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Scenario F Blok 24

Mrs. Tari, 37 years old, from middle income family comes to doctor at a public healty center
with chief complain of vaginal bleeding. She experienced post coital bleeding for one month.
Since one years ago she has been complaining about vaginal discharge with smelly odor and
sometimes accompanied by vulvar itchy. She already has two children before and the youngest
child is six years old. Her husband is a truck driver. She has never gone to the doctor relatied to
her ccomplain about vaginal discharge, not using any medication, no history of papsmear
examination, and no history of HPV vaccination. She has a history of using intrauterine device
(IUD) as contraception for five years since her youngest child birth and the IUD has been
remove one year ago. Her older sister died two years ago cause by breast cancer.
You act as the doctor in public health center and be pleased to analyse this case.
In the examination findings:
Height: 155 cm, weight: 50 kg
Blood preasure: 120/80 mmHg, pulse: 80 x/menit, RR: 20 xmenit
Palpebral conjungtiva: anemic
Breast: there was no mass on both mammae
Abdomen: flat and souffl, symmetric, uterine fundus in not palpable, there are no mass, no
painful tenderness and no free fluid sing.
Internal examination
Inspection: vulva and uretra was normal, there was no mass on the vulva, urethra, hymen and
perineum.
Speculum examination: mass on the portio size 2x2 cm, exophytic, fragile, easy to bleed, no
infiltration to the vagina, flour +

Bimanual examination: servix is soft, the external os is closed, no cervical motion tenderness,
exophytic mass size 2x2x1 c,.fragile easy to bleed, no infiltration to the vagina, uterine size in
normal, both adnexa and parametrium are withing normal limit.
Then you performed VIA, the resukt was you could define the external os, squamous columnar
junction and there war thick acetowhite epithelium at the 2 oclock untile 5 oclock position, so
you performed biopsy.
Laboratorium result: Hb 8,3 gr/dL ; WBC 12.000/mm ; thrombocyte 770.000/mm3; ESR 0
mm/hour
The next week, the patient come with the histophatology result squamous cell carcinoma
moderate differentiation, without limphovascular space invasion. You gave the informed
concent to the patient and family to refer her to the hospital, she asked you the diagnosis, kind of
examination that will be performed to her, and the possible treatment.
I.

KlarifikasiIstilah
1.
Vaginal bleeding :perdarahan yang melalui vagina termasukperdarahan yang
2.

daridinding vagina ataudari organ genitalia lainnya.


HPV : human papilloma virus adalah virus yang menginfeksi area kulitdan

3.

organ kelamin.
IUD :sebuahalatkontrasepsi yang berupakomponenkecilpanjangnya

4.

dimasukankedalamrahimuntukmencegahkehamilan.
Pap

cm
smear

:prosedurpewarnaansitologisexfoliatifuntukmendeteksidanmendiagnosisberba
gaikondisiterutamakondisikeganasandanprakeganasanpadatraktus
5.
6.
7.

wanita.
Souffle :suaraauskultasi yang terdengarsepertimeniup.
Acetowhite :kilauberwarnakeputihan di permukaanepitel.
Exophytic
:berkaitandenganpertumbuhan
tumor

genitalia

luar

berkembangbiakpadaepitel exterior ataupermukaan organ ataustruktut lain


dimanapertumbuhanberasal.
II.

IdentifikasiMasalah
1. Ny,

Tari,

37

tahun,

darikeluargapenghasilanmenengahdatangkedokterdengankeluhanutamaperdarahan
vagina.

2. Pasienmengalamipendarahanpascacoituselama

bulan.

Sejaksetahun

yang

lalupasienmengeluhadasekret di vagina denganbaubusukdanterkadangdisertai rasa


gatalpada vulva.
3. Pasiensudahmemiliki

anak,

yang

paling

mudaberusia

tahun.

Suamipasienseorangsupirtruk.Kakakperempuanpasienmeninggal 2 tahun yang


lalukarenakankerpayudara.
4. Pasientidakpernahberobatkedokterterkaitkeluhantentangsekret
tidakmenggunakanobat-obatan,
smeerdantidakadariwayatvaksinasi

tidakadariwayatpemeriksaan

vagina,
pap

HPV. Pasienmemilikiriwayatmenggunakan

IUD selama 5 tahunsejakkelahirananakterakhirdansudahdilepas 1 tahun yang lalu.


5. In the examination findings:
Height: 155 cm, weight: 50 kg
Blood preasure: 120/80 mmHg, pulse: 80 x/menit, RR: 20 xmenit
Palpebral conjungtiva: anemic
Breast: there was no mass on both mammae
Abdomen: flat and souffl, symmetric, uterine fundus in not palpable, there are no
mass, no painful tenderness and no free fluid sing.
Laboratorium result: Hb 8,3 gr/dL ; WBC 12.000/mm ; thrombocyte
770.000/mm3; ESR 0 mm/hour.
6. Internal examination
Inspection: vulva and uretra was normal, there was no mass on the vulva, urethra,
hymen and perineum.
Speculum examination: mass on the portio size 2x2 cm, exophytic, fragile, easy to
bleed, no infiltration to the vagina, flour +.
Bimanual examination: servix is soft, the external os is closed, no cervical motion
tenderness, exophytic mass size 2x2x1 c,.fragile easy to bleed, no infiltration to
the vagina, uterine size in normal, both adnexa and parametrium are withing
normal limit.
7. Then you performed IVA, the result was you could define the external os,
squamous columnar junction and there war thick acetowhite epithelium at the 2
oclock untile 5 oclock position, so you performed biopsy.
The next week, the patient come with the histophatology result squamous cell
carcinoma moderate differentiation, without limphovascular space invasion. You
gave the informed concent to the patient and family to refer her to the hospital,

she asked you the diagnosis, kind of examination that will be performed to her,
and the possible treatment.
III.

