IDENTITAS

This is the identity of the patient

Name
Age
Gender
Address
Religion
Culture
Date check

: Baby A
: 15 months
: Male
: Gondanglegi
: Moeslem
: Java
: 29 January 2015

ANAMNESA
The main complaint : itching and bumps are filled with fluid.
From the history of present :
History of present illness:
Patients come with his parents with complaints of itching on the chest and there are bumps
containing clear fluid, and the scars are still wet and bumps that have been broken reddish. This
complaint is felt since 1 week ago around the nose and chest. The patient's parents said initially
there was little bump but over time becomes wide. Not hot, not painful, just itchy. Because very
annoying itch and scratch until the patient is often broken. Bumps are easily broken and after the
outbreak of the former bump dries brownish yellow with a reddish base.
The patient's parents had brought the patient to the midwife and was given pills and ointment
acyclovir. Because there is no improvement and bumps increasingly widespread, the patient was
taken for treatment to the Ambullatory Installation Kanjuruhan Hospital Kepanjen.
From history before :

The patient never like this before

Allergy history denied.

The family disease history:

No family is sick like this.

Allergy history denied.

History of contact with patients with the same complaint (+)

PHYSICAL EXAMINATION

General conditions

: Good

Awareness

: Compos mentis ( GCS E4V5M6)

Status of nutrition

: enough

Vital signs
Tensi

: Did not measure

Pulse

: Did not measure

RR

: Did not measure

Temperature : Did not measure

Weight

: 6,5 kg

Head to toe examination

Head

: There not abnormality

Eyes

: There not abnormality

Ear_Nose_Throat : Have a skin disorders

Face

: There not abnormality

Mouth

: There not abnormality

Neck

: There not abnormality

GI Track

: There not abnormality

Thoraks

: Have a skin disorders

Abdomen

: There not abnormality

Genitalia system : There not abnormality

Gluteal

: There not abnormality

Ekstremitas

: There not abnormality

Effloresensi

Looks macular erythematous sharp margin/firm boundaries, vesicles (+), blister (+), koloret
erythematous base (+)

PLANNING ADDITIONAL EXAMINATION

Gram staining streptococcus aureus (+) colour blue purplish

RESUME
History of present illness:
Patients come with his parents with complaints of itching on the chest and there are bumps
containing clear fluid, and the scars are still wet and bumps that have been broken reddish. This
complaint is felt since 1 week ago around the nose and chest. The patient's parents said initially
there was little bump but over time becomes wide. Not hot, not painful, just itchy. Because very
annoying itch and scratch until the patient is often broken. Bumps are easily broken and after the
outbreak of the former bump dries brownish yellow with a reddish base.
The patient's parents had brought the patient to the midwife and was given pills and ointment
acyclovir. Because there is no improvement and bumps increasingly widespread, the patient was
taken for treatment to the Ambullatory Installation Kanjuruhan Hospital Kepanjen.
From history before :

The patient never like this before

Allergy history denied.

The family disease history:

No family is sick like this.

Allergy history denied.

History of contact with patients with the same complaint (+)

DIAGNOSIS :

DIFFERENTIAL DIAGNOSIS :

MANAGEMENT
Non medikamentosa
1.
2.
3.
4.

after direct contact with patients are advised to wash hands

maintain hygiene yourself with regular baths
avoid hot and humid temperatures that bacteria are not quickly spread
ventilation or air exchange good

Medikamentosa

Topical antibiotic
Fucidat acid cream 2%

Systemic antibiotic
Amoxicillin 3x150 mg