Status RSU UKI/Obstetri/Obgyn RSU UKI/04.

10

No. MR

RUMAH SAKIT UMUM FKUKI

SMF OBSTETRI GINEKOLOGI
Jl. Mayjen Sutoyo no. 2, Cawang, Jakarta 13630
Tel. ( 021 ) 8092317 ext. 205 / 108

STATUS GINEKOLOGI

IDENTITAS

PASIEN SUAMI / ORANG TUA / KELUARGA

Nama : ...........................................
Umur : ...........................................
Pendidikan : ...........................................
Pekerjaan : ...........................................
Agama : ...........................................
Suku Bangsa : ...........................................
Alamat : ...........................................
...........................................
...........................................
...........................................
Nama : .................................................
Umur : .................................................
Pendidikan : .................................................
Pekerjaan : .................................................
Agama : .................................................
Suku Bangsa : .................................................
Alamat : .................................................
.................................................
.................................................
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Tanggal masuk RS : ........................................................ Jam : ............................

Asal Pasien : datang sendiri / poli umum / poli spesialis / konsul bagian lain / rujukan
Oleh : ..............................................................................................................

I. SUBJEKTIF ( Primer Sekunder )

1. Keluhan utama :
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2. Keluhan tambahan :
1. ..............................................................................................................................................
2. ..............................................................................................................................................
3. ..............................................................................................................................................
4. ..............................................................................................................................................
5. ..............................................................................................................................................

3. Kronologi keluhan / penyakit sekarang

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4. Riwayat Haid
a. Haid pertama umur : ............................................................................................tahun

b. Siklus haid :
i Siklus : teratur / tidak teratur
..................................................................................hari / bulan
ii Lamanya : ..............................................................................................hari
iii Banyaknya : ....................................... ganti kain / ......................................cc
iv Sakit saat haid :+/- minum obat : + / -

a. Haid 3 bulan terakhir

Tanggal Bulan Tahun Lamanya Banyaknya

5. Riwayat perkawinan
a. Menikah / tidak menikah / janda
jika menikah : 1 / 2 / 3 / 4 / 5 kali
b. Lama perkawinan yang terakhir : ................................................................bulan / tahun

6. Riwayat kehamilan dan persalinan yang lalu

1. Kehamilan sebelumnya : P ............................................... A ..............................................
2. Jumlah anak hidup : ........................................................................................... orang
3. Umur anak terkecil : ........................................................................................... tahun

7. Riwayat penyakit dahulu

No. Kelainan Berdasarkan Sistem Keterangan ( jika ada )

1 SSP
2 Kardiovaskuler
3 Traktus Respiratorius
4 Traktus Gastrointestinal
5 Traktus Urogenital
6 Hematologi
7 Imunologi / Metabolik
8 dll ........................................

8. Riwayat penyakit dalam keluarga

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 Status RSU UKI/Obstetri/Obgyn RSU UKI/04.10

No. Kelainan Berdasarkan Sistem Keterangan ( jika ada )

1 SSP
2 Kardiovaskuler
3 Traktus Respiratorius
4 Traktus Gastrointestinal
5 Traktus Urogenital
6 Hematologi
7 Imunologi / Metabolik
8 dll ........................................

10. Riwayat Operasi

No. Jenis Operasi Tahun Keterangan

1
2
3
4

10. Metode Keluarga Berencana

Jenis Tahun
Tidak KB
Hormonal ( pil, suntik, susuk )
IUD ( lipes, loops, cooper T, ... )
Kondom
Alamiah ( kalender , interuptus )
Kontap
Lain - lain

11. Hal – hal lain dan kebiasaan – kebiasaan yang berhubungan dengan ginekologi

……………………………………………………………………………………………...
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II. OBJEKTIF

A. PEMERIKSAAN UMUM
Keadaan umum : ......................................................................................................
Kesadaran : ......................................................................................................
Tekanan darah : ……………………………………………………..…… mmHg
Nadi : ……………………………………………...……… kali / menit
Suhu : ……........................................................................................  C
Pernafasan : ……………………………………………...……… kali / menit

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 Status RSU UKI/Obstetri/Obgyn RSU UKI/04.10

Tinggi badan : ............................................................................................... cm

Berat badan : …………………………………………………............…… kg
BMI : …….............................................................................................

