Samudra Hadi Santosa

030.05.201
Patients comes with a skin peels around her
body since 3 days ago

mrs.D
45 years
Cibereum
Islam
smp
married
housewife
Skin peels since 3 days ago
Fever
Headache
Coughing up phelgm
The eye balls become yellowish with an
redish of the conjungtiva
Lost of appetite
Skin itch
Patients feel fever for more than 1 weeks
patient drink a drug ( doesnt know the name)
3 days after consumed the drug, patient
complained about still feeling the
fever,headache and coughing up phlegm and
peeling on her skin that started from the lips and
than becoming a rash that surrounding her
bodies and followed by itching of the skin
Patient loss her appetite 3 days before get in to
the hospital
And than 1 day before patient enter to the
hospital, the eyeballs become yellowish and her
conjungtiva become redden

Patient never like this before
Patient never have an operating history
Patient never have an hospitalize history
Patients deny that no ones in her family have
the same symptoms like she
There is no history of hypertension, diabets
Patients doesnt know that if she had an
allergies to something
Patients rarely consumed a drug if she sick
Patient has a good appetite ( she eats 3
times a day)


General condition
awareness: compos mentis
Impression of pain: severely ill
Vital sign
Blood pressure: 110/60mmHg
temperature: 37,4oC
Nadi : 84x/menit
Pernafasan : 20x/menit
Head
Form : normocepali
Eyes : isokor, CA -/-, S+/+
Nose : rash
Ears : rash
Lips : rash
Neck : lymph node fells bigger
Thorax
Cor
I : ictus cordis doesnt seen
P : Ictus cordis palpable at between ribs VI lateral 2 fingers
from left midclav
Per upper limit : between ribs II lane left parasternal
- left limit : between ribs V lateral from left midclav
lane
- right limit : between ribs IV right sternalis line
A : Core sound 1-2 reguler, murmur -, gallop -

Thorax
Paru
I : shape and move simetricaly, there is no left
chest wall motion, there is rash
P: same vocal fremity right - left
Per : sonor
A : breathing sound vesikuler, wh -/-, rh -/-

Abdomen
I : there is rash, stomach looks bigger
P :
left lobe hepar palpable 2 finger under the arcus costae
right lobe hepar palpable 2 finger
spleen not palpable
kidney ballotement not palpable
pressure pain
Per : pekak
A : BU + normal
Ekstremitas :
look : rash
feel : pain
move : active(+), passive(+)

Steven johnson syndrome
Drug induced Hepatitis
AKI




Toxic epidermal necrolysis
Erythema multiforme
Laboratorium
Hb : 8 - Ureum : 284,3
Leukosit : 23.000 - kreatinin : 8,40
GDS : 51 - SGOT : 98
Trombosit : 335.000 - SGPT : 74
Ht : 22 - bil. Total : 21,0
Hitung jenis : 0/0/0/34/4/5- prot. Total : 6,03
D-Dimer : 8034,05 - albumin : 2,711
-USG : Hepatomegali- globulin : 3,32
- Fosfatase alkali : 736


Steven jhonson syndrome
Sepsis
Aki
Drug induced hepatitis
IVFD D5% 40cc
Amino inf + aminofusin hepar
Ceftriaxon inj 2x3gr (sepsis)
Lasix 2x1amp (eva. Urin)
Ranitidin 2x1amp
As.folat tab 3x1
CaCo3 tab 3x1
Metil prednisolon 2x12 mg
Curcuma (tambahan hepar protektor)
Heparin 50mg/kgBB diberikan dlm 20 jam
Ad vitam : dubia ad bonam
Ad functionam : dubia ad bonam
Ad sanationam : dubia ad bonam