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