CASE REPORT

Identity of Patient
Name : Ms. Tv
Sex : Female
Registration Number : 89-09-07
Age : 10 years old
Address : Lam Gapang, Banda Aceh
Hospitalized : January 7th, 2013
Examination day : January 7th, 2013

Anamnesis
1. The Chief Complaint
Blister contains clear water with itchy all over the body since 2 days ago.
2. Additional Complaint
Dizziness, headache, fever.
3. History of Present Illness
Patient come to hospital with chief complaint of blister contains the clear water
with itchy on all over body since 2 days ago. The firstly red rash appears on trunk,
and then became blister on neck, hand, legs and over all his body. The lesions
tended to different all over the body. Some lesion on his extremities is being
broke. Patient also complaint dizziness and headache, and sometime fever
appears. Patient never contact with another person with same disease, and did not
have complaint sore throat, cough, and abdominal pain.
4. History of Past Illness
Ever suffered from measles.
5. Family History
None of his family had this kind of disease.
6. Social History
Patient take a bath twice day with a good sanitary, daily patient activity is to go to
school and play with friends
7. History of medicine
Patient used of drugs from clinic paracetamol syrup for two days, and patient not
used traditional medicine.

Physical Examination
Vital Sign : in normal condition

General Status
1. Skin : further explanation in status of dermatology

2. Head
Eye : hyperemic on conjunctiva (-/-), lagophthalmus (-/-)
Mouth : mucosa hyperemic (-), beslag (-),
Lips : in normal condition
Tongue: in normal condition
Tonsils : enlargement (-)
Pharynx : hyperemic (-)

3. Neck : in normal condition

4. Chest
Form : normochest
Movement : symmetrical
Breathe Type : thoracal-abdominal
Retraction : suprasternalis (-), intercostalis (-)
Palpation : Stem fremitus in normal condition

Percussion :
Location Right Chest Left Chest
Superior sonor sonor
Media sonor sonor
Inferior sonor sonor
 Auscultation :
Principal Breath Sound Right Chest Left Chest
Superior vesikuler vesicular
Media vesicular vesicular
Inferior vesicular vesicular
Additional Breath
Right Chest Left Chest
Sound
Superior Rh (-), wh (-) Rh (-), wh (-)
Media Rh (-), wh (-) Rh (-), wh (-)
Inferior Rh (-), wh (-) Rh (-), wh (-)

5. Heart : in normal condition

6. Abdomen : in normal condition

7. Genetalia : in normal condition

8. Anal : in normal condition

9. Extremities :
SUPERIOR INFERIOR
Extremities
Right Left Right Left
Pale - - - -
Edema - - - -
Icteric - - - -
Redness - - - -
Dermatological status

Picture
 (A) (B)

(D) (E)

(E)
(F)

Figure :
visit at January 7th 2013. vesicle contain clear fluid based on erythematous
 macule all over the body. (A) (B) regio coli (C) thoracalis anterior (D)
abdominalis (E) thoracalis posterior (F) superior extremity.

Dermatology status :
Regio coli, upper and lower extremity, abdomen, anterior and posterior thoracalis
lessions there were vesicle contain clear fluid based on erythematous macule discrete
distribution.

Regio thoracalis posterior, regio ekstremitas superior :

Multiple vesicle contain clear fluid on the basis of erythematous erosion

Differential Diagnosis:
1. Varicella
2. Bullous impetigo
3. Generalized herpes zoster
4. Insect bites
5. Allergic contact dermatitis

Supporting Examination:
Tzanck test : negative ; not found multinucleated giant cells

Diagnosis:
Varicella

Management:
Supportif
Bed rest
Medication
Systemic
 1. Antiviral : acyclovir 5 x 640 mg (for 7-10 days)
2. Antihistamine : mebhydroline napadisylate 3 x 25 mg ( for 5 days)
3. Antipyretic : paracetamol 3x250 mg (if fever)
Topical
1. Antibiotic : fucidic acid cream 5 gr twice a day (for erosion; hand, back)
2. Talcum acidum salycillium 2% (for vesicle; neck, chest, leg)
Education
1. Do not touch and contaminate the lesion
2. Taking a bath usually to prevent secondary infection

Prognosis:
Quo ad vitam : dubia ad bonam
Quo ad functionam : dubia ad bonam
Quo ad sanactionam : dubia ad bonam