STATUS PASIEN OBSTETRI

ANAMNESIS
A. Identitas Pasien

Nama Ibu
Usia
Alamat
Pekerjaan
Agama
Pendidikan

:
:
:
:
:

Nama Suami :
Usia
:
Pekerjaan
:
Pendidikan :
Lama menikah

B. Keluhan Saat Ini

Keluhan Utama
C. .....................................................................................................................
Keluhan Tambahan
D. G P A ........................................................................................................
E. .....................................................................................................................
F. .....................................................................................................................
G. .....................................................................................................................
H. .....................................................................................................................
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I. Riwayat Haid
Hari Pertama Haid Terakhir :
Taksiran Persalinan :
Menarche :
Siklus Haid :
Lama Haid :
J. Riwayat Kehamilan Saat Ini
Gejala trimester I (amenore,mual,muntah,perdarahan)
K. .....................................................................................................................
L. .....................................................................................................................
Gejala trimester II dan III (perdarahan, gerakan janin, hipertensi,
preeklampsia)
M. .....................................................................................................................
N. .....................................................................................................................
O. .....................................................................................................................
Penyakit yang sedang diderita dan kebiasaan (asma, hipertensi, diabetes,
jantung, merokok, minum alkohol, dll)
P. .....................................................................................................................
.....................................................................................................................
Q. Pemeriksaan Antenatal Care
R........................................................................................................................
S........................................................................................................................
T. Riwayat Kehamilan dan Persalinan

Anak
1. .
2. .
3. .
4. .
5. .
U.
V.

(Hidup : P/2th/Dokter/SC/3,2/Impending Eklampsi)

(Abortus : 3bln/Kuret/RS)

W. Riwayat Pernikahan
X........................................................................................................................
Y.........................................................................................................................
Z........................................................................................................................
AA.
Riwayat Penyakit Ibu

Hipertensi
Diabetes Melitus
TB Paru
Hepatitis (A/B)
Asma

Infeksi Saluran Kemih

Penyakit Jantung
Penyakit Ginjal
Alergi Obat
Transfusi Darah

AB.
Riwayat Penyakit Keluarga
Diabetes Melitus
Hipertensi
Hamil Kembar (Gemelli)
Kelainan Bawaan
AC.
Riwayat Penyakit yang Memerlukan Tindakan Pembedahan
Dilatasi atau Kuretase
Seksio Sesarea
Serviks Inkompeten
Operasi non-Ginekologi
Prematur
AD.
Riwayat Mengikuti Program Keluarga Berencana (KB)
AE...............................
AF................................
AG.
Riwayat Imunisasi
AH...............................
AI................................
AJ. PEMERIKSAAN FISIK
A. Tanda Vital
Tekanan Darah
:
mmHg
Nadi
:
x/menit regular, equal, isi cukup
Pernapasan :
x/menit cepat/lambat
o
Suhu
:
C
Berat Badan :
kg
Tinggi Badan:
cm
AK.
B. Pemeriksaan Umum
Kepala
: Konjungtiva Anemis () Sklera Ikterik ()
Leher : Pembesaran KGB () Tekanan Vena Jugularis 5 .cm
Thoraks
:
a. Inspeksi :
AL.Kelainan kulit
AM.
Pergerakan dada (simetris/asimetris)
AN.
Iktus Cordis ICS .
b. Palpasi
AO.
Iktus Cordis ICS
AP. Fremitus taktil (simetris/asimetris)
AQ.
Fremitus vocal (simetris/asimetris)
AR.
Krepitasi, Nyeri Tekan (+/-)
c. Perkusi
AS.
Terdengar (sonor) dikedua lapang paru
AT. Batas Jantung atas, kiri, kanan
AU.
Batas Hepar Paru ICS
d. Auskultasi
AV. Vesicular Breath Sound terdengar di Kanan/Kiri lapang paru
AW.
Wheezing (/) Rhonki (/)
AX.
Bunyi Jantung Murni regular/irregular S1 () S2 ()
AY. Murmur () Gallop ()
Abdomen :
a. Inspeksi
AZ.
Kelainan Kulit :

