Identity Mrs.

SRI/38/ P0A0/RA
Chief complain Amenorrhae
History Since 15 years old, complained irregular menstruation and
almost not having menstruation at all. 1 years ago, os came to
SpOG and had been given norethisteron 5 mg for 1 cycles, and she
got menstruation, mixturition and defecation normal.
Marital- 1x/ 8 month.
obstetric Menarche at 14 y, irregular, Dismenorea (-)
status LMP 18-02-2017 ; 19-02-2017
Gynecology BP : 110/80 mmhg RR: 20 x/mnt BW : 57 kg
examination HR : 82 x/mnt T : 36.50C Hieght : 152 cm
Abdominal palpation : flat, flexible, symmetrical, uterine fundal
is not palpated ,mass (-), sign free fluid (-).
US 1-2-2017 - Uterine was RF smaller than normal, size 1,84x1,01x1,83 cm
- Endometrial line (+) 0.16 cm, regular stratum basal
- Both of Ovaries smaller than normal
- Dextra : 0,67x0,58 cm
- Sinistra :0,57x0,74
C/ Internal genital hypoplasia
Diagnosis Secondary Amenorrhea

Therapy - Combined contraceptive pill

- Evaluation 1 month