AnalisisMasalah
1. Ny, Tari, 37 tahun, dari keluarga penghasilan menengah datang ke dokter dengan
keluhan utama perdarahan vagina.
a. Apa hubungan usia, sosio ekonomi dengan kasus ?(puput, frischa)
b. Apa etiologi dan mekanisme pada perdarahan vagina ?(harvinder, alek)
c. Bagaimana cara membedakan perdarahan vagina fisiologis dan patologis ?
(dea, riana)
2. Pasien mengalami pendarahan pasca coitus selama 1 bulan. Sejak setahun yang
lalu pasien mengeluh ada sekret di vagina dengan bau busuk dan terkadang
disertai rasa gatal pada vulva.
a. Bagaimana etiologi dan mekanisme perdarahan pasca coitus ?(sakty, Arvin)
b. Bagaimana etiologi dan mekanisme sekret di vagina dengan bau busuk dan
disertai rasa gatal pada vulva ?(theo, mathius, jojop)
c. Bagaimana riwayat perjalanan penyakit ?(monic. Ari)
3. Pasien sudah memiliki 2 anak, yang paling muda berusia 6 tahun. Suami pasien
seorang supir truk. Kakak perempuan pasien meninggal 2 tahun yang lalu karena
kanker payudara.
a. Bagaimana hubungan riwayat obstetri dengan kasus ? (dea, riana)
b. Apa hubungan riwayat pekerjaan suami dengan kasus ? (harvinder, alek)
c. Apa makna klinis dari kakak perempuan meninggal karena kanker
payudara ?(harvinder, alek)
4. Pasien tidak pernah berobat kedokter terkait keluhan tentangs ekret vagina, tidak
menggunakan obat-obatan, tidak ada riwayat pemeriksaan pap smear dan tidak
ada riwayat vaksinasi HPV. Pasien memiliki riwayat menggunakan IUD selama
5 tahun sejak kelahiran anak terakhir dan sudah dilepas 1 tahun yang lalu.
a. Apa makna klinis dari pasien tidak pernah berobat ke dokter terkait keluhan
tentang sekret vagina, tidak menggunakan obat-obatan, tidak ada riwayat
pemeriksaan pap smear dan tidak ada riwayat vaksinasi HPV ?(theo, matius,
jojop)
b. Apamaknaklinisriwayatpenggunaan IUD padakasus ?(monic, ari)
5.

In the examination findings:


Height: 155 cm, weight: 50 kg

Blood preasure: 120/80 mmHg, pulse: 80 x/menit, RR: 20 xmenit


Palpebral conjungtiva: anemic
Breast: there was no mass on both mammae
Abdomen: flat and souffl, symmetric, uterine fundus in not palpable, there are
no mass, no painful tenderness and no free fluid sing.
Laboratorium result: Hb 8,3 gr/dL ; WBC 12.000/mm ; thrombocyte
770.000/mm3; ESR 30 mm/hour.
a. Bagaimana interpretasi dan mekanisme abnormal dari pemeriksaan diatas ?
(puput, frischa)
6. Internal examination
Inspection: vulva and uretra was normal, there was no mass on the vulva,
urethra, hymen and perineum.
Speculum examination: mass on the portio size 2x2 cm, exophytic, fragile, easy
to bleed, no infiltration to the vagina, flour +.
Bimanual examination: servix is soft, the external os is closed, no cervical
motion tenderness, exophytic mass size 2x2x1 c,.fragile easy to bleed, no
infiltration to the vagina, uterine size in normal, both adnexa and parametrium
are withing normal limit.
a. Bagaimana interpretasi dan mekanisme abnormal daripemeriksaan di atas ?
(dea, riana)
7. Then you performed IVA, the result was you could define the external os,
squamous columnar junction and there war thick acetowhite epithelium at the 2
oclock untile 5 oclock position, so you performed biopsy.
The next week, the patient come with the histophatology result squamous cell
carcinoma moderate differentiation, without limphovascular space invasion.
You gave the informed concent to the patient and family to refer her to the
hospital, she asked you the diagnosis, kind of examination that will be performed
to her, and the possible treatment.
a. Bagaimana interpretasi dan mekanisme abnormal dari pemeriksaan di atas ?
(sakty, Arvin)
b. Bagaimana cara pemeriksaan IVA ?(puput, frischa)
c. Bagaimana gambaran histopatologinya ?(theo, matius, jojop)
8. AnalisisAspekKlinis
a. Bagaimana cara penegakan diagnosis pada kasus ? (dea, riana)
b. DD ? (monic, ari)

c.
d.
e.
f.
g.
h.
i.
j.
k.
l.

WD dandefinisi ?(shakty, Arvin)


Etiolog ?(harvin, alek)
Epidemiologi ?(harvinder, alek)
Faktorresiko ?(puput, frischa)
Patofisiologi ?(monic, ari)
Manifestasiklinis ?(shakty, Arvin)
Penatalaksanaan ? (theo, matius, jojop)
Komplikasi ?(dea, riana)
Prognosis ? (shakty, Arvin)
SKDI ?semuanya

Learning Issue
1. Ca servix(puput, frischa, harvinder, alek, monic, ari)
2. HPV (sakty, Arvin, theo, jojop, matius, dea, riana )

Hipotesis
Ny. Tari, 37 tahun mengalami pendarahan vagina akibat karsinoma sevix.