fauzan anshar_lbm 6_sgd 22_modul 18
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8/21/2019 Fauzan Anshar_LBM 6_SGD 22_Modul 18
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VAGINAL DISCHARGE
STEP 1
Adneksa : alat alat organ panggul sekitar dari uterus atau rai!"
!isaln#a: o$ariu!" tu%a &allopi dan lige!entu!n#a
Vaginal dis'arge : 'airan #g keluar dari $agina(
STEP )
1( *# does se 'o!plaints o$er 1+ da#s o& !enstruation,)( *# does se as &oul-s!elling" dis'arge %et.een irregular !erstrual
'#'le,/( Is tere an# relation %et.een er and er !oter .o died 'ause o&
'er$i'al 'an'er,0( *# te patient needed to test %# SG and istopatolog# e2a!ination,+( *at is te relation %et.een ane!i' and o%esit#,3( *at4s te interpretation o& g#ne'ologi$al e2a!ination,5( *at4s te relation %et.een te si6e o& uterus and te a%do!inal pain,7( *at(s te 'orrelation o& patient irregular !enstruation '#'le" so!eti!es
#.i'e in a !ont,8( *at is te sign o& se ad %een !arried and ne$er 'on'ei$ed,19(*at4s te 'orrelation %et.een age and te pro%le! o& te patient,11(*# did te patient ad tis 'ondition sin'e se .as #oung,1)(Dierential Diagnosis,1/(Treat!ent o& te s'enario,10(Risk &a'tor o& tis s'enario,1+(Clini'al e2a!ination o& tis s'enario,
STEP /
1( *# does se 'o!plaints o$er 1+ da#s o& !enstruation,Akti$itas;<sik peker=aan %erat( >a# 'ause i!%alan'e o& estrogen and
progesteron(Psikis stress" a2iet#(
Nor!al duration o& !estruation is %et.een /-7 ari
>enoragia" %e'ause o& a%nor!al ea$# and prolonged !enstrual period?e'ause o& te i!!aturit# o& #potala!us" #po<sis a2is" o$ariu!"
endo!etriu!( H#popisis is not in nor!al 'ondition and te o$ariu! is not
!atture Te pro%a%ilit# o& te 'ase is leio!#o!a" adeno!iosis" polip
endo!etriu!" #perplasia endo!etriu!" 'er$i'al 'an'er" !al&or!ation
arter# or $ein in uteri" ae!ostasis distur%an'e as like $on .ile%rand
disease" distur%an'e &a'tor )"+"5"8" 1/( Tro!%ositopenia and platelet
distur%an'e" t#roid disease" renal &ailure" s#ste!i' lupus erite!atosous"
adeno!a" prola'tino!ia" stress and o$er e2er'ise(
Dia%eti'" o%esit# and intake o& !edi'ation @antiepile'ti'" antipsi'oti'
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)( *# does se as &oul-s!elling" dis'arge %et.een irregular !enstrual
'#'le,Boul s!elling 'aused %# $agina dis'arge di$ided ):
P#siologis Tere4s !u'ous tat produ'ed %# 'er$i2" te 'olor o& !u'ous is 'lear and
i& 'onta!inated %# air .ould 'ange to .ite or #ello. and te a!ount is
depends on estrogen le$el( Te a'tor tat 'aused $aginal dis'arge is
e!otional 'ondition" o$ulation '#'le" and se2ualit#(Patolog#Generall# appened 'ause tere4s in&e'tion &ro! genitalia &e!inina(
Se'ret4s se'retion .i' purulent 'an 'ause %# in&e'tion &ro! gardnerela
$aginalis tri'o!oniasis and !oniliasis %a'ter#( ?eside tat" erpes
progenitalis and gonnoreae disease also 'an 'ause $anigal dis'arge(I& te anato!i'al genital 'ondition is nor!al" tere .ill %e no dis'arge
Endo!etriosis: te endo!etriu! .ill %e ti'kened tat .ill easil# %leed
and %a'terial .ill 'o!e to te %leeding and 'ause &oul-s!elling(
/( Is tere an# relation %et.een er and er !oter .o died 'ause o&
'er$i'al 'an'er, ika i%u dari pasien !eningal karena kanker ser$iks ada
%akat;potensi;ke!ungkinan anak =uga terkena kanker karena turunan dari
genetik(Li&est#le: tapi =ika idup seat ada ke!ungkinan penurunan potensi
terkena kanker(
0( *at is te 'orrelation %et.een o%esit# and sign" s#!pto! o& patient,%esitas %an#ak kolesterol trans&or!ed into estrogen estrogen
