POLI

/ BANGSAL *) coret

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
:..
Masuk RS : Tanggal .. Jam
No. MR : ..
b.
ANAMNESA(Dilakukan
tanggal:..
(Alloanamnesa/autoanamnesa)
II.1. Keluhan Utama :______________________________________
II.2. Riwayat Penyakit Sekarang :______________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
II.2. Riwayat HAID
:______________________________________
II.2. Riwayat Perkawinan
:______________________________________
II.2. Riwayat Persalinan
:______________________________________
II.2. Riwayat Pemakaian Kontasepsi:____________________________________
II.2. Riwayat Penyakit Dahulu
:______________________________________
II.2. Riwayat Penyakit Keluarga :______________________________________
II.2. Riwayat Operasi Sebelumnya:___________________ Tahun : ___________
III.

PEMERIKSAAN FISIK ( tanggal : ..)

III.1. Status Generalis

Keadaan Umum :
Gizi :
Dada :
Abdomen

TB:

Kesadaran :
BB

TD :

ND :

S:

Kepala :

Paru :

Jantung :

Nfs :

: Status Ginekologis

1
Status Ginekologi Thn 2014

POLI

/ BANGSAL *) coret

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) : ..................................................................................

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

: ________________________________
2
Status Ginekologi Thn 2014

POLI

/ BANGSAL *) coret

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. ....................................................................................................................

h.

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

: ...................................................................................................................

_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
i.

PEMERIKSAAN PENUNJANG (Jika ada)

VIII.1. Pemeriksaan Radiologi

_____________________________________________________________________
_____________________________________________________________________
VIII.2. ___________________________________________________________________
_____________________________________________________________________
j.

DIAGNOSA PASTI
______________________________________________________________
_____________________________________________________________________
______________________________________________________________
______________________________________________________________
3
Status Ginekologi Thn 2014

POLI

XI.

/ BANGSAL *) coret

RENCANA TINDAKAN
______________________________________________________________
______________________________________________________________
______________________________________________________________
_____________________________________________________________________
______________________________________________________________
______________________________________________________________

XII. LAPORAN TINDAKAN

______________________________________________________________
______________________________________________________________
______________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

XIII. PROGNOSA__________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Mengetahui :
Dokter Ruangan

Mahasiswa yang memeriksa

(dr.,SpOG)

()
4
Status Ginekologi Thn 2014

POLI

NIP :

/ BANGSAL *) coret

NIM :

STATUS FOLOW UP
TANGGAL
JAM

PERJALANAN PENYAKIT

TERAPI

PARAF

5
Status Ginekologi Thn 2014

POLI

/ BANGSAL *) coret

6
Status Ginekologi Thn 2014