LAPORAN KASUS

I. Identity

Name : Ny. T
Place, Date of Birth : Bogor, 23 Agustus 1942
Age : 75 yo
Gender : Female
Address : Jl. Komplek KODAM 3 . Cililitan Blok V
Education : Elementary School
Occupation : Housewife
Marital Status : Married
Religion : Islam
Citizenship : Indonesian
No. RM : 373980

II. Anamnesis
Anamnesis performed by autoanamnesis in Polyclinics of Skin and
Sex of TK II Moh Ridwan Meuraksa Hospital on March 22, 2018 at
11:05 pm.

Main Complaint
The appearance of reddish spots on the right abdomen and groin
since less than 1 week ago.

Additional Complaint
Itching in the groin and right part of the stomach, especially when
sweating since 1 week before coming to the hospital.

The Historical Illness

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 Patient came to Polyclinics of Skin and Sex of TK II Moh Ridwan
Meuraksa Hospital with complaints of reddish spots accompanied by
itching in the right abdomen and groin since less than 1 week ago.
Itchy complaints increase when the patient is sweating. The red spots
begin with the abdomen then appear in the groin and extend within the
area. History of insect bites and contact with irritant material is denied.
Patients admitted often scratching the itchy part of the stomach as well
as the groin.
Patients have allergies to shrimp whose reactions are hives. Shrimp
eating history is denied. A long history of taking medicine is denied.
The itching and reddish complaints on the other body folds are denied.
Complaints of reddish or blackish spots with thick scales are denied.
Hot burning complaints in certain parts of the skin are denied.
Patients take a bath twice a day, and change underwear twice a day.
Patients admitted to rarely changing clothes if they were inside the
house. The history of wearing clothes and towels together is denied.
Patients often sweat and the body mass index calculations show
patients overweight.
Patient lives at home with her husband and child. A history of
similar diseases in the family is denied. The patient home is 50m2. The
floor is covered with ceramic without carpet, with adequate ventilation
and irradiation.

III. History of Past Illness

- Patient say never had a complaint like this before.
- Patient has shrimp allergy whose reaction is itching.
- History of hypertension, diabetes mellitus, kidney, lung, heart
disease, asthma, and allergic rhinitis is denied.

Family Medical History

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 - No family member has the same complaint as the patient.
- History of hypertension, heart, lung, kidney, asthma, allergic
rhinitis, and diabetes mellitus in the family is denied.
IV. Physical Examination
Awareness : Composmentis
General Condition : Good
Vital Signs:
- Blood Pressure :130/100 mmHg
- Pulse : 70x/min
- Breathing : 20x/min
- Temperature : 37ºC

Nutritional Status:

- Height : 160 cm
- Weight : 70 kg
- IMT : 27,3 kg/m² (Overweight)

Generalist Status:

- Head : Normocephal.
- Eyes : Not hyperemic, no jaundice, conjunctiva no
anemis, no udem. Eyes within normal
limits.
- Neck : There is no enlargement of KGB and
thyroid.

- Thorax :
 Heart : Heartbeat 1 & 2 regular heart sounds,
murmur (-), gallop (-).
 Pulmo : Vesikuler, ronkhi (-/-), wheezing (-/-).
- Abdomen : Good turgor, tenderness (-), bowel sound
(+), peristaltic bowel (-).

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 - Ekstremities : Good reflexes, warm acral, edema (-).

Dermatologikus Status

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 In the bilateral inguinal regio there is a billion-placard erythematous
plaque, diffuse-circumcircular, polycyclic edges, with a fine skuama over regional
erythematous plaque. In the right lumbar abdominal regio there is erythematous,
anular, circular, and discrete plaque

Resume

Patient came to Polyclinic of Skin and Sex of TK II Moh Ridwan Meuraksa

Hospital with complaints of reddish spots accompanied by itching on the right
abdomen and groin since less than 1 week ago. Itchy complaints increase when the
patient is sweating. The red spots begin with the abdomen then appear in the groin
and extend in the area. Patients rarely change clothes if they are inside the house.

From physical examination was obtained IMT patient overweight. In

dermatologic status, in the bilateral inguinal regio there is erythematous plaque,

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diffuse-circumcircus, polycyclic edges, with a fine skuama over regional
erythematous plaques. In the right lumbar abdominal regio there are erythematous,
anular, circular, and discrete plaques.

V. Diagnosis
- Tinea cruris et corporis
VI. Differential Diagnosis
- Erythrasma
- Candidiasis intertriginosa
VII. Supporting Investigation
No investigation was performed.
VIII. Penatalaksanaan

Medikamentosa

 Systemic:
- Oral Antimycotics : Ketoconazole 2 x 200 mg / day for 2 weeks.
- Oral Antihistamine: Loratadine 1 x 10 mg / day for 10 days.
 Topical:
Topical antimicrobial : 2% 2x1 Ketoconazole Cream for 4 weeks.

Non-Medikamentosa:

1. Explain to the patient that the disease is caused by the fungus.

2. Prevent scratching
3. Keeping the temperature and moisture under the clothes so as not
to overheat. Avoid tight clothes.
4. Avoid sharing personal equipment, such as towels or clothes.
5. Immediately wash clothes after use and always use clean clothes
which absorb sweat.
6. Take medicine according to the rules and do not stop the
treatment without a doctor's permission.

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IX. Prognosis
Quo ad vitam : Ad bonam
Quo ad functionam : Ad bonam
Quo ad sanationam : Dubia ad bonam