2. Kepala
a. Mata :
i. Konjungtiva : ………………………………………………………….………
ii. Sklera : ………………………………………………………….………
b. Gigi : ………………………………………………………………………………
c. THT : ...………………………..…………………………………………………...

3. Leher : .…………………………………..……………………………………………
.…………………………………………......…………………………………

4. Thorax :

a. Jantung : ………….....…………………………………………………………….
……….....……………………………………………………………….
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b. Paru : ………….....…………………………………………………………….
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5. Abdomen :
a. Inspeksi : ………….....…………………………………………………………….
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b. Palpasi : ………….....…………………………………………………………….
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c. Perkusi : ………….....…………………………………………………………….
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d. Auskultasi : ………….....…………………………………………………………….
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6. Ekstremitas :
a. Superior : ………….....…………………………………………………………….
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b. Inferior : ………….....…………………………………………………………….
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B. PEMERIKSAAN GINEKOLOGI
1. Pemeriksaan luar
a. Muka : ……..……………………………………………………………………

b. Payudara : ………….....…………………………………………………………….
……….....……………………………………………………………….

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 Status RSU UKI/Obstetri/Obgyn RSU UKI/04.10

c. Abdomen : ………….....…………………………………………………………….
……….....……………………………………………………………….
……….....……………………………………………………………….

d. Genitalia eksterna
i. Distribusi rambut pubis : .........................................................................................

ii. Fluksus : .........................................................................................

Fluor : .........................................................................................

iii.Vulva : .........................................................................................
..........................................................................................

2. Pemeriksaan dalam ( atas indikasi : ……………..……………………………………… )

a. Inspekulo ( dilakukan / tidak dilakukan )
i. Fluksus : ………………………………………………………………………
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ii. Fluor : ………………………………………………………………………

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iii.Vulva : ………………………………………………………………………
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iv. Vagina : ………………………………………………………………………

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v. Portio : ………………………………………………………………………
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b. Vaginal toucher
i. Vulva : ………...……………………………………………………
...........………………………………………………………

ii. Vagina : ………...……………………………………………………

...........………………………………………………………

iii. Portio : ……...………………………………………………………

: ……...………………………………………………………
: ……...………………………………………………………

iv. Uterus : ……...………………………………………………………

: ……...………………………………………………………

v. Adnekasa Kanan : ……...………………………………………………………

……..........……………………...…………………………………....

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 Status RSU UKI/Obstetri/Obgyn RSU UKI/04.10

vi. Adnekasa Kiri : ……...………………………………………………………

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vii.Cavum douglasi : ……...………………………………………………………

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c. Rectal Taucher / rectovaginal toucher ( atas indikasi : …………………………......)

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3. Pemeriksaan khusus :
a. Tes valsava : ………………………………………………………………………

b. Lain – lain : ………………………………………………………………………

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C. PEMERIKSAAN LABORATORIUM DAN PEMERIKSAAN PENUNJANG

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III. ASSESMENT
A. DIAGNOSIS KERJA
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B. DIAGNOSIS BANDING
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C. PROGNOSIS
Ad vitam : ......................................................................................................................
Ad functionum : ......................................................................................................................
Ad sanationum : ......................................................................................................................

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 Status RSU UKI/Obstetri/Obgyn RSU UKI/04.10

C. DAFTAR MASALAH
Aktif
1. ..............................................................................................................................................
2. ..............................................................................................................................................
3. ..............................................................................................................................................
4. ..............................................................................................................................................
5. ..............................................................................................................................................
6. ..............................................................................................................................................

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

IV. PLANNING
1. Rencana pemeriksaan untuk konfirmasi diagnosis
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2. Rencana pengobatan / penatalaksanaan khusus

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3. Rencana pendidikan / inform consent

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Nama dokter muda :

Dokter Jaga / Dokter Konsulen Obgin
Jakarta, ........................................................

(...................................................................)

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PEMANTAUAN PERAWATAN
(Follow up)

Nama dan
Tanggal Waktu Follow up
tanda tangan

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