BA.
Bentuk
a. Auskultasi
BB.
Bising Usus ()
x/menit
a. Perkusi
b. Palpasi
BC.
Nyeri Tekan (.)
BD.
Hepar
BE.
Lien
Ekstremitas
a. Atas
: Edema (../..) akral hangat, CRT <3
b. Bawah
: Edema (../..) akral hangat, CRT <3
BF.
C. Pemeriksaan Obstetri
Pemeriksaan Luar
a. Inspeksi
Wajah : Kloasma Gravidarum (.)
Payudara :
BG.
Papila Mammae (menegang, menghitam)
BH.
Kelenjar Mongomeri (
)
Abdomen :
BI.
Bentuk (Cembung, simetris/asimetris)
BJ.
Striae Gravidarum ( )
BK.
Linea Nigra ( )
BL.
Bekas Luka ( )
BM.
b. Palpasi
BN.
Ballotemen Test (
)
BO.
HIS (/../)
BP. TBBA :
Leopold I
BQ. Tinggu Fundus Uteri :
cm
BR.
Bagian atas janin :
BS.
Lingkar Perut :
cm
BT.
Letak Anak :
Leopold II
BU.
Punggung Kanan/Kiri
Leopold III
BV.
Presentasi :
Leopold IV
BW. Bagian kepala yang masuk Pintu Atas Panggul (PAP) :
c. Auskultasi
BX.
Denyut Jantung Janin
BY. 1
3
5
=
x/menit regular/irregular
BZ.
Pemeriksaan Dalam (Vaginal Touche)
a. Inspeksi
CA.
Kelainan kulit
CB.
Ruam
CC.
Cairan yang keluar (fluor albus, ketuban, lendir, darah)
b. Palpasi
CD.
Pembesaran Kelenjar
CE.
Vulva : Nyeri Tekan (-)
CF. Vagina : Rugae (+) Massa (-) Nyeri Tekan (-)

CM.

CG.
Portio : tebal/tipis/lunak/kaku
CH.
Pembukaan :
cm
CI. Ketuban :
CJ. Presentasi :
CK.
Penurunan Kepala : Station
CL.
Bishop Score

CN.

FAKT
OR

CV.
Pem
bukaan
DB.
Pend
ataran
DH. Stati
on
DN. Konsi
stensi
DT.
Posis
i

CO.
CQ.

CW.

DC. 030
DI.
-3
DO.

Kak

CR.
CX.

1
1-2

DD. 4050
DJ.
-2

SKOR

CS.

CT.

CU.

CY.

3-4

CZ.

5-6

il
DA.

DE.

60-

DF.

80

DG.

-1/0

DL.

+1/

DM.

Has

70
DK.

DP.
me DQ. Lun
u
dium
ak
DU. pos DV.
ten DW. ant
terior
gah
erior
DZ.
JUMLAH

+2
DR.
-

DS.

DX.

DY.

EA.
EB.
EC........................................................................................................................... S
ARAN PEMERIKSAAN PENUNJANG
ED...........................................................................................................................
Laboratorium
a. Darah Rutin (Hb, Ht, Leukosit, Trombosit)
b. Protein Urin
c. SGOT
d. SGPT
e. Ureum
f. Kreatinin
g. Clotting Time
h. Bleeding Time
i. Golongan Darah
j. Gula Darah Sewaktu
k. hCG
l. Antigen Hepatitis B Virus
USG
NST
EE. RESUME
EF. .....................................................................................................................

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EG..................................................................................................................... D
IAGNOSIS
EH......................................................................................................................
EI. .....................................................................................................................
EJ.
EK.RENCANA TERAPI
a. Non Farmakologis
EL. .....................................................................................................................
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b. Farmakologis
EM................................................................................................................
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c. Bedah
EN......................................................................................................................
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d. Edukasi
EO......................................................................................................................
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EP. PROGNOSIS
EQ.....................................................................................................................
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