I.

SKENARIO
Mrs. Tari 37 years old from middle income family comes to doctor at a public
health center with chief complain of vaginal bleeding. She experienced post coital
bleeding for 1 month. Since one years ago she has been complaining about vaginal
discharge with smelly odor and sometimes accompanied by vulvar itchy. She
already has 2 children before and the youngest child is 6 years old. Her husband is
a truck driver. She has never gone to the doctor related to her complain about
vaginal discharge, not using any medication, no history of paps smear
examination, and no history of HPV vaccination. She has a history of using
intrauterine device (IUD) as contraception for 5 years since her youngest child
birth and the IUD has been removed one year ago. Her older sister died 2 years
ago caused by breast cancer.
You act as a doctor in public health center and be pleased to analyse this case.
In the examination findings:
Height : 155 cm, weight: 50kg
BP : 120/80 mmHg, pulse: 80x/menit, RR: 20x/menit
Palpebral conjunctiva: anemic
Breast : there was no mass on both mammae
Abdomen : flat and souffl, symmetric, uterine fundus is not palpable, there are no
mass, no painful tenderness and no free fluid sign.
Internal examination:
Inspection : vulva and urethra 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 : cervix is soft, the external os is closed, no cervical motion
tenderness, exophytic mass size 2x2x1 cm, fragile, easy to bleed, no infiltration to
the vagina, uterine size is normal, both adnexa and parametrium are within normal
limit.
Then you performed IVA, the result was you could define the external os,
squamocolumnarjunction and there was thick acetowhite epithelium at the 2
oclock until 5 oclock position, so you performed biopsy.
Laboratory :
Hb 8,3 g/dL; WBC 12.000/mm3; PLT 770.000/mm3; ESR 30 mm/hour.
Histopathology :
The next week, the patient come with the histopathology 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.
II.

KLARIFIKASI ISTILAH
Istilah
Smely odor
Vaginal discharge
Post coital
Pap smear examination

Keterangan
Bau yang tidak sedap.
Ekskresi atau substansi yang dikeluarkan dari vagina.
Sesudah melakukan hubunga seksual antara pria dan wanita
Metode screening ginekologi yang digunakan untuk

HPV

mendeteksi kanker rahim yang disebabkan oleh HPV

(Human Papilloma Virus) adalah sekumpulan virus yang
menginfeksi manusia pada sel epitel di kulit dan membrane
mukosa (salah satunya adalah daerah kelamin) dan dapat

IVA

menyebabkan keganasan
Pemeriksaan screening kanker serviks dengan cara inspeksi

IUD

visual pada serviks dengan pemberian asam asetat

Sebuah alat kontrasepsi berupa kumparan kecil panjangnya 3

Souffle

cm dimasukkan ke dalam Rahim untuk mencegah kehamilan.

Bunyi yang timbul karena aliran darah dalam arteri arteri

Exophytic
Fragile
Flour

pada uterus.
Proliferasi pada epitel permukaan yang tumbuh kearah luar.
Mudah pecah.
Adalah keputihan yakni cairan bukan darah yang berlebihan

Acetowhite epithelium

keluar dari kelamin perempuan.

Daerah epitel yang memberikan gambaran warna putih

Parametrium

secara sementara mengikuti aplikasi dari asam asetat

Lapisan dinding yang paling luar dari Rahim dan

Adneksa

berhubungan dengan rongga perut/

Adalah jaringan yang berada di sekitar Rahim termasuk tuba

Squamous cell carcinoma

fallopi dan ovarium.

Karsinoma yang datang dari sel sel yang terletak pada
permukaan leher Rahim yang dikenal dengan squamous.

Limphovascular

space

invasion
III.

IDENTIFIKASI MASALAH
Keluhan utama : Mrs. Tari 37 years old from middle income family comes to
doctor at a public health center with chief complain of vaginal bleeding

Riwayat Perjalanan Penyakit : She experienced post coital bleeding for 1

month. Since one years ago she has been complaining about vaginal discharge
with smelly odor and sometimes accompanied by vulvar itchy.
Riwayat Keluarga : She already has 2 children before and the youngest child is 6
years old. Her husband is a truck driver. Her older sister died 2 years ago caused
by breast cancer.
Riwayat pengobatan : She has never gone to the doctor related to her complain
about vaginal discharge, not using any medication, no history of paps smear
examination, and no history of HPV vaccination. She has a history of using
intrauterine device (IUD) as contraception for 5 years since her youngest child
birth and the IUD has been removed one year ago.
In the examination findings:
Height : 155 cm, weight: 50kg
BP : 120/80 mmHg, pulse: 80x/menit, RR: 20x/menit
Palpebral conjunctiva: anemic
Breast : there was no mass on both mammae
Abdomen : flat and souffl, symmetric, uterine fundus is not palpable, there are no
mass, no painful tenderness and no free fluid sign.

Internal examination:
Inspection : vulva and urethra 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 : cervix is soft, the external os is closed, no cervical motion
tenderness, exophytic mass size 2x2x1 cm, fragile, easy to bleed, no infiltration to
the vagina, uterine size is normal, both adnexa and parametrium are within normal
limit.
IVA examination :
the result was you could define the external os, squamocolumnarjunction and
there was thick acetowhite epithelium at the 2 oclock until 5 oclock position, so
you performed biopsy.
Laboratory :
Hb 8,3 g/dL; WBC 12.000/mm3; PLT 770.000/mm3; ESR 30 mm/hour.
Histopathology :
The next week, the patient come with the histopathology 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.

IV.

