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CHAPTER II
CASE REPORT
IDENTI TY OF PA T IEN T
Name : Mr. M
Sex : Male
Registration Number : 1-00-65-66
Age : 40yo
Job : Pei!ab ri"er
Aress : #s. $arut% $g Melati% &euta'ang
(xamination ate : July% )r
*014
ANAMNESIS
The Chief Complaint:
+,e it!,ing sensation on re sin ras, on genital organs
History of Present Illnesss:
Patients "isite t,e !lini! it, main !om'laints it!,ing sensation on re
sin ras, o/ t,e genital organ sin!e 1 year ago. +,e it!,y sensation /olloing it,
'ain in genital organ. or t,e /irst% t,e re sin ras, a''ear less t,an /i"e% ) ays
a/ter t,t t,eres in!reasing number o/ re sin ras,% an be!ause o/ it!,y sensation
,e s!rat!,e t,e sin so t,e small reis, s'ot no is bigger t,an be/ore an /eels
'ain. 2e /elt t,e it!,y sensation !onstantly ,a''ene an it isturb ,is aily
a!ti"ities.
History of Preio!s Illness:
+,e 'atient amitte t,at ,e ne"er /elt lie t,is !onition be/ore.
History of Family Disease:
None o/ ,is /amily ,a t,e same isease or !om'laint lie t,is. 2is
/amily ,a"ent an allergy neit,er.
History of Treatment:
+,e 'atient amitte t,at ,e e"er got t,era'y by a o!tor at Jaarta 3lini!
be/ore. ut ue to la! o/ in!ome% ,e !ant !ontinue t,e t,era'y.
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History of So"ial Ha#its:
+,e 'atient not marrie yet% but ,e o/ten oing /reesex !,anging 'artners
not only it, /emale sex orers but also it, male 'artners. 7t,er t,an t,at 'atient also amitte t,at ,e use to rining alo,ol an !annabis /or long time.
PHYSICA$ E%AMINATION
Dermatolo&i"al Stat!s:
At region genitalia a''eare it, ,i'er'igmentation 'at!,% s,ar'ly
marginate it, regular ege % !o"ere it, t,in s8uama. +,e lesion is multi'le
it, nummular /orm an si9e is * !m an istribution o/ t,e lesion is regional.
igure 1. Sy',ilis $rae taen July% )r *014
+,e oun s,oe ,i'er'igmentation 'at!,% !o"ere it, t,in s8uama.
S,a''e lie a !oin.
At 'lantar 'eis ex et sin a''eare it, ,i'o'igmentation 'la8ue% not s,ar'ly
marginate it, irreguler ege !o"ere it, t,in s8uama. +,e lession is multi'le%
an istribution o/ t,e t,e lession is bilateral.
*
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igure *. +inea Peis taen July% )r *014
+,e oun s,oe ,i'er'igmentation 'at!,% !o"ere it, t,in s8uama.
DIFFERENTIA$ DIA'NOSE
#i/erential #iagnose $enital:
1. Sy',ilis $rae
*. Sim'les 2er'es $enital). &oniloma Auminata
4. Mole ;l!er
#i//erential #iagnose Peis
1. +inea Peis
*. 3onta!t #ermatitis
). <i!,en Sim'lex 3,roni!s
RES(ME
Patients "isite t,e !lini! it, main !om'laints it!,ing sensation on re
sin ras, o/ t,e genital organ sin!e 1 year ago. +,e it!,y sensation /olloing it,
)
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'ain in genital organ. or t,e /irst% t,e re sin ras, a''ear less t,an /i"e% ) ays
a/ter t,t t,eres in!reasing number o/ re sin ras,% an be!ause o/ it!,y sensation
,e s!rat!,e t,e sin so t,e small reis, s'ot no is bigger t,an be/ore an /eels
'ain. 2e /elt t,e it!,y sensation !onstantly ,a''ene an it isturb ,is aily
a!ti"ities.
At region genitalia a''eare it, ,i'er'igmentation 'at!,% s,ar'ly
marginate it, regular ege % !o"ere it, t,in s8uama. +,e lesion is multi'le
it, nummular /orm an si9e is * !m an istribution o/ t,e lesion is regional
At 'lantar 'eis ex et sin a''eare it, ,i'o'igmentation 'la8ue% not
s,ar'ly marginate it, irreguler ege !o"ere it, t,in s8uama. +,e lession is
multi'le% an istribution o/ t,e t,e lession is bilateral.
P$ANNIN' DIA'NOSE
- Serology Sy',ilis test
- #ar /iel test
- $ram Staining
- +9ann! +est
DIA'NOSE
Sy',ilis $rae = +inea Peis
TREATMENT
- Systemi! :
3etiri9ine 10 mg tablet *x1
- +o'i!al :
+,yamisin *>=esoxymet,asone 0%*5> !ream in t,e morning an nig,t
ED(CATION
- #ont s!rat!, t,e lesion.
- 7/ten using a moisturi9er in sin
PRO'NOSE
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?uo a @itam : #ubia a bonam
?uo a un!tionam : #ubia a bonam
?uo a Sana!tionam : #ubia a bonam
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