pemfigus vulgaris
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PEMFIGUS VULGARIS
Andi Imron
Ifran
Alifia Rahayu AB
PATIENT IDENTITY Name : Mr. M.A Gender : Male Age : 60 years old Marital status : Marriage Religion : Moslem Address : Jl. A.P. Pettarani
No.19 Sidrap Job : - Addmission date : 27/02/2012 Medical record no : 072964
HISTORY TAKING Chief Complaint: scaly skin the whole body Brief anemnesis: since ±2 week with itchy.
Beginning only in the form of red spots to fragile bubbles when rubbed. Initial lesion appeared at the head and spread to the body ,back until the limb above. History of fever denied. history of traditional medicine (+), given coconut oil and red onion. history of seeing a doctor (+) but no change.
CURRENT STATUS Consciousness : Compos Mentis General Condition : Moderate Hygiene : Moderate Nutrition : Moderate Vital sign BP : mmHg
Pulse : x/minutesRR : /minutesTemperature: 0C
PHYSICAL EXAMINATION Anemic (-), icterus (-), cyanoses
(-) Cor/ Pulmonal: Normal Abdomen: Normal, peristaltic (+) Extremities: Edema (-) Lymph nodes: Enlargement (-)
DERMATOLOGIS STATUS Look : Regio scalp, regio abdomen, regio
trunck. Eff : hyperkeratosis erythematous
plaque, erythematous base, thick skuama.
Look : Regio ektremitas superior Eff : thick skuama, ekskoriasi,
erythematous macules. Look : Regio genitalia, regio axilla D/S Eff : erythematous plaque, thick
skuama, madidans
LABORATORY RESULT
Ureum : 31 mg/dl (N= 10 - 50 mg/dL) Creatine : 0,8 mg/dl (N= 0,6 - 1,1 mg/dL) GDS : 434 mg/dl (N= 70 -100 mg/dL) SGOT : 19 U/I (N= 0 – 37 U/I) SGPT : 19 U/I (N= 0 – 42 U/I) WBC : 12.8 (10 3 /uL) (N = 4000-10000 mm3) RBC : 4.61 (10 6 /uL) HB : 13,6 (g/dL) HCT : 41.5 (%) (N = 37 – 47 %) PLT : 290 (10 3 /uL) (N= 150000-400000
mm3) Albumin : 3,3 mg/dL (N= 3.8 – 5.1 mg/dL)
RESUME
Mr. M.A came to hospital with itchy since ±2 week ago. Beginning only in the form of red spots to fragile bubbles when rubbed. Initial lesion appeared at the head and spread to the body ,back until the limb above. History of fever denied. history of traditional medicine (+), given coconut oil and red onion. history of seeing a doctor (+) but no change.
His diagnosis is Pemphigoid vulgaris
Physical examination: Moderate Look : Regio scalp, regio abdomen, regio trunck. Eff : hyperkeratosis erythematous plaque, erythematous
base, thick skuama. Look : Regio ektremitas superior Eff : thick skuama, ekskoriasi, erythematous macules. Look : Regio genitalia, regio axilla D/S Eff : erythematous plaque, thick skuama, madidans
DIFFERENTIAL DIAGNOSIS
Pemphigoid foliaseus
DIAGNOSIS Pemphigoid vulgaris
DISCUSSION
RECOMMENDED EXAMINATION
TREATMENT & MANAGEMENT
PROGNOSIS
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