Portofolio perdarahan uterus disfungsional
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Oleh :
dr. Aditya Prabawa
Program Internsip Dokter Indonesia
RSUD Bengkulu Tengah – Puskesmas PekikNyaring
Bengkulu 2013
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√ LAPORAN KASUS
√ FORMAT PORTOFOLIO
√ TINJAUAN PUSTAKA
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IDENTITASNama : Ny.N
Jenis Kelamin: Wanita
Umur : 39 tahun
Pendidikan : SMP
Pekerjaan : Ibu Rumah Tangga
Agama : Islam
Alamat : Sukarami
Tgl. Masuk RS:
25 Juni 2013 pukul 08.30 WIB
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ANAMNESIS
Autoanamnesis, 25 Juni 2013 pukul 08.30 WIB
Keluhan Utama◦ Menstruasi dalam jumlah banyak sejak 5 hariSMRS
Keluhan tambahan◦ Sakit kepala, lemas
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FebruariMaret
Durasi haid 9 hari , jumlah 6-8 pembalut
Flek 2 hari
April Mei
Juni
IGD RSUD Benteng
- Haid dengan jumlah darah 6-8 pembalut sehari sejak 5 hari- Sakit kepala- Pucat
RIWAYAT PENYAKIT SEKARANGDurasi haid8 hari, jumlah 8 pembalut
Haid (-)
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Riwayat menstruasiMenarche umur 14 thn,
lama 4 hari, siklus tidak teratur ( 24-30 )4x ganti pembalutDysmenorrea (+)
Riwayat penyakit dahulu Flek paru (-) Darah tinggi (-) Kencing manis (-) Alergi (-) Keputihan (-) Penyakit organ kandungan
(-)
Riwayat penyakit keluarga
Kakek Menderita darah tinggi(+)
Tidak ada anggota keluargayang mengalami keluhanserupa
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√ Riwayat pernikahan : 1 kali, 1999
√ Riwayat kehamilan dan persalinanPasien belum pernah hamil ( Nulipara )
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Riwayat kontrasepsi
Tidak pernah
menggunakan
kontrasepsi jenis apapun
Riwayat pengobatan
Pil KB (-)
Pengencer darah ( - )
OAT ( - )
Riwayat kebiasaan
Alkohol (-),
rokok (-),
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PEMERIKSAAN FISIK (1)
Status Generalis
Keadaan umum :Tampak sakit sedang
Kesadaran :Compos mentis (15 )
Tanda Vital :
TD : 120/80 mmHg, lengan kanan,
berbaring
N : 88 x/menit, reguler, volume
adekuat, equal kanan dan kiri
RR : 20x/m, reguler
S : 36.7 0C ( aksiler )
BB : 55 kg
TB : 160 cm
25/06/2013 pk.08.45
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STATUS GINEKOLOGI
Abdomen
Inspeksi : datar
Palpasi : supel, nyeri tekan regio hipogastrika dan iliaka kanan, hepar dan lien dalam batas normal
Perkusi : nyeri ketok (-)
Auskultasi : bising usus (+) normal
Genitalia:
Inspeksi : Vulva vagina tenang, rambut mons pubis normal, hiperemis (-)
Inspekulo : Rugae vagina (+), hiperemis (-), polip (-), flour albus (-)Portio bulat, licin, hiperemis (-), polip(-), darah (-), OUE tertutup
VT : Pembukaan (-), nyeri goyang portio (-), massa adneksa (-), nyeri tekan (-), parametrium lemas.
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Laboratorium ( 25 Juni 2013 pkl.09.00 )
Hb : 10,3 gr/dL
Ht : 33 %
Leukosit : 5500/mm3
Trom : 343.000/ mm3
GDS : 180 mg/dL
Urinalisis : makroskopis dan mikroskopis dalambatas normal
Tes kehamilan : β-HCG (-)
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♀ 39 tahun
> Haid jumlah banyak
sejak 5 hari
Perdarahan pervaginam,
warna: merah hitam,
jumlah: 6-8
pembalut
Sakit kepala, lemas, nyeri
perut25 Juni 201308.30
Februari :
Menometrorrhagia
Maret :
Menometrorrhagia
April : perdarahan
bercak
Mei : Amenorrhea
Mengeluhperdarahan banyakdari kemaluan
RSUD
Kakek HipertensiMenarche 14 tahun, siklus tidak teraturInfertilitas 14 tahunKontrasepsi (-)
Riwayat leukorrhea (-)Hipertensi (-)DM (-)Penyakit ginekologi (-)Pengobatan (-)
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Status generalis
KU/Kes : TSS/CM
TD: 120/80 mmHg
N: 88 x/menit
RR : 20x/m
S: 36,70C
Mata: conjungtiva anemis +/+
Status Ginekologi Abdomen : nyeri tekan regio
hipogastrika dan illiakadekstra
Genitalia eksterna : Dalambatas normal
LAB Hb : 10, 3 gr/dL
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1. Suspek Perdarahan Uterus Disfungsional
2. Infertilitas primer
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Diagnosis Banding
HiperplasiaEndometrium
Karsinomaendometrium
Mioma uteri submukosum
Adenomiosis
Endometriosis
Displasiaserviks
Servisitis
Polipserviks
Karsinomaserviks
Trombositopenia
Defisiensifaktor
pembekuan
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IVFD Ringer Lactat 30 tetes/menit
Injeksi Asam traneksamat 1 gram / 8 jam i.v.