dapat !e!i'u peru!%uan !assa di uterus @leio!#o!a: or!onal
response gro.t
S#ndro! o$ariu! pol#'isti': estrogen dari kolesterol" %an#ak estrogen #g
ditangkap estrogen reseptor di endo!etriu!(
+( *at4s te relation %et.een te si6e o& uterus and te a%do!inal pain,In nor!al !estruation te pain onl# last &or 1-) da#s(
e!ungkinan ada !assa #g terdesak saat kontraksi #g =uga dapat!endesak ner$us ner$us di uterus saat !ens(
3( *at4s te 'orrelation o& patient irregular !enstruation '#'le" so!eti!es
t.i'e in a !ont" and ane!i',
5( *at is te sign o& se ad %een !arried and ne$er 'on'ei$ed,?elu! pun#a anak" &aktor or!onal !e!pengarui" $aginal dis'argeAdan#a !assa di uterus" ada ke!ungkinan asil konsepsi tidak %isa
tertana! di endo!etriu!(
>ass in endo!etriu! .ill ini%it te 6#gote to i!plant(
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7( *at4s te 'orrelation %et.een age and te pro%le! o& te patient,e!ungkinan dari !uda pasien ini suda dite!ukan adan#a !assa #g
!enga!%at pasien untuk a!il dan ter=adin#a !enstruasi #g la!a(
8( *at4s te 'orrelation %et.een er !oter 'ondition and te patient
'ondition tat4s not pregnant #et,
19(*# did te patient ad tis 'ondition sin'e se .as #oung, Akti$itas;<sik peker=aan %erat( >a# 'ause i!%alan'e o& estrogen and
progesteron(Psikis stress" a2iet#(
Nor!al duration o& !estruation is %et.een /-7 ari>enoragia" %e'ause o& a%nor!al ea$# and prolonged !enstrual period?e'ause o& te i!!aturit# o& #potala!us" #po<sis a2is" o$ariu!"
endo!etriu!( H#popisis is not in nor!al 'ondition and te o$ariu! is not
!atture Te pro%a%ilit# o& te 'ase is leio!#o!a" adeno!iosis" polip
endo!etriu!" #perplasia endo!etriu!" 'er$i'al 'an'er" !al&or!ation
arter# or $ein in uteri" ae!ostasis distur%an'e as like $on .ile%rand
disease" distur%an'e &a'tor )"+"5"8" 1/( Tro!%ositopenia and platelet
distur%an'e" t#roid disease" renal &ailure" s#ste!i' lupus erite!atosous"
adeno!a" prola'tino!ia" stress and o$er e2er'ise(
Dia%eti'" o%esit# and intake o& !edi'ation @antiepile'ti'" antipsi'oti'
11(*at4s te interpretation o& g#ne'ologi$al e2a!ination,A%nor!al uterus: te si6e .as a%out s.an4s egg(?agai!ana 'ara !elakukan p& pe!%esaran uterus,
1)(*# te patient needed to test %# SG and istopatolog# e2a!ination, To see i& tere4s a !ass or enlarge!ent in te uterus" dan apaka ada
keganasan pd !assan#a TSHHSG : Hidrosal<ngograp# @,
To2oplas!a : Ig> and IgGPap s!ear
1/(Dierential Diagnosis,Leio!#o!aEndo!etriosisCa 'er$i2
10(Treat!ent o& te s'enario,Hig Dose Estrogen
1+(Risk &a'tor o& tis s'enario,%esit#Geneti'
Li&e st#le @?adHor!one
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13(ter 'lini'al e2a!ination o& tis s'enario, TSHHSG : Hidrosal<ngograp# @,
To2oplas!a : Ig> and IgGPap s!ear
STEP 5
1( *# does se 'o!plaints o$er 1+ da#s o& !enstruation,
Uterine fibroids arise from the myometrial layer of the uterine corpus or, less
commonly, the uterine cervix, and may occur singly or multiply. Fibroids may remain
within the muscular layer (intramural) or protrude outwardly to become subserosal in
location or inwardly towards the endometrial cavity, where they become known as
submucous fibroids. Subserosal and submucosal fibroids may become
pedunculated. Abnormal vaginal bleeding that often accompanies the presence of
fibroids is felt to occur as a result of distortion of the endometrial lining and therefore
is seen much more commonly with submucous fibroids. For the same reason, cavity