ANALISIS MASALAH
Keluhan utama : Mrs. Tari 37 years old from middle income family comes to
doctor at a public health center with chief complain of vaginal bleeding
a. Apa hubungan umur dan social ekonomi dengan keluhan yang dialami?
(denara, fenrizal)
b. Apa penyebab dan mekanisme dari pendarahan vagina? (fitri, Mia)
c. Apa saja makna klinis dari perdarahan vagina? (aisyah, Felicia)
Riwayat Perjalanan Penyakit : She experienced post coital bleeding for 1
month. Since one years ago she has been complaining about vaginal
discharge with smelly odor and sometimes accompanied by vulvar itchy.
a. Bagaimana hubungan post coital bleeding dengan perdarahan vagina yang
dialaminya? (feliani, dwina)
b. Bagaimana penyebab dan mekanisme :
- Post coital bleeding (Felicia, Aisyah)
- Smelly odor (Mia, Fitri)
- Vulvar itchy (Fenrizal, Denara)
c. Apa saja mikroorganisme yang dapat menyebabkan smelly odor dan vulvar
itchy? (Abdi, Diana)
d. Apa saja flora normal yang terdapat pada vagina? (Farah, Dwina)
Riwayat Keluarga : She already has 2 children before and the youngest child
is 6 years old. Her husband is a truck driver. Her older sister died 2 years ago
caused by breast cancer.
a. Apa hubungan riwayat keluarga dengan keluhan :
- Mempunyai 2 anak (Patima, Felicia)
- Suaminya supir truk (Dwina, Farah)
- Kakak perempuannya meninggal 2 tahun lalu akibat kanker payudara
(Diana, Abdi)
Riwayat pengobatan : She has never gone to the doctor related to her
complain about vaginal discharge, not using any medication, no history of

paps smear examination, and no history of HPV vaccination. She has a

history of using intrauterine device (IUD) as contraception for 5 years since
her youngest child birth and the IUD has been removed one year ago.
a. Apa indikasi dari vaksinasi HPV? (denara, Fenrizal)
b. Apa syarat pemeriksaan pap smear? (fitri, Mia)
c. Apa makna klinis dari not using any medication no history of paps smear
examination, and no history of HPV vaccination, a history of using
intrauterine device (IUD)? (Aisyah, Felicia)
In the examination findings:
Height : 155 cm, weight: 50kg
BP : 120/80 mmHg, pulse: 80x/menit, RR: 20x/menit
Palpebral conjunctiva: anemic
Breast : there was no mass on both mammae
Abdomen : flat and souffl, symmetric, uterine fundus is not palpable, there are no
mass, no painful tenderness and no free fluid sign.
a. Bagaimana interpretasi dan mekanisme abnormal dari pemeriksaan fisik?
(Feliani, Dwina)
Internal examination:
Inspection : vulva and urethra 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 : cervix is soft, the external os is closed, no cervical motion
tenderness, exophytic mass size 2x2x1 cm, fragile, easy to bleed, no infiltration to
the vagina, uterine size is normal, both adnexa and parametrium are within normal
limit.
a. Bagaimana interpretasi dan mekanisme abnormal dari pemeriksaan interna?
(Felicia, Aisyah)
b. Apa syarat dilakukannya pemeriksaan dalam? (Mia, Fitri)
IVA examination :
the result was you could define the external os, squamocolumnarjunction and
there was thick acetowhite epithelium at the 2 oclock until 5 oclock position, so
you performed biopsy.
a. Bagaimana interpretasi dan mekanisme abnormal dari pemeriksaan IVA?
(Fenrizal, Denara)
b. Bagaimana gambaran dari acetowhite epithelium? (Abdi, Diana)
c. Bagaimana indikasi dan syarat dilakukannya IVA? (Farah, Dwina)
Laboratory :

Hb 8,3 g/dL; WBC 12.000/mm3; PLT 770.000/mm3; ESR 30 mm/hour.

a. Bagaimana interpretasi dan mekanisme abnormal dari pemeriksaan lab?
(Patima, Felicia)
Histopathology :
The next week, the patient come with the histopathology 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 gambaran dari pemeriksaan histopatologi? (Dwina, Farah)
V.

HIPOTESIS
Mrs. Tari 37 tahun mengalami kanker serviks et causa suspect infeksi high
grade HPV
1. Bagaimana cara mendiagnosis kasus ini? (Diana, Abdi)
2. Apa saja diagnosis banding kasus ini? (Denara, Fenrizal)
3. Apa saja pemeriksaan penunjang yang diperlukan untuk menyingkirkan
diagnosis banding? (Fitri, Mia)
4. Apa diagnosis pada kasus ini? (Aisyah, Felicia)
5. Apa definisinya? (Feliani, Dwina)
6. Bagaimana epidemiologinya? (Felicia, Aisyah)
7. Bagaimana etiologinya? (Mia, Fitri)
8. Apa saja faktor resiko kasus ini? (Fenrizal, Diana)
9. Bagaimana patofisiologi kasus ini? (Abdi, Dwina)
10. Bagaimana patogenesis kasus ini? (Farah, Patima)
11. Apa saja gejala klinis kasus ini? (Patima, Farah)
12. Apa saja terapi yang harus diberikan? (Dwina, Abdi)
13. Bagaimana cara pencegahannya? (Diana, Fenrizal)
14. Apa komplikasi dari kasus ini? (Denara, Mia)
15. Bagaimana prognosisnya? (Fitri, Felicia)
16. Jelaskan kompetensi dokter pada kasus ini? (Aisyah, Feliani)

VI.

LEARNING ISSUE
1. Anatomi dan Histologi Serviks. (denara, Mia, Fenrizal, Diana)
2. Karsinoma sel skuamosa (Kanker Serviks) ( fitri, Felicia, Abdi, Dwina)
3. IVA dan Pap Smear (Aisyah, Feliani, Farah, Patima)