Asam mefenamat 3 x 500 mg per oral
Norethisterone acetat 1 x 5 mg peroral
( selama 14 hari kemudian stop 14 hari, ulangi selama 3 bulan)
Farmabion 1 x 1 tablet peroral
Klomifene sitrate 1 x 50 mg ( dimulai dari harike-5 siklus haid selama 5 hari )
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Diet Tinggi kalori tinggi protein 1500 Kkalori/hari
Bedrest total
Konsultasi ke dokter spesialis Obstetri Ginekologi
Saran pemeriksaan lebih lanjut meliputi :
Ultrasonografi 3D TA/TV,
Hemostasis ( BT, CT, PT, aPTT, fibrinogen, d-dimer),
Pap smear, IVA,
fungsi tiroid ( TSH, T3, T4),
fungsi hati ( SGOT,SGPT ),
fungsi ginjal ( ureum, kreatinin ),
prolaktin,
DHEAs.
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Penatalaksanaan infertilitas pada prinsipnyamenunggu kondisi pasien stabil ( rawat jalan ) kemudian mencari penyebab baik dari faktor istrimaupun suami.
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Saran pemeriksaan yang dilakukan :
Istri :
1. Hormon reproduksi ( FSH, LH, Estrogen pada hari ke 3 s/d 7 dan Progesteron, Prolactin pada hari ke-22)
2. Hidrotubasi, histerosalpingografi.
Suami :
Analisis sperma lengkap ( jumlah sperma/mL, bentuk, gerakan, persentase sperma hidup serta pencairan air mani )
Jika tidak ditemukan kelainan dan dengan pengobataninduksi ovulasi tidak berhasil, maka pasangandisarankan untuk teknik reproduksi berbantu ( TRB )
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PROGNOSIS
Ad vitam : bonam
Ad functionam: dubia ad bonam
Ad sanationam: dubia ad bonam
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FOLLOW UP ( 26/06/2013 PKL. 08.30 )
S : Darah haid berkurang, 5 pembalut,
nyeri perut berkurang
O: KU / Kes : baik / CM
TD : 110/70
N :84x/m
RR : 20x/m
S : 36o C
Status generalis
Mata : conjungtiva anemis +/+
Thorax:
Cor: S1-S2 reguler Gallop (-)
Murmur (-)
Pulmo: SN vesikuler Ronchi -/-
Wheezing -/-
Abdomen : nyeri tekan (+)
Status ginekologi
Darah pada pembalut (+)
A : - Anemia e.c. susp. Perdarahan uterus
disfungsional
- Infertilitas primer
P :
Observasi Tanda vital
IVFD RL 20 tpm
Injeksi Asam Traneksamat 1 gram / 8 jam
i.v.
Asam mefenamat 3 x 500 mg per oral
Norethisterone acetat 1 x 5 mg( hari ke -2)
Farmabion 1 x 1 tablet per oral
Klomifene sitrate 1 x 50 mg
Bed rest
Diet TKTP
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FOLLOW UP ( 27/06/2013 PKL. 08.15 ) S : perdarahan berkurang (2-3 pembalut)
O: KU / Kes : baik / CM
TD : 110/70
N :76x/m
RR : 20x/m
S : 36o C
Status generalis
Mata : conjungtiva anemis +/+ ( slight
anemis )
Thorax:
Cor: S1-S2 reguler Gallop (-) Murmur(-)
Pulmo: SN vesikuler Ronchi -/-
Wheezing -/-
Abdomen : nyeri tekan (+)
Status ginekologi
Darah pada pembalut (+)
Konsul dr. Deddy Fitri, Sp.OG ( 10.30 ) :
dilakukan Ultrasonografi 2-D
Hasil USG : Uterus antefleksi, ukuran 6,6 cm,
bentuk normal, tebal dinding endometrium 8
mm, kedua ovarium normal, cairan bebas
minimal.
