I. The patient’s identity:

Name: Ms.. N
Gender: Female
Age: 17 years
Religion: Islam
Ethnic groups: Javanese
Occupation: Student
Status: Not married
Date of inspection: March 30, 2009
II. Basic data:

II.1. Anamnesa:
• Main Complaint:
feeling heat and pain in the back and left chest.

• History of desease rightnow:
8 days ago the body was hot, feverish, coughing runny nose, head ache on the left. By his mother, his back scraped by using eucalyptus oil, but the patient complained of pain in her back is. Since 3 days ago appeared continuous pain, and there are bubbles clustered at the back and left chest. Denied allergy history, never use an ointment or chemicals in the chest and back area. History of venereal disease denied.

• History of desease Formerly:
o She ever had chickenpox at the age of 4 years,
o suffering from pneumonia when she was 5 years old, until the patient into hospital,
o have asthma.
o It’s never suffered like this before

• Family Illness History:
Close family or relatives did not have the same illness.

• Social History:
12th grade and no similar illness in the vicinity. Previously, the patients often consume herbs.

II. 2. Physical Examination:

Status generalists:
The patient looked healthy with a full awareness (compus mentis).
Blood pressure: 120/80
RR: 19 times / min
pulse: 76 times / min
T: 37 degrees Celsius
a-i-c-d: negative
thorak: cor / pulmo within normal limits
abd: liver / lien was not palpable
ex: akral warm.merah, dry; edema: negative / negative

Lokalis Status:
Regio:
In the region of the left thorak found a group of above vesikle macular erythema.

Effloresensi:
Vesicel found scattered bands in accordance with the above dermatome skin erythema, pustul (-), krusta (+), erosion (-), dry skin, bull containing turbid fluid, the skin between bands normal, the age of lesions on the same mob, age lesions from one another is not the same.

III. List of Issues:
• There was pain, heat,in the back and left chest.
• There are scattered vesicel in the back and left chest .

IV. Resume:
Miss N, 17-year-old is complaining of pain accompanied bubbles clustered in the back and left since 3 days ago. Miss N. ever had varicela as a child.
V. Assessment:
Herpes Zooster Thorakal Sinistra
Differential Diagnosis:
1. Varicella
2. Alergica contact dermatitis
3. Herpes simplex
4. Pemfigus vulgaris
VI. Planning:
Diagnose: –
Therapy:
Acyclovir 800mg dd 5 (for 7 days)
3 dd Mefenamat acid 500mg p.r.n.
Salicyl powder 2% p.r.n. S u.e.

Monitoring: complaints and lesions.
Education:
1. Explained to the patient about his disease.
2. Keep your body clean.
3. Keeping bubbles not broken.
4. Eating and drinking regularly.
5. Explaining the procedure for taking drugs.