distortion can cause recurrent second trimester loss. Uterine fibroids that obstructmenstrual flow can cause dysmenorrhoea. Large uterine fibroids, regardless of
location, can cause mass effects on contiguous organs such as the bowel and
bladder and cause symptoms of urinary frequency, urgency, and incontinence as well
as constipation. They can outstrip their blood supply and cause acute or chronic pain
as they degenerate. Pedunculated submucous uterine fibroids can dilate the uterine
cervix and prolapse into the vagina where they can become infected.
Various mechanisms have been proposed to explain the strong association between
heavy menses and uterine fibroids. They have included ulceration over the surface of
submucous uterine fibroids, anovulation associated with uterine fibroids, increased
endometrial surface area, and interference with normal uterine contractility. To date,
none of these explanations have been conclusively validated by clinical
research. [14]
More recently, research into this area has centred on a vascular dysregulation,
thought to be mediated by a number of growth factors. It is now hypothesised that
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fibroid-associated bleeding is related to dilatation of the small veins (venules) within
the myometrium and endometrium of uteri containing fibroids, thus interfering with
the haemostatic actions of platelets and fibrin plugs. [15]Nevertheless, a cause and
effect has not been established.
Leiomyoma growth is influenced by progesterone interaction with some growth factors; it
upregulates the epidermal growth factor (EGF) (mitogenic) [73] and transforming growth
factor- (TGF-)F3 (bimodal action) [86] expression. On one hand, progesterone seems to
downregulate IGF-I expression through PRB, while PRA appears to inhibit this function [84].
ttp:;;%estpra'ti'e(%!=('o!;%est-
pra'ti'e;!onograp;+35;%asi's;patop#siolog#(t!l
Progesteron !e!ungkinkan pe!%esaran tu!or dengan 'ara down-
regulation apoptosis dari tu!or( Estrogen %erperan dala! pe!%esaran
tu!or dengan !eningkatkan produksi !atriks ekstraseluler @Hadi%roto"
)99+(
a( Perdaraan a%nor!alGangguan perdaraan #ang ter=adi u!u!n#a iper!inore" !enoragia dandapat =uga ter=adi !etroragia" Perdaraan a%nor!al ini #ang dapat!en#e%a%kan ane!ia de&esiensi %esi(Pato<siologi perdaraan uterus a%nor!al #ang %eru%ungan dengan!io!a uteri !asi %elu! diketaui dengan pasti( ?e%erapa penelitian!enerangkan %a.a adan#a disregulasi dari %e%erapa &aktorpertu!%uan dan reseptor-reseptor #ang !e!pun#ai e&ek langsung pada
&ungsi $askuler dan angiogenesis( Peru%aan-peru%aan ini !en#e%a%kankelainan $askularisasi aki%at disregulasi struktur $askuler didala! uterus#ang !en#e%a%kan ter=adin#a $enule e'tasia(
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Ga!%ar )() : Representasi ga!%ar uterus nor!al dan struktur$askulern#ani$ersitas Su!atera tara
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A( Pele%aran pe!%ulu dara pada endo!etriu! dan !io!etriu! padauterus nor!al?( Pele%aran pe!%ulu dara o%struksi <sik pada pe!%ulu dara uterus!io!atosus@Su!%er : Gross aren L" ?A
?e%erapa &aktor #ang !en=adi pen#e%a% perdaraan ini" antara lainadala :- Per!ukaan endo!etriu! #ang le%i luas dari pada %iasa
- Peningkatan $askularisasi aliran $askuler ke uterus
- lserasi endo!etriu! pada !io!a su%!ukosa
- o!presi pada pleksus $enosus didala! !io!etriu!