A : - Anemia e.c. susp. Perdarahan uterus
disfungsional
- Infertilitas primer
P :
Observasi Tanda vital
IVFD RL 20 tpm
Injeksi Asam Traneksamat 1 gram / 8 jam i.v.
Asam mefenamat 3 x 500 mg per oral
Norethisterone acetat 1 x 5 mg( hari ke -2)
Farmabion 1 x 1 tablet per oral
Klomifene sitrate 1 x 50 mg
Bed rest
Diet TKTP
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FOLLOW UP ( 28/06/2013 PKL. 08.15 ) S : perdarahan berkurang (1-2 pembalut)
O: KU / Kes : baik / CM
TD : 110/80
N :80x/m
RR : 20x/m
S : 36o C
Status generalis
Mata : conjungtiva anemis +/+ ( slight
anemis )
Thorax:
Cor: S1-S2 reguler Gallop (-) Murmur(-)
Pulmo: SN vesikuler Ronchi -/-
Wheezing -/-
Abdomen : nyeri tekan (+)
Status ginekologi
Darah pada pembalut (+)
Hb : 11 gr/dL
A : - Anemia e.c. susp. Perdarahan uterus
disfungsional perbaikan klinis
- Infertilitas primer
P :
Observasi Tanda vital
IVFD RL 20 tpm
Asam Traneksamat 3 x 500 mg per oral
Asam mefenamat 3 x 500 mg per oral
Norethisterone acetat 1 x 5 mg( hari ke -2)
Farmabion 1 x 1 tablet per oral
Klomifene sitrate 1 x 50 mg
Bed rest
Diet TKTP
Pasien rencana rawat jalan
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√ LAPORAN KASUS
√ FORMAT PORTOFOLIO
√ TINJAUAN PUSTAKA
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FORMAT PORTOFOLIO
SUBJEKTIF
OBJEKTIF
DIAGNOSIS
PENGOBATAN
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SUBJEKTIF
Haid jumlah banyak (5 hari)
Siklus tidak teratur ( 4 bulan )
Belum hamil ( 14 tahun )
Nyeri perut kanan bawah
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PEMERIKSAAN PENUNJANG
Hb : 10.3 gr/dL
GDS : 180 mg/dL
HCG : (-)
USG 2D normal
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DIAGNOSIS
Suspek perdarahan uterus disfungsional
Infertilitas
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PENGOBATAN
IVFD Ringer Laktat
Inj Asam traneksamat
Asam Mefenamat
Progestin
Farmabion
Klomifen sitrate
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Diet Tinggi kalori tinggi protein 1500 Kkalori/hari
Bedrest total
Konsultasi ke dokter spesialis Obstetri Ginekologi
Saran pemeriksaan lebih lanjut meliputi :
• Ultrasonografi 3D TA/TV,
• Hemostasis ( BT, CT, PT, aPTT, fibrinogen, d-dimer),
• Pap smear, IVA,
• fungsi tiroid ( TSH, T3, T4),
• fungsi hati ( SGOT,SGPT ),
• fungsi ginjal ( ureum, kreatinin ),
• prolaktin,
• DHEAs.
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Analisis penyebab dari faktor suami dan istri
Pengaturan waktu senggama
Induksi ovulasi
Tehnik reproduksi berbantu
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√ LAPORAN KASUS
√ FORMAT PORTOFOLIO
√ TINJAUAN PUSTAKA
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Perdarahan uterus abnormal yang terjadi tanpakelainan pada saluran reproduksi, penyakit medistertentu atau kehamilan.
Diagnosis perdarahan uterus disfungsional (PUD) ditegakkan per ekslusionam.
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Hysteroscopy D & C
IVF
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1. Hendarto H. Gangguan Haid/ Perdarahan Uterus Abnormal. Dalam : Baziad A. Ilmu Kandungan edisi ketiga. P.T.Bina Pustaka Sarwono Prawirohardjo. Jakarta.2011. Hal 162-185.
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13. Albers J, Hull S, Wesley R. Abnormal uterine bleeding. J Am Fam Physician 2004 ; 69 : 1915 – 26.
14. The Royal College of Obstetricians and Gynecologist. The management of menorrhagia in secondary care ; 1999.
15. Walden M. Primary care management of dysfunctional uterine bleeding. JAAPA 2006 ; 19 : 32 – 39.
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