ulkus genitalia
TRANSCRIPT
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Ulcus Genitalia
Yurike Adehline
Sazida Subethan
Muh. Syarif
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CASE REPORT
Name : Mr. N
Gender : Female
Age : 43 years old
Marital status : Married
Address : Andi Mangerangi 22
Admission date : 5 November 2012
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HISTORY TAKING Chief complain :
Itching and sores on regio vulva Brief Anamnesis :
It first appear as a redness spot in vulva and it was itchy then it’s scratched by her, after that appeared lots of reddish-black spots watery. Smell Leukorrhea (+), pain (-). Patient also complain sores in her lips tasted like burning.
At first, The Patient separated injectable contraception and she got menstruation for three months. After the menstruation finished, she complained excessive leukorrhea and it had been going on since 6 months ago until today.
History of treatment (+) in Puskesmas. She was given an ointment, yellow and white pills.
Medical History : Fever (+) 2days before come to the hospital Cough (+) 4days before come to the hospital
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PHYSICAL EXAMINATION
Anemic (-) icterus (-) cyanosis (-) Location : Regio Vulva and Inguinalis Effloresensi : ecscoriasis , ulcus, nodules Cor/Pulmonal : in normal limit Abdomen : normal, peristaltic (+) Extremities : edema (-) Lymph nodes : Enlargement (-)
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CURRENT STATUS
Consciusness : compos mentis General condition : Moderate Hygiene : Moderate Vital sign : BP 90/60 mmHg
pulse 88x/minute
RR 22x/minute
Temperature 36,9°C
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DERMATO-VENEROLOGY STATUS
Location 1 : Regio Vulva Efflouresence : Ulkus ,ecscoriasis, nodul Location 2 : Regio Inguinalis Efflouresence : Ulkus ,ecscoriasis, nodul
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LABORATORY RESULT WBC : 65.000/μL RBC : 5.060.000/μL PLT : 344.000 Hb : 13,0 gr/dL HCT : 41,7% Neutrophils : 3,9x103/ μL Blood glucose in time : 71 Ureum : 9,7 Creatinin : 0,51 SGOT : 22,4 SGPT : 13,6 VCT : non reactive
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RECOMMENDED EXAMINATION
PAPANIKOLAOU test (Swab Vagina) Biopsy Tissue pH test
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RESUMEA female,43 y.o, come to the hospital with complain Itching and
sores on regio vulva. It first appear as a redness spot in vulva and it was itchy then it’s scratched by her, after that appeared lots of reddish-black spots watery. Smell Leukorrhea (+), pain (-). Patient also complain sores in her lips tasted like burning.
At first, The Patient separated injectable contraception and she got menstruation for three months. After the menstruation finished, she complained excessive leukorrhea and it had been going on since 6 months ago until today.
History of treatment (+) in Puskesmas. She was given an ointment, yellow and white pills.
Vital sign : in normal limit
dermato-venerology status : Regio Vulva : Ulkus ,ecscoriasis, nodul Regio Inguinalis : Ulkus ,ecscoriasis, nodul
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DIAGNOSIS
Ulcus Genitalia
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TREATMENT
R/
1. NaCl 0,9% compress in morning – evening after bath
2. Fuson cream (topical applying after bath)
3. Sores care
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DIFFERENTIAL DIAGNOSIS
Condiloma Lata