History of Past Illnesses

History of chronic hypertension : denied

History of kidney disease : denied
History of diabetes mellitus
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: denied
History of auto immune disease : denied
History of asthma : denied
History of allergy hshhh : denied
History of surgery : denied
History of cancer : denied

Familial History

History of hypertension : denied

History of kidney disease : denied
History of liver disease : denied
History of diabetes mellitus : deniedzz
History of auto immune disease : denied
History of cancer : denied
History of absence of menstruation : denied
YOU

XY
Menstruation History
Menarche :12 years old
Menstrual cycle : irregular since 1 years ago every 20
days
Amount of menstrual blood : 2-3 pads / day ( ± 60 cc )
First day of last menstruation : June 20th 2017
 
Contraception History
No use of contraception.
 
Marital Historyhttps://slideplayer.info/slide/11282190/
Single- never been married
 
Obstetric History
Never been pregnant
PHYSICAL
EXAMINATION
  Physical Examination
General condition : good
Consciousness : compos mentis

Vital Sign
• Blood pressure : 120/70 mmHg
• Heart rate : 82 bpm
• Respiratory rate : 20x/minute
• Temperature : 36,7°C
• Weight : 72 kg
• Height : 149cm
• BMI : 32,43 Kg/
GENERAL
EXAMINATION
Eyes : icteric sclera (-), anemic conjunctiva (-)
Mouth : wet mucosa oral, no signs of inflamation
Thorax
• Heart : cardiomegaly (-), regular heartbeat, murmur (-), gallop (-)
• Lung : simetric, vesicular breath sounds +/+, rhonchi -/-, wheezing -/-
• Mammae : areola hyperpigmentation -/-, nipple retraction -/-,
Abdomen
• Inspection : convex, signs of acites (-)
• Palpation : pain (-), mass(-),
• Percussion : timpanic of all abdomen region
• Auscultation : bowel sounds (+), 8 times / minutes

Extremities :
Upper extremities -/-, Lower extremities -/-, CRT <2 seconds, upper
extremities physiologic reflex +/+, lower extremities physiologic reflex +/+,
patologic reflex -/-
 GYNECOLOGIC
EXAMINATION
Breast Examination
Inspection :
Shape : symetric
Skin : peu d’orange (-), dimpling (-)tumor (-)lesion (-), mass(-)
Nipple : discharge (-) retraction (-)
Axilla lymph : no enlarge lymph

Palpation : discharge (-), mass(-)

External Genital Examination

Inspection :
Pubic hair : in normal limit
Ostium urethrae externum : pus (-) inflammstion (-), polip (-), blood (-
Hymen : Intac
Skin : inflammation (-) scars (-)
Clitoris : in normal limit
Vagina introitus : tumor (-), uteri prolapse (-), myoma (-), polip (-),inflammation (-)
odorless, fluor albus (-), condiloma (-) ulcus (-0
Bartholini gland : tumor (-) edeme (-),
Perineum : scars (-)
USG Findings
• Uterus : shape : in normal limit Laboratory findings
• Adnexa : in normal limit Urine
• Douglass cavity : in normal limit • BhCG Urine :
negatives
• Tumor/mass : negative
• Result : Ginecology in normal limits
RESUME
Ms. A 16 years old came to RSUD R. Syamsudin, S.H., Sukabumi. Patient
complaint about her cessasion of menses for 4 months. The pregnancy is denied. The
patient claimed to be unmarried and never had sexual intercourse. Currently the patient
is ongoing treatment in the Departement of Psychiatri. Patients routinely doing the
treatment since the age of 14 years (26 October 2015). Patients are diagnosed with
Schizophren. 1 years ago the patient also had experienced the same complaint. Patients
went to the community health care for the treatment and 1 month later she got her
menstruation again. Patients say sometimes the menstruation are irregular but not sure
when.

