

PEMERIKSAAN MIKROBIOLOGI :

P"."!iksaa# S"/iaa# Basa)*La#0s#0 : tia( ila(u(an

P"1a!#aa# /"#0a# KOH : tia( ila(u(anP"1a!#aa# GRAM : tia( ila(u(an

P"1a!#aa# GIEMSA : tia( ila(u(an

P"1a!#aa# 2i") N""s"# : tia( ila(u(an

PEMERIKSAAN SEROLOGIK :

T"s S"!oo0i VDRL : - Kai,a,if : tia( ila(u(an

- Ka#,i,a,if : tia( ila(u(an

T"s S"!oo0i TPHA : - Kai,a,if : tia( ila(u(an

- Ka#,i,a,if : tia( ila(u(an

T"s S"!oo0i Lai# : tia( ila(u(an



PEMERIKSAAN HISTOPATOLOGI : tia( ila(u(an

PEMERIKSAAN LAIN : tia( ila(u(an

PEMERIKSAAN AN+URAN :

Pe&eri(saaan %ist/2at/l/-i

RESUME :

Pasien S7 la(i)la(i7 4$ ta%un7 atan- (e P/li(lini( Kulit an Kela&in RSUD AA 2aa

tan--al 1 Dese&,er 01$en-an (elu%an uta&a -atal)-atal i 2un--un- (a(i se+a( ta%un

*an- lalu.

Dari ana&nesa ia2at(an -atal)-atal i 2un--un- (a(i. !atal ,ersi3at %ilan- ti&,ul. !atal

serin- i2iu /le% stres an irasa(an teruta&a ,ila tia( sean- ,era(ti5itas.Paa a6aln*a

,era( (e&era%an an sei(it ,en-(a( *an- isertai rasa -atal7 la&a)(ela&aan ,era( &en+ai

&ene,al an ,e6arna (e/(latan7 ,er,atas te-as7 ,eru(uran 4 &7 en-an sisi( *ante,al.

A6aln*a sisi( terse,ut ti2is7 se&a(in serin- i-aru( sisi( se&a(in te,al an tia( tera2at ,intil)

,intil. 'i(a i-aru( tia( tera2at ara% i ,a6a% sisi( an +i(a i-aru( ,a-ian tu,u% *an- lain

tia( &unul -a&,aran *an- seru2a. Pasien 2erna% ,er/,at seniri7 teta2i tia( aa 2eru,a%an.

Dari 2e&eri(saan er&at/l/-i 2aa /rsu& 2eis7 &a(ula erite&;<=7 2la(

%i2er2i-&entasi ;<=7 ,atas te-as7 s(ua&a (asar an te,al;<=7 li(eni3i(asi;<=7 u(uran 4 &7

2a2ul ;)=7 ,atas te-as7 s(ua&a (asar an te,al;<=7 3en/&ena tetesan lilin ;)= an 3en/&ena Aus2it

;)=7 3en/&ena K/e,ner ;)=.

DIAGNOSIS BANDING :

) "i(en si&2le( (r/nis

) Ps/riasis 5ul-aris

) Tinea 2eis

DIAGNOSIS : "i(en si&2le( (r/nis

TERAPI

• UMUM :

) Men-%inari stres

) Tia( &en--aru( lesi 2aa (ulit

) K/ntr/l ulan-

• K#USUS :

SISTEMIK : etiriin ;Inial OD 10 &- N/.?= 11ta,

"OKA" : es/*&et%as/n ;inersi/n rea& 1@ -r= i/les(an se%ari

Asa& salisilat i/les(an se%ari

• TINDAKAN : )

PROGNOSIS :

) BUO AD SANAM : u,ia a ,/na&

$



) BUO AD CITAM : /na&

) BUO AD KOSMETIKUM : u,ia a &ala&

D/(ter : r. Rena Irta YulisSIPSTR: 09??01$

Ala&at : 'l. Di2/ C N/.

#2 : 081$@4@1990

1 Dese&,er 01$

R etiriin 10 &- ta, N/.?

S 1 1

R

M3 la /int a in 2/t n/ I

S u e ;2a-i &ala&=

Pr/ : Tn. S

Usia : 4$ ta%un

4



es/*&et%as/n 1@ -r

Asa& salisilat Inersi/n /int a tu,e I

@

case dr sh liken

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