Laporan Skenario f Blok 23 Kel.8

8/12/2019 Laporan Skenario f Blok 23 Kel.8

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SKENARIO F BLOK 23 2014

Mrs. Lina, 29 years old, attends the primary health centre with her husband.

They have been trying to get pregnant for 3 years but failed. She has regular menstrual

cycles, every 28 days. There was no history of intermenstrual or postcoital bleeding.

There was no pain during her period , no contraception used, no history of drug

consumption (including alcohol and tobacco). She didnt have previous abdominal

surgery, no history of allergies, no pelvic infection and no chronic disease. Her husband

(32 years old) is a bank employee. He had no history of mumps and medication for any

disease. He had no history mumps and medication for any disease. He was not smoking

and alcohol consumption. He also didnt have allergies. This couple enjoyed regular

intercourse.

You act as a doctor in the clinic and be pleased to analyse this case.

In the examination finding :

Wife

Height = 160 cm ; weight 55 kg ; BMI 21 kg/mm2

; blood pressure = 110/170 mmHg;

Pulse = 80 x/m ;RR = 18 x/m.

Palpebral conjunctiva looked normal , no exopthalmus, no sign of hirsutism, no thyroid

enlargement, no galactorrhoea , secondary sexual characteristics are normal.

External examination: abdomen flat and souffl , symmetric, uterine fundal not

palpable, there are no mass pain terndernes and free fluid sign.

Internal examination

Speculum examination : portio not livide, externa; os closed, no fluor, no fluxus, there

are no cervical erotion , laceration or polyp.

Bimanual examination : cervix is firm, the external os closed, uterine size normal, both

adnexa and parametrium within normal limit.

Laboratorium exam :

Hb 12 g/dl ; WBC 8.000 /mm3 ; RBC 4,3x106

/mm3; Ht 36 vol%; Platelets 250.000/mm

3;

ESR 15 mm/hour; Blood type A Rh (+); Blood film: normal

Urine: normal

*Ultrasound: normal internal genitalia; sonohysterography: normal utrerine and both

tubal patency.


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Postcoital test: normal

Husband

Height = 176 cm; Weight 72 kg; BMI = 23 kg/m2; Blood pressure = 120/80 mmHg; Pulse =

76x/m; RR = 20x/m

Palpebral conjunctiva looked normal, no exopthalmus, no thyroid enlargement, no

gynecomastia, secondary sexual characteristic are normal.

External examination: abdomen flat and tender, symmetric, no sign of hepatomegaly

and inguinal hernia

Genitalia examination

Penis: normal; testes: normal size and volume; scrotum: no varicocele

Laboratory examination

Hb 14 g/dL; WBC 8.000/L; RBC 4,3x106/L, Ht 42 vol%; platelets 350.000/L; ESR 6

mm/hour;

Blood type O Rh (+); Blood film: normal. Blood chemistry: normal. Hormonal: FSH, LH

and testosterone level: normal

Urine: normal

Semen analyse: volume 4.5 ml; sperm concentration 0.1x106/ml; motility 22% forward

progression, 15% rapid forward progression; morphology 5% with normal forms.

I. KLARIFIKASI ISTILAH

1. Intermenstrual bleeding :2. Postcoital bleeding : : Pendarahan yang terjadi setelah melakukan

senggama

3. Contraception : : Upaya menghindari atau mencegah terjadinya kehamilansebagai akibat pertemuan antara sel telur yang matang dan sperma

4. Mumps : penyakit akut dan menular yang disebabkan oleh miksovirusterutama menyerang anak-anak, kelenjar ludahh, paling sering paratiroid tetapi

jaringan lainnya seperti selaput otak dan testis pada pasien laki-

5. Enjoy Regular intercourse :6. Hirsutism : Pola distribusi rambut abnormal khusus pada wanita7. Galaktorrhea : aliran air susu yang berlebihan atau spontan atau sekresi air susu

terus menerus tidak berhubungan dengan menyusui

8. Fluxus :


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9. Souffl :10. Firm :11. Adnexa parametrium :12. Sonohisterographay : Pemeriksaan untuk mendekteksi adanya kelainan pada

rongga Rahim dan saluran telur

13. Postcoital test : Tes yang digunakan untuk menguji infertilitas14. Ginecomastia : Perkembangan kelenjar susu laki-laki yang berlebihan sampai

tingkat fungsional

15. Varicocele : varikositas pleksus pampiniformis korda spermatika, yangmembentuk benjolan skrotum yang terasa seperti kantong cacing

16. Semen : pengeluaran cairan sewaktu ejakulasi pada seorang pria, terdiri darisekresi kelenjar yang berhubungan dengan traktus urogenitalia dan berisi

spermatozoa

17. Regular menstrual cycle : periode timbulnya kembali18. Abdominal surgery : Pembedahan pada region abdomen19. Exopthalmus : protrusion mata yang abnormal20. Secondary sexual :21. BMI :

II. IDENTIFIKASI MASALAH

1. Mrs. Lina, 29 years old, attends the primary health centre with her husband. Theyhave been trying to get pregnant for 3 years but failed

2. She has regular menstrual cycles, every 28 days3. There was no history of intermenstrual or postcoital bleeding4. There was no pain during her period , no contraception used, no history of drug

consumption (including alcohol and tobacco)

