The patient’s identity:

from wikipedia.org

Name: Ms.. A.
Gender: Female
Age: 20 years
Religion: Islam
Ethnic groups: Javanese
Occupation: Student
Date of inspection: March 30, 2009

II. Basic data:

II.1. Anamnesa:
Main complaint: Warm Body, appears small bubbles in the chest, arms and thighs.

Disease History Today:
Patients complain rather warm body since 3 days ago and appeared small bubbles spread throughout the body, more and more grows. the bubbles first appeared in the chest area, then spread to the upper arm and back. The use of drugs or ointments denied by the patient.

Formerly Disease History:
Never sick like this before.

Family Disease History:
No one suffered like this in the family, a family history of allergies to be denied.

Social History and hobbies:
The patient did not smoke and do not consume alcohol. No one suffered like this in the environment. Allergy history denied.

II. 2. Physical Examination:

Status generalists:
Good general condition. GCS 4 5 6. Compos Mentis. Vital sign in the normal range.

Lokalis Status:
Regio: thrunk,
Effloresensi:
There are vesicles spread with age is not the same. Vesicles most widely encountered in the chest area.

III. List of Issues:
1. Body Sumer since 3 days ago.
2. No contact with varicella patients.
3. There is a vesicle-vesicle spread with age is not the same.
4. There was no history of allergies.

IV. Resume:

Ms. A, 20 years old, from complaints warm bodies anamnesa obtained 3 days, and there is little bubbles spread in the chest area, arms, and thighs. No one suffered like this either within the family and friends. Allergy history denied.

V. Assessment:
Varicella.
Differential Diagnosis:
1. Herpes Zoster
2. Herpes simplex
3. Koksaki viral Eksantem
4. Impetigo Kontagiosa

VI. Planning:
Diagnose: –
Therapy:
Acyclovir 800mg ∫ 1 No. 5 dd. XXXV
Vit C 500mg ∫ No. 3 ss 1. XXI

Monitoring: complaints and lesions.
Education:
1. Explained to the patient about his disease.
2. Keep your body by eating health, nutritious and balanced diet.