- >io!etriu! tidak dapat %erkontraksi opti!al karena adan#a sarang
!io!a di antara sera%ut !io!etriu!" seingga tidak dapat !en=epitpe!%ulu dara #ang dilaluin#a dengan %aik @Pra.iroard=o" )997(
)( *# does se as &oul-s!elling" dis'arge %et.een irregular !enstrual
'#'le,
The vaginal discharge can become chronic and foul-smelling, due to fibroid
expulsion, and surgical evacuation of the uterus may be required.http://www.gponline.com/clinical-review-uterine-fibroids/article/111!"#
/( Is tere an# relation %et.een er and er !oter .o died 'ause o&
'er$i'al 'an'er,
0( *at is te 'orrelation %et.een o%esit# and sign" s#!pto! o& patient,
A study found that the risk of myomas increased 21% with each 10 kg increase
in body weight and with increasing body mass index [21]. Shikora et al.
reported similar results in women with greater than 30% body fat [22]. The
adipose tissue converts adrenal and ovarian androgens into estrogens,
whereas several mechanisms associated with obesity lead to decreased
synthesis of sex hormone binding globulin. Consequently, the increase of
biologically available estrogens could be responsible for increasing myoma
prevalence and/or growth in overweight and obese women . Furthermore,
Nair and Al-Hendy evaluated the association between obesity-related chronic
inflammation and initiation, as well as the progression of uterine leiomyoma by
using an in $itro model with representative cell lines of adipocytes and human
uterine leiomyoma cells. They demonstrated that coculture of adipocytes and
uterine leiomyoma cells results in an increased proliferation of leiomyoma
cells, and they have also demonstrated that TNF- treatment increases human
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uterine leiomyoma cells proliferation in a concentration-dependent manner
[23].
Estrogens are able to regulate the expression of growth factors by activating some
signaling pathways. Estrogens upregulate platelet-derived growth factor (PDGF)expression in leiomyoma cells, while they downregulate activin and myostatin in
human myometrial explants. In addition, estrogens also downregulate epidermal
growth factor (EGF) expression but upregulate the expression of EGF-R in both
myometrium and leiomyoma cells. These estrogen actions are accomplished through
the rapid activation of different kinds of kinases; some of them [ 75] result to be
increased in both immortalized uterine smooth muscle and leiomyoma cell lines under
estrogen stimulation. In addition, Park and colleagues reported that estrogens may
also stimulate the proliferation of leiomyoma cells by activating ATP-sensitive
potassium channels [76].
