PATIENTS STATUS

Name : Madam Rosna

Age : 31 years

Address : Kubba

Status : Married

Admitted on : 3rd July 2015

Ward : L3 AB ISO BED2

Chief Complaint: Redness lesion since 4 months ago.

Brief Anamnesis: A woman 31 years old was admitted to the hospital with chief complaint of
redness lesion found on her face, both arms and legs, abdomen, and her back since 4 months ago.
She feels like burning sensation around the lesions. There is history of falling down from stairs
and her lower part of back bone was broken. Both of her feet are swollen. Her right hip was
injured. History of leprosy infection since 2 years ago, on treatment for a year, then she is given
Prednison 2x2 tablet for 2 years. 4 months ago is the last time taking medication. No fever is
detected.

From the first physical examination

Location : Region fascialis, abdominalis, extremities superior et inferior dextra et sinistra

Efluorescence : erythema macula, hyperpigmentation, scaly, edema (extremity inferior dextra)

Location : Region hip posterior dextra

Efluorescence : erythema macula, edema, hyperpigmentation, madidans ulcer

Vital sign : Blood pressure : 120/70mmHg

Pulse Rate : 86 beat/minute

Respiratory rate : 20 time/minute

Temperature : 36,7C
The patient was diagnosed with Reaction of Morbus Hansen type 1, Morbus Hansen Relapse and
compression fracture of Lumbal I-IV

The current status

General condition: Compos mentis

Moderate sickness

Good nutrition

Vital sign : Blood pressure : 120/70mmHg

Pulse Rate : 88 beat/minute

Respiratory rate : 20 time/minute

Temperature : 36,8C

Current dermatology status (Day 7)

Location : Region fascialis, abdominalis, extremities superior et inferior dextra et sinistra

Efluorescence : erythema macula, hyperpigmentation, edema

Location : Region hip posterior dextra

Efluorescence : erythema macula, edema, hyperpigmentation, madidans

RESUME

A woman 31 years old was admitted to the hospital with chief complaint of erythema macula
found on her face, both arm and leg, abdomen, and her back since 4 months ago. She feels like
burning sensation around the lesions. There is history of trauma which caused lumbal fracture.
Her feet are swollen. Her right hip was injured. History of leprosy infection since 2 years ago,
she is on treatment for a year, then she is given Prednison 2x2 tablets for 2 years. 4 months ago is
the last time taking medication. No fever is detected.

Currently, the patient was diagnosed with Reaction of Morbus Hansen type 1, Morbus Hansen
Relapse and compression fracture of Lumbal I-IV. For the current treatment from Dermatology
Department are intravenous fluid ringer lactate 20 drops/minute, Dexamethason injection
1amp/24 hours/ intravenous, neurobion drips 1amp/24 hours/intravenous, compress Natrium
Chloride 0,9% on the ulcer and lesion on the back, Lanolin 10% + Vaselin add (half of the upper
part body in the morning and half of the lower part of the body at evening), Gentamycin cream
(morning-evening). Dermatology department is waiting for the Acid-Fast Bacillus Test result and
plain x-ray photo.