bismillahirahmannirahim .. good morning. introduce my name barrel candysa.

this morning I
will present the results of my case report titled seborrhoeic dermatitis. my patient was named
is…….

Name: Tn. L
No. Medical Records: 37.64.83
Age: 22 Years
Last Educational: SMK
Occupation: Army
Unity: YONARHANUDSE-6
Islam
Address: Dormitory ARHANUDSE-6
Suku Bangsa: Sasak
Marital Status: Not Married
Last Educational: SMK
Room: Polyclinic Skin and Gender
Hospital Entrance Dates: January 03, 2018

II. ANAMNESIS
Autoanamnesis conducted on January 9, 2018 at 10:30 pm in Polyclinic Skin and Gender RS.
TK II. Ridwan Meuraksa.
Anamnesis done by: Autoanamnesis
Main Complaints: Itching on the neck, body and hands since three months ago
Additional Complaints: Bentol and when scratched out of water

III. DISEASE HISTORY NOW

Patients come to the hospital skin clinic. TK II Ridwan Meuraksa with itchy complaints on the
neck, body and both hands since three months ago. Itching is felt every time and interfere with
daily activities. Originally seen a bump but when scratched out liquid like water. Then the
patient treated, by the doctor given the drug and recommended to routinely use hand body /
body lotion.
During the interview, the patient is in the second control process. On the neck, the body and
both hands appear spotted, skin peeling and yellowish white. The itchiness is still felt but has
been reduced unlike at the beginning of treatment. Patients admitted that their condition was
improving, especially after taking the medicine after the first control. Patients admitted bathing
twice a day, especially after outdoor activities. Patients deny any history of asthma, shortness
of breath or sneezing in the morning. Daily patient rarely exposed to irritant substances. The
patient also admitted that he is a light smoker who smokes 1-2 cigarettes per day. Then, the
doctor provides loratadine and methyl prednisolone therapy.

IV. PAST MEDICAL HISTORY

Previously the patient had never felt a complaint like this. Patients also deny the presence of
hypertension, high blood sugar, heart, food allergy or medication, asthma and also never feel
sneezing in the morning or allergic rhinitis.

V. FAMILY DISEASE HISTORY

In the patient's family has never experienced such complaints and also denies the presence of
hypertension, heart, lung, high blood sugar, kidney, drug or food allergy, asthma and also
sneezing in the morning or allergic rhinitis.
VI. PHYSICAL EXAMINATION
Awareness: Composmentis
General Condition: Good

Vital Signs
Blood Pressure: 120/80 mmHg
Nadi: 60 times / minute
Breathing: 20 times / min, Regular
Temperature: 36 ° C

Nutritional status
Height: 175 cm
Weight: 65 kg
IMT: 21,24 kg / m²

VII. GENERALIS STATUS

Head: Normosephal
Eyes: Sclera not jaundice, conjunctiva no anemis, no madarosis no conjunctival injection
Tooth and Mouth: hyperemic (-), caries (-)
ENT: T1 / T1 tonsils, hyperemic (-)
Neck: No KGB enlargement
Thorax: Pulmo: Ronki (- / -), Wheezing (- / -)
Cor: normal BJ I & II, murmur (-), gallop (-)
Abdomen: Tenderness (-), bowel sound (+)
Ekstermitas: not edema
Acral: Warm
CRT: Less than 2 seconds

VIII. DERMATOLOGICUS STATUS

In the region of colli, thorax, abdominal, superior extremity dextra et sinistra there are multiple,
circular, milier-sized papules with crusting and fine skuama.

IX. SUPPORTING INVESTIGATION

In this patient has not been investigated.

X. RESUME
The 22-year-old male patient came with itchy complaints on the neck, body and hands since
three months ago. Itching is felt every time and interfere with daily activities. Originally seen
a bump but when scratched out liquid like water.
In the second control, the neck, the body and both hands are seen multiple, circular, milier-
sized papules with crusting and fine skuama. Currently the itchiness is still felt but has been
reduced unlike at the beginning of treatment. Patients admitted the situation had started to
improve especially after after the first control. Then the doctor gave loratadine and methyl
prednisolone therapy.

XI. DIAGNOSIS AND DIAGNOSIS APPEALS

Diagnosis: seborrheic dermatitis.
Differential Diagnosis: Psoriasis, adult atopic dermatitis, irritant contact dermatitis,
dermatophytosis, rosacea.

XII. GOVERNANCE
Non-Medical
1. Use body lotion / hand body.
2. Keep yourself clean like a bath 2x a day, if the lesion is on the head use a shampoo containing
anti malassezia drugs such as (selenium sulfide, zinc pyrithione, ketoconazole, and terbinafine
solution 1%).
3. Patient education to come back control to monitor the progress of the disease.
Medikamentosa
1. Loratadine 1x10 mg (after eating)
2. Methyl prednisolone 2x4 mg (after eating)

XIV. PROGNOSIS
Quo ad vitam: Ad bonam
Quo ad functionam: Ad bonam
Quo ad sanationam: Dubia ad bonam
Quo ad cosmeticum: Ad bonam