Ulcus Genitalia

Yurike Adehline

Sazida Subethan

Muh. Syarif

CASE REPORT

Name : Mr. N

Gender : Female

Age : 43 years old

Marital status : Married

Address : Andi Mangerangi 22

Admission date : 5 November 2012

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

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 (-)

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

DERMATO-VENEROLOGY STATUS

Location 1 : Regio Vulva Efflouresence : Ulkus ,ecscoriasis, nodul Location 2 : Regio Inguinalis Efflouresence : Ulkus ,ecscoriasis, nodul

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

RECOMMENDED EXAMINATION

PAPANIKOLAOU test (Swab Vagina) Biopsy Tissue pH test

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

DIAGNOSIS

Ulcus Genitalia

TREATMENT

R/

1. NaCl 0,9% compress in morning – evening after bath

2. Fuson cream (topical applying after bath)

3. Sores care

DIFFERENTIAL DIAGNOSIS

Condiloma Lata