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PATIENTS IDENTITY

Name
: Supriadi.
Gender
: Male.
Age
: 15 years old.
Marital status
: Single.
Religion
: Muslim.
Address
: Balombong, Enrekang.
Occupation
: Student.
Register. no.
: 654033.
HISTORY TAKING
Date of history taking: 1st April 2014.
Chief complain:
There is a wound around his anal and scrotum since 4 days ago.
Further anamnesis:
The first wound appear when he was defecating a quite hard in consistency of
feces and then he scratched it. It causes the wound to be widen. He also felt pain
around the wound area. The left testis of the patient also looks edema and
accompanied with a fever.
Systematically anamnesis:
He was treated with Acute Lymphoblastic Leukemia around 1 months ago.
PHYSICAL EXAMINATION
Date of examination: 1st April 2014
General condition
: Moderate.
Consciousness
: Compos mentis.
Vital sign
:
o Blood pressure
: 100/70 mmHg.
o Heart rate
: 100 x/m.
o Respiratory rate : 28 x/m.
o Temperature
: 36 C.
DERMATOLOGICAL STATUS
1

Location
Efflorescence
Location
Efflorescence

: Perianal region.
: Erythema, erosion, excoriation, fissure.
: Scrotum region.
: Erythema, edema.

DIAGNOSIS
Perianal cellulitis.
DIFFERENTIAL DIAGNOSIS
THERAPY
Compress with NaCl 0.9% (Morning, Evening, Night)
Bactoderm cream
LABORATORY EXAMINATION RESULT
Full Blood Count (1st April 2014)
o WBC : 0.18 10^3/uL.
o RBC : 3.42 1-^6/uL.
o HGB : 9.5 g/dL.
o HCT : 27.7 % .
o PLT : 24 10^3/uL.
o Result: Pancytopenia
Liver Function:
o Total billirubin
: 7.97 mg/dl.
o Direct billirubin : 4.63 mg/dl.
o SGOT
: 51 U/L.
o SGPT
: 65 U/L.
nd
Urine test (2 April 2014)
o Billirubin : 3+
o Nitrite
: Positive.
Bone Marrow Aspiration (11th March 2014)
o Result: ALL- L1.
__________________________________________________________________
2nd April 2014 (1st day)
DERMATOLOGICAL STATUS
2

Subjective
: Wound around the anus, erythema around the wound, pain.
Objective
: Dermatological Status
Location
: Perianal region
Efflorescence
: Erythematous macule, erosion, excoriation, madidans pus.
DIAGNOSIS
Perianal cellulitis.
THERAPY
Compress with NaCl 0.9% for 5 minutes every 2 hours.
_________________________________________________________________
3rd April 2014 (2nd day)
DERMATOLOGICAL STATUS
Subjective
: Wound around the anus, redness around the wound decreased,
pain decreased.
Objective
: Dermatological Status
Location
: Perianal region
Efflorescence
: Erythematous macule, erosion, excoriation, madidans.
DIAGNOSIS
Cellulitis.
THERAPY
Compress with NaCl 0.9% for 5 minutes every 2 hours.
Bactoderm cream (Morning, Evening, Night).
__________________________________________________________________
4th April 2014 (3rd day)
DERMATOLOGICAL STATUS
Subjective
: Wound around the anus, redness around the wound decreased,
pain decreased, wound accompanied with a little bit of blood,
pus decreased.
Objective
: Dermatological Status
Location
: Perianal region
Efflorescence
: Erythematous macule, erosion, excoriation, madidans.
DIAGNOSIS
Cellulitis.
THERAPY
Compress with NaCl 0.9% for 5 minutes every 2 hours.
Bactoderm cream (Morning, Evening, Night).
3

__________________________________________________________________
5th April 2014 (4th day)
DERMATOLOGICAL STATUS
Subjective
: Wound around the anus, redness around the wound decrease,
pus decreased, patient complaint that he cannot sleep because of
the pain.
Objective
: Dermatological Status
Location
: Anal region
Efflorescence
: Erythematous macule, erosion, excoriation, madidans.
DIAGNOSIS
Cellulitis.
THERAPY
Compress with NaCl 0.9% for 5 minutes every 2 hours.
Bactoderm cream (Morning, Evening, Night).
Planning: Debridement.
_________________________________________________________________
6th April 2014 (5th day)
DERMATOLOGICAL STATUS
Subjective
: Wound around the anus, redness around the wound decrease,
pus decreased, pain decreased.
Objective
: Dermatological Status
Location
: Anal region
Efflorescence
: Erythematous macule, erosion, excoriation, madidans, fissure,
crust.
DIAGNOSIS
Cellulitis.
THERAPY
Compress with NaCl 0.9% for 5 minutes every 2 hours.
Bactoderm cream (Morning, Evening, Night).
Planning: Debridement on 7th April 2014.
__________________________________________________________________
7th April 2014 (6th day)
DERMATOLOGICAL STATUS
Subjective
: Wet wound around the anus, redness around the wound
cannot be seen anymore, pain decreased.
4

Objective
: Dermatological Status
Location
: Anal region
Efflorescence
: Erosion, excoriation, madidans, fissure, crust.
DIAGNOSIS
Cellulitis.
THERAPY
Compress with NaCl 0.9% for 5 minutes every 2 hours.
Bactoderm cream (Morning, Evening, Night).
Necrotomy and debridement.
__________________________________________________________________
8th April 2014 (7th day)
DERMATOLOGICAL STATUS
Subjective
: Wound around the anus, redness around the wound cannot
decreased, pain decreased, bleeding after necrotomy negative.
Objective
: Dermatological Status
Location
: Anal region
Efflorescence
: Erosion, excoriation, madidans.
DIAGNOSIS
Cellulitis.
THERAPY
Compress with NaCl 0.9% for 5 minutes every 2 hours.
Bactoderm cream (Morning, Evening, Night).
Metcovasin cream (Night)
_________________________________________________________________
9th April 2014 (8th day)
DERMATOLOGICAL STATUS
Subjective
: Wet wound around the anus, redness around the wound
decreased, pain decreased, bleeding after necrotomy negative.
Objective
: Dermatological Status
Location
: Anal region
Efflorescence
: Erosion, excoriation, madidans.
DIAGNOSIS
Cellulitis.
THERAPY
Compress with NaCl 0.9% for 5 minutes every 2 hours.
5

Bactoderm cream (Morning, Evening, Night).


Metcovasin cream (Night)
__________________________________________________________________
10th April 2014 (9th day)
DERMATOLOGICAL STATUS
Subjective : Wound is getting better.
Objective : Dermatological Status
Location
: Anal region
Efflorescence
: Erosion, excoriation, madidans.
DIAGNOSIS
Cellulitis.
THERAPY
Compress with NaCl 0.9% for 5 minutes every 2 hours.
Bactoderm cream (Morning, Evening, Night).
Metcovasin cream (Night)