General examination : Obesity grade II

Physical examination : normal
Gynecology examination : in normal limits
Laboratory findings :BhCG Urine negatives
USG findings : Gynecology in normal limits
 WORKING DIAGNOSIS
 Ms. A, 16 years old with Secondary Amenorrhea
 
Management
• Primolut 1 x 5mg

Psychiatri Management
• Haloperidol 2x1,5mg
• Trihexyphenidyl 2x1mg
• Chlorpromazine 1x50mg

Prognosis
Quo ad vitam : dubia ad bonam
Quo ad functionam : dubia ad malam
Quo ad sanationam : dubia ad malam
Case Analysis
1. How to diagnose this patient ?
2. How the management of this patient?
3. How the Prognosis ?
Evaluation Case
Anamnesis Patient complaint about her cessasion of
menses for 4 months.
The pregnancy is denied.
The patient claimed to be unmarried and
had never been sexual intercourse.
 
Currently the patient is ongoing treatment
in the Departement of Psychiatry
 
Patient currently using Antipsychotic
medication
Theory
Cessation of menstruation for
6 consecutive months in a
woman who has previously
had regular periods
Etiology : Iatrogenic
Psychotrophic phenothiazine
derivative drugs— Dopamine
receptor blocking agents
raise the prolactin level
 
Antipsychotic-induced
amenorrhea is not a rare
event among women treated
for schizophrenia. Hormonal
side effects of antipsychotic
medication, such as
amenorrhea, can complicate
the lives of women.
LITERARUTE REVIEW
Physical Examination General examination General examination :
BMI, extreme emaciation or
Presence of acne, striae. marked obesity, presence of
BMI : 32.43 acne,
 
Abdominal examination :
Presence of striae
associated with obesity
Hypothalamic factors weight
related amenorrhea

Imaging Studies USG findings : USG Findings in normal

- Uterus : shape : in limts
normal limit
- Adnexa : in normal limit
- Douglass cavity : in numerous small cystwith
normal limit increase ovarian stroma
- Tumor/mass : negative
andvascularity - typical of
Result : Ginecology in
normal limits PCOS
 
 Urine
Investigation of secondary Exclude Pregnancy
• BhCG Urine : negatives
amenorrhea Estimation serum TSH,
  prolactin, X-ray,CT,MRI Sella
  turcica
 
  Step I
  Progesterone challenge test
  Pelvic USG
  Step II
  Estrogen-progesterone
  challenge test
  Step III
Estimation of serum
gonadotropin is to be done.
Step IV
Gnrh Dynamic test
 Case Theory
- Weight reduction in obese patients is the first line of treatment
Management
- The management use of a dopamine agonist, of which bromocriptine
Primolut 1 x 5mg
is the most widely used.
- Antipsychotics appear to spare dopamine blockade
Psychiatri Management
Haloperidol 2x1,5mg within the brain's tubero-infundibular tract, a
Trihexyphenidyl 2x1mg dopamine pathway that also controls prolactin
Chlorpromazine 1x50mg
  secretion
This may not, however, be appropriate if the cause is a psychotropic
medication, for example, a phenothiazine being used to treat
schizophrenia. In these cases it is reasonable to continue he drug and
prescribe a low dose COC prepartion to counteract the symptoms of
oestrogen deficiency.

- Serum prolactin concentrations must then be carefully monitoredto

ensure that they do not rise further.

- Bromocriptine should be commenced at a dose of half a tablet at night

(1.25 mg) and increased gradually, every 5 days to 2.5 mg at night and
then 1.25 mg in the morning with 2.5 mg at night until the daily dose
is 7.5 mg (in two or three divided doses).
How the prognosis of this patient?

In secondary amenorrhea with comparatve fewer investigations the result is

satisfactorty. But the precentage of cures falls steeply as the duration of
amenorrhea lengthens. However, with or without treatment, spontaneous
resumption of menstruation occurs in about 60 percent cases of secondary
amenorrhea of more than one years duration. So in this patient can be said to have
prognosis dubia ad bonam
CONCLUSION

MS. A 16 YEARS OLD WITH SECONDARY AMENORRHEA

THE DIAGNOSIS WAS MADE CORRECTLY, ACCORDING TO THE HISTORY, PHYSICAL
EXAMINATION, USG FINDINGS AND LABORATORY FINDINGS.