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BAGIAN / SMF OBSTETRI & GINEKOLOGI

FAKULTAS KEDOKTERAN UNIVERSITAS RIAU / RSUD ARIFIN
ACHMAD PEKANBARU
STATUS GINEKOLOGI
I.
INDENTITAS PENDERITA
Nama
:Nama Suami :..
Umur
:Umur
:..
Pendidikan :Pendidikan : ..
Pekerjaan
:Pekerjaan :..
Agama
:Agama
:..
Suku
:Suku
:..
Status
:Alamat
:..
Alamat:..
No.MR: ..
Masuk RS : Tanggal .. Jam
b.
ANAMNESA(Dilakukan
tanggal..
(Alloanamnesa/autoanamnesa)
II.1. Keluhan Utama:_______________________________________________
_______________________________________________________________
II.2. Riwayat Penyakit Sekarang:_____________________________________
_______________________________________________________________
_______________________________________________________________
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_______________________________________________________________
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_______________________________________________________________
II.3. Riwayat HAID:________________________________________________
II.4. Riwayat Perkawinan:___________________________________________
II.5. Riwayat Persalinan:____________________________________________
II.6. Riwayat Pemakaian Kontasepsi:__________________________________
II.7. Riwayat Penyakit Dahulu:_______________________________________
II.8. Riwayat Penyakit Keluarga:______________________________________
II.9. Riwayat Operasi Sebelumnya:___________________ Tahun: __________
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III.

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PEMERIKSAAN FISIK ( tanggal : ..)

III.1. Status Generalis

Keadaan Umum :
Gizi :

Kesadaran :

TB:

BB

Dada :

TD :

ND :

S:

Kepala :

Paru :

Jantung :

Nfs :

Abdomen

: Status Ginekologis

Genitalia

: Status Ginekologis

Ekstremitas

: ______________________________________________
_______________________________________________

III. 2. Status Ginekologi :

Muka

:________________________________________________________

Mamma: _______________________________________________________
Aksilla : _______________________________________________________
Abdomen: ______________________________________________________
Inspeksi:___________________________________________________
Palpasi:___________________________________________________
Perkusi : ________________________________________________________
Auskultasi: ______________________________________________________
Genitalia Eksterna :
Inspeksi / Palpasi

Genitalia Interna / Pemeriksaan dalam

Inspekulo :

-Vagina:...........................................................................
- Porsio:...........................................................................

VT / Bimanual Palpasi
-

Uterus

:
(besar, arah, konsistensi, mobil / tidak, nyeri

goyang/tekan):.........................................................................
...................................................................................................
-

Adneksa kiri / kanan (teraba / tidak teraba, ovarium dan

tuba):................................................................................
.........................................................................................
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Parametria kiri / kanan (lemas/kaku, berbenjol/tidak,

nyeri tekan/tidak):.............................................................
.........................................................................................

Kavum doglasi (menonjol/tidak, nyeri/ tidak)

Rectal Toucher / Recto Vaginal Toucher bila perlu dilakukan. :

........................................................................................................
......................................................................................................
IV.

PEMERIKSAAN LABORATORIUM RUTIN BILA SUDAH ADA

IV.1. Darah Lengkap : Hb : _________________________________________

Leukosit

: _________________________________________

LED

: _________________________________________

Hitung Jenis : _________________________________________

IV.2. Faal Hemostatik : ____________________________________________
IV.3. Kimia Darah : ________________________________________________
IV.4. Urine : _____________________________________________________
e.

RESUME PEMERIKSAAN :

f.

DIAGNOSIS
-

DIAGNOSIS KERJA : .................................................................

DIAGNOSIS BANDING

1
2

g.

PEMERIKSAAN PENUNJANG DIAGNOSTIK YANG DIUSULKAN :

1. ....................................................................................................................
2. ....................................................................................................................
3. ....................................................................................................................

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h.

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TERAPI
Simtomatik:................................................................................................................
Supportive:.................................................................................................................
.
Kausal: .......................................................................................................................

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
i.

PEMERIKSAAN PENUNJANG (Jika ada)

VIII.1. Pemeriksaan Radiologi

_____________________________________________________________________
_____________________________________________________________________
VIII.2._________________________________________________________________
_____________________________________________________________________
j.
DIAGNOSA PASTI
______________________________________________________________
_____________________________________________________________________
______________________________________________________________
______________________________________________________________
XI.

RENCANA TINDAKAN

______________________________________________________________
______________________________________________________________
______________________________________________________________
_____________________________________________________________________
______________________________________________________________
______________________________________________________________

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XII. LAPORAN TINDAKAN

______________________________________________________________
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XIII. PROGNOSA_________________________________________________
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______________________________________________________________________

Mengetahui :
Dokter Ruangan

Mahasiswa yang memeriksa

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(dr.,SpOG)
NIP :

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()
NIM :

STATUS FOLOW UP
TANGGAL
JAM

PERJALANAN PENYAKIT

TERAPI

PARAF

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