ttp:;;...(inda.i('o!;=ournals;ogi;)91/;15/170;
Satu studi prospekti& di=alankan dan di=u!pai ke!ungkinan risiko
!enderita !io!a uteri adala setinggi )1 untuk setiap kenaikan
19kg %erat %adan dan dengan peningkatan indeks !assa tu%u(
Te!uan #ang sa!a =uga turut dilaporkan untuk .anita dengan /9
kele%ian le!ak tu%u( Ini ter=adi kerana o%esitas !en#e%a%kanpe!ingkatan kon$ersi androgen adrenal kepada estrone dan
!enurunkan or!on sex-binding globulin( Hasiln#a !en#e%a%kan
peningkatan estrogen se'ara %iologikal #ang %isa !enerangkan
!engapa ter=adi peningkatan pre$alensi !io!a uteri dan
pertu!%uann#a @Parker" )995(S#ndro! o$ariu! pol#'isti': estrogen dari kolesterol" %an#ak estrogen #g
ditangkap estrogen reseptor di endo!etriu!(
+( *at4s te relation %et.een te si6e o& uterus and te a%do!inal pain,
Rasa Nyeri
Rasa n#eri %ukanla ge=ala #ang kas tetapi dapat ti!%ul karena
gangguan sirkulasi dara pada sarang !io!a" #ang disertai
nekrosis sete!pat dan peradangan( Pada pengeluaran !io!a
su%!ukosa #ang akan dilairkan" pada pertu!%uann#a #ang
!en#e!pitkan kanalis ser$ikalis dapat !en#e%a%kan dis!enore(
The pathogenesis of pain associated with these lesions is also a mystery. Someauthors have suggested that pain could result from local pressure by the tumor oncutaneous nerves. However, the histologic findings do not show that prominent nervefibers are associated with these tumors. Others have theorized that specific
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infiltrating cells may play a role; one study of 2 angioleiomyomas revealed thatpainful tumors had fewer mast cells than asymptomatic ones. !et others havesuggested that muscle contraction may be pivotal in the induction of pain.
The e"citation of the arrector pili muscle occurs via the sympathetic nervous system.
#orepinephrine, secreted by postganglionic nerve fibers, activates the alpha$receptors of the muscle. %uscle contraction ensues; this is triggered by the influ" of ions, most specifically calcium. &nderstanding this basic physiologic process may berelevant to the medical treatment of symptomatic leiomyomas.
http'((emedicine.medscape.com(article()*+--$overviewaw2aab/b2b2
3( *at4s te 'orrelation o& patient irregular !enstruation '#'le" so!eti!es
t.i'e in a !ont" and ane!i',
5( *at is te sign o& se ad %een !arried and ne$er 'on'ei$ed,
7( *at4s te 'orrelation %et.een age and te pro%le! o& te patient,
8( *at4s te 'orrelation %et.een er !oter 'ondition and te patient
'ondition tat4s not pregnant #et,
*anita dengan garis keturunan tingkat perta!a dengan penderita
!io!a uteri !e!pun#ai peningkatan )"+ kali ke!ungkinan risiko
untuk !enderita !io!a uteri di%anding dengan .anita tanpa garis
keturunan penderita !io!a uteri( Penderita !io!a #ang
!e!pun#ai ri.a#at keluarga penderita !io!a uteri !e!pun#ai )
kali lipat kekuatan ekspresi dari VEGB- (a myoma-related growth
factor) di%andingkan dengan penderita !io!a #ang tidak
!e!pun#ai ri.a#at keluarga penderita !io!a uteri @Parker" )995(
19(*# did te patient ad tis 'ondition sin'e se .as #oung,
11(*at4s te interpretation o& g#ne'ologi$al e2a!ination,?agai!ana 'ara !elakukan p& pe!%esaran uterus,
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1)(*# te patient needed to test %# SG and istopatolog# e2a!ination,HSG : Hidrosal<ngograp# @,0eiomyomas are smooth muscle tumors that are generally well differentiated. The
characteristic smooth muscle nuclei are elongated with blunt ends, and they are often
described as cigar or eel shaped. 1hen these fibers are cut in cross$section, perinuclear
vacuolization may be appreciated. 1ith electron microscopy, the smooth muscle cells of a
leiomyoma appear normal.
ttp:;;e!edi'ine(!eds'ape('o!;arti'le;19+55//-.orkupa95)/
1/(Dierential Diagnosis,10(Treat!ent o& te s'enario,
1+(Risk &a'tor o& tis s'enario,
13(ter 'lini'al e2a!ination o& tis s'enario,HSG : Hidrosal<ngograp# @,
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