5. She didnt have previous abdominal surgery, no history of allergies, no pelvicinfection and no chronic disease

Her husband (32 years old) is a bank employee. He had no history of mumps and

medication for any disease. He had no history mumps and medication for any

disease

6. He was not smoking and alcohol consumption. He also didnt have allergies. Thiscouple enjoyed regular intercourse


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III. ANALISIS MASALAH

1. Mrs. Lina, 29 years old, attends the primary health centre with her husband.They have been trying to get pregnant for 3 years but failed.

a. Klasifikasi infertile ? pada kasus ini termasuk yang mana ? ( prime, sekunder) 1

2. She has regular menstrual cycles, every 28 daysa. Normal siklus menstruasi (durasi , panjang siklus, jumlah darah yang keluar) ? 2b. Hubungan siklus menstruasi dengan infertilitas? 3c. Kelainan yang dapat terjadi pada kelainan menstruasi ? 43. There was no history of intermenstrual or postcoital bleeding.a. Etiologi dan makna klinis intermenstrual bleeding ? 5b. Hubungan intermenstrual bleeding dengan infertilitas ? 6c. Etiologi dan makna klinis postcoital bleeding ? 7d. Hubungan postcoital bleeding dengan infertilitas ? 84. There was no pain during her period , no contraception used, no history of drug

consumption (including alcohol and tobacco)

a. Makna klinis tidak ada nyeri saat menstruasi , kontrasepsi, pemakaian obat ,hubungkan dengan infertilitas ? 9

5. She didnt have previous abdominal surgery, no history of allergies, no pelvicinfection and no chronic disease.

a. Makna klinis riwayat operasi abdomen , tidak ada alergi , tidak ada infeksi pelvis,dan penyakit kronik (hubungkan degan infertilitas) 10

6. Her husband (32 years old) is a bank employee. He had no history of mumps andmedication for any disease. He had no history mumps and medication for any

disease

a. Makna klinis tidak ada riwayat penyakit mumps, tidak ada konsumsi alcohol danmerokok, tidak ada alergi (hubgunan dengan infertilitas) 11

7. He was not smoking and alcohol consumption. He also didnt have allergies. Thiscouple enjoyed regular intercourse.

a. Hubungan enjoy regular intercourse dengan kasus (jumlah penetrasi , lama,berapa kali) ? 12

8. Height = 160 cm ; weight 55 kg ; BMI 21 kg/mm2 ; blood pressure = 110/170mmHg; Pulse = 80 x/m ;RR = 18 x/m.


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Palpebral conjunctiva looked normal , no exopthalmus, no sign of hirsutism, no

thyroid enlargement, no galactorrhoea , secondary sexual characteristics are

normal.

a. Makna klinis jika ditemukan kelainan pada pemeriksaan fisik istri ? 13b. Bagaimana hubungan BMI dengan Infertilitas ? 14c. Makna klinis seks sekunder ? 159. External examination : abdomen flat and souffl , symmetric, uterine fundal not

palpable, there are no mass pain terndernes and free fluid sign.

Internal examination

Speculum examination : portio not livide, externa; os closed, no fluor, no fluxus,

there are no cervical erotion , laceration or polyp.

Bimanual examination : cervix is firm, the eexternal os closed, uterine size

normal, both adnexa and parametrium within normal limit.

a. Interpretasi pemeriksaan internal dan external pada istri ? 16b. Makna klinis jika ada kelainan ? 1710.Height = 176 cm; Weight 72 kg; BMI = 23 kg/m2; Blood pressure = 120/80 mmHg;

Pulse = 76x/m; RR = 20x/m

Palpebral conjunctiva looked normal, no exopthalmus, no thyroid enlargement,

no gynecomastia, secondary sexual characteristic are normal.

External examination: abdomen flat and tender, symmetric, no sign of

hepatomegaly and inguinal hernia

Genitalia examination

Penis: normal; testes: normal size and volume; scrotum: no varicocele

Laboratory examination

Hb 14 g/dL; WBC 8.000/L; RBC 4,3x106

/L, Ht 42 vol%; platelets 350.000/L;

ESR 6 mm/hour;

Blood type O Rh (+); Blood film: normal. Blood chemistry: normal. Hormonal:

FSH, LH and testosterone level: normal

Urine: normal

Semen analyse: volume 4.5 ml; sperm concentration 0.1x106/ml; motility 22%

forward progression, 15% rapid forward progression; morphology 5% with

normal forms.

a. Interpretasi pemeriksaan pada suami ? 18


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b. Makna klinis dan mekanismenya (analisis semen) ? 1911.Bagaimana DD pada kasus? 2012.Bagaimana cara mendiagnosis kasus ini? 2113.Bagaimana working diagnosis pada kasus? 2214.Bagaimana epidemiologi kasus ini? 2315.Bagaimana tatalaksana pada kasus ini (bayi)? 2416.Apa saja pemeriksaan penunjang yang diperlukan pada kasus ini? 2517.Bagaiama pathogenesis pada kasus ini ? 2618.Bagaimana komplikasi pada kasus? 2719.Bagaimana pencegahan pada kasus ini? 2820.Bagaimana prognosis pada kasus? 2921.SKDI 30

Analisis Masalah LI

Aca 1 11 21 2 12 22

Randi 2 12 22 3 13 23

CRV 3 13 23 4 14 24

Intan 4 14 24 5 15 25

Mukhlis 5 15 25 6 16 26

Muthi 6 16 26 7 17 27

Ira 7 17 27 8 18 28

Ana 8 18 28 9 19 29

Faris 9 19 29 10 20 30

Dika 10 20 1 11 21 3

Laporan Skenario f Blok 23 Kel.8

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