Case Report :

ATOPIC DERMATITIS
PUTRI JATI UTAMI

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PATIENT IDENTITY

 Name : Ms. N
 Age : 23 yo
 Gender : Female
 Address :
 Religion : Moslem
 Date of Admission :
SUBJECTIVE
CHIEF COMPLAINT : Rashes on the flexures in front of her elbows 1
week prior to hospital admission

HISTORY OF PRESENTING ILLNESS :

Patient developed rashes on the flexures in front of her elbows 1 week
prior to hospital admission. Patient also complains itchy and dry skin.
These complaints often developed when patient break a sweat. The patient
often has these complaints since 10 years ago, but according to her this
is the most severe.
Patient used to treat her complaints with Hydrocortisone from the nearest
community health center, but this time the complaints still occurs
PAST MEDICAL HISTORY:
 Same complaints since 10 years ago
 History of allergic rhinitis and asthma were denied
 History of Amoxicillin drug allergy (+) and shrimp food allergy (+)

FAMILY HISTORY
 History of same complaints from her father (+)
 History of allergic rhinitis and asthma from all her family members were de
nied
 PHYSICAL EXAMINATION
OBJECTIVE
General
• Mildly ill
Condition

Consciousness • Compos mentis

• BP : 120/80 mmHg
• Pulse : 96 x/min, regular
Vital sign
• Respiration : 20 x/min, reguler
• Temperature : 37,0oC
STATUS GENERALIS

 Head : Normocephal
 Eyes : pupils isocor 3mm, CA -/-, SI -/-
 Ears, Nose, Throat : Hyperemia pharynx (-) T1/T1
 Neck : Anterior neck folds (+)
 Thorax
Pulmo : Chest expansion symmetrical, vesicular (+/+), ronchi (-/-),
wheezing (-/-)
Cor : Regular S1 S2 heart sound, gallop (-), murmur (-)
 Abdomen : Flat, tympani all quadrant
 Extremities : warm, oedema (-/-), CRT <2s
Local Status
DERMATOLOGICAL STATUS

Regio cubiti dextra-sinistra

Erythematous plaques on the flexures in front of the elbows

with lichenification and small multiple papules with erosion to
crusts
ASSESSMENT AND PLAN

Differential Diagnosis
– Atopic Dermatitis
– Irritant Contact Dermatitis
– Psoriasis
This patient has :

3 major criteria :
 pruritus,
 dermatitis affecting flexural surfaces in adult
 chronic or relapsing dermatitis

3 minor criteria :
 presents of anterior neck folds
 triggers from foods and environmental factors
 dry skin
CLINICAL DIAGNOSIS :

ATOPIC DERMATITIS
PLAN :
Diagnostic tests
– Patch test
– WBC differential count

Medications
– Topical : Inerson 15gr oint, use on the elbows
flexures afterbath

– oral : Loratadine 10 mg 1x1 tab/day

Prognosis
– Quo ad vitam : bonam
– Quo ad functionam : bonam
– Quo ad sanationam : Dubia ad malam
MEDICAL JOURNAL
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