CASE REPORT

HERPES ZOSTER

By:
Nadhila Adani
1102013196

Supervisor:
dr. Dian Andriani SpKK, M. Biomed, MARS Kol CKM (K)

DEPARTMENT OF DERMATOLOGY AND VENEREOLOGY

FACULTY OF MEDICINE YARSI UNIVERSITY
RS TK II MOH RIDWAN MEURAKSA
2018
 CASE REPORT

I. PATIENT’S IDENTITY
Name : Ny. S
Sex : Female
Place, Birth Date : Cirebon, 12-11-1958
Age : 59 years old
NRM : 38 44 96
Address : Kampung Duku
Occupation : Housewive
Marriage Status : Married
Education : Senior High School
Religion : Islam
Nationality : WNI
Payment : BPJS
Examination Date : April 26th 2018

II. ANAMNESIS
Anamnesis was done by auto-anamnesis on April 26th 2018 10.45 WIB at
Dermatology and Venereology Policlinic in TK II Moh Ridwan Meuraksa
Hospital.

Main Complaint:
Rash in the chest and right arm since twelve days before in hospital that
has started to dry.

Additional Complaint:
Itch and heat around the lesion area.

1
Ongoing Disease History:
Patient came to the dermatology and venereology policlinic at Moh
Ridwan Meuraksa Hospital with a rash complaint around right chest and arm that
has started to dry. There are itch and heat around lesion area. In the beginning
patient felt stiff around chest and arm. In the next day, on April 14th 2018, bubbles
with liquid that itchy and warm on the lesion was found. The bubbles appeared in
large quantities and sizes, it begun on the right side of chest and go to the right
arm.
Patient said that she already tried with ketoconazole cream for 2-3 days,
but it doesn’t work to the bubbles. Then, patient went to puskesmas and got send
to Moh. Ridwan Meuraksa Hospital. The patient already got some medication that
were Acyclovir 5 x 800mg, Paracetamol 3 x 1tab, Neurodex 2 x 1 tab, and
Acyclovir Zalf 1 x 1 in Moh. Ridwan Meuraksa Hospital on April 20th 2018.
Patient said that she have histories of diabetes mellitus, hypertension and,
asthma. Patient never has something like this before, and there were no one with
the same condition in her environment.

Former Disease History:

- History of diabetes mellitus ( + )
- History of hypertension ( + )
- History of asthma ( + ) relapse when cold.

Family Disease History:

- There is no family member that has the same complaint as the patient.
- Father of the patient has a history of hypertension and diabetes mellitus.

III. PHYSICAL EXAMINATION

1. General State
General circumstances : Good
Awareness : Compos mentis, cooperative
State of nutrition : Good

2
Vital sign
Blood pressure : 130/80 mmHg
Heart beat : 77 x/min
Respiration : 20 x/min
Temperature : 36,6o
Height : 155 cm
Weight : 63 kg
IMT : 27 kg/m2
Head : Normochepal
Eyes : Conjunctiva isn’t anemic, no sclera
jaundiced
Neck : Lymph and thyroid glands aren’t palpable
enlarged
Thorax
Cor : S1-S2 regular (+), murmur (-), gallop (-)
Pulmo : Vesicular breath sounds (+/+), ronchi -/- ,
wheezing -/-
Abdomen : Tenderness (-), bowel sounds (+) normal
Genitalia : Undone
Extremities : Warm acral, oedem (-)

3
 2. Dermatology State

Pict 1. Regio Thorachal Anterior

Pict 2. Regio Ventral Brachii dan Antebrachii Dextra

On regio thorachal anterior and ventral brachii and antebrachii dextra there
are plaques eritematosa multiple, lenticular size, unilateral spread, sirkumskripta,
with skuamas and crustas.

IV. Additional Examinationx

Additional examination are not done.

4
V. Resume
A 59 years old female came to the department of dermatology and
venereology in Moh Ridwan Meuraksa Hospital with complain about rash in the
right chest and arm that has started to dry. The rash feels itchy and warm. In the
beginning, patient felt stiff around chest and arm. The next day, on April 14th
2018, bubbles with liquid that itchy and warm on the lesion was found. The
bubbles appeared in large quantities and sizes, and begun on the right side of
chest and went to the right arm.
From physical examination, the general states was normal. From the
dermatology state, regio thorachal anterior and ventral brachii and antebrachii
dextra there are plaques eritematosa multiple, lenticular size, unilateral spread,
sirkumskripta, with skuamas and crustas.

VI. Work Diagnosis

- Healing herpes zoster thoracalis dextra

VII. Differential Diagnosis

- Herpes simplex
- Varicella

VIII. Therapy
Non Medikamentosa:
1. Explain the patient about this disease is one that was caused by a virus.
2. Educate the patient to use the medication regularly and not stopping it
without doctor’s permission.
3. Educate the patient to not changing clothes and towel with other
people.
4. Keep the body clean by taking a bath two times a day using water and
soap also to wash hands before and after touch the lesion.
5. Cutting nails.

5
 6. Avoid scratching if it feels itchy, because scratch can cause an
infection.
7. Keep the blisters to not ruptured.

Medikamentosa:
Systemic :
1. Antibiotic oral : Amoxicillin 500mg 3 x 1 tab for 5 days.
2. Antipyretic oral : Paracetamol 500mg 3 x 1 tab (if in pain)
3. Neurons vitamin oral: Neurodex 1 x 1 tab.

IX. Prognosis
Quo ad vitam : dubia ad bonam
Quo ad functionam : dubia ad bonam
Quo ad sanationam : dubia ad bonam