kasus ruangan neuro

8/10/2019 Kasus Ruangan Neuro

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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.

*



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,

)



'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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