No.

MR

Obstetric & Gynecology Departement

Medical School / General Hospital FK UKI
Jl. Mayjen Sutoyo No. 2, Cawang, Jakarta 13630, Indonesia
Tel. ( 021 ) 8092317 ext. 205 / 108

GYNECOLOGY STATUS

IDENTITY
PATIENT HUSBAND/ PARENT / FAMILY
Name : ……………………….......... Name : ………………………………...........
Age : ……………………….......... Age : ………………………………...........
Education : …………………………..... Education : ………………………………...........
Occupation : …………………………..... Occupation : ………………………………...........
Religion : …………………………..... Religion : ………………………………...........
Tribe : …………………………..... Tribe : ………………………