fauzan anshar_lbm 6_sgd 22_modul 18

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'



)( *# 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(



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



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

http://bestpractice.bmj.com/best-practice/monograph/567/resources/references.html#ref-14




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(


http://www.hindawi.com/journals/ogi/2013/173184/#B73



http://bestpractice.bmj.com/best-practice/monograph/567/basics/pathophysiology.html










Ga!%ar )() : Representasi ga!%ar uterus nor!al dan struktur$askulern#ani$ersitas Su!atera tara



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

http://www.gponline.com/clinical-review-uterine-fibroids/article/1115934



http://www.gponline.com/clinical-review-uterine-fibroids/article/1115934





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




http://www.hindawi.com/journals/ogi/2013/173184/




http://www.hindawi.com/journals/ogi/2013/173184/



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,

http://emedicine.medscape.com/article/1057733-overview#aw2aab6b2b2

http://emedicine.medscape.com/article/1057733-overview#aw2aab6b2b2



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# @,

http://emedicine.medscape.com/article/1057733-workup#a0723



fauzan anshar_lbm 6_sgd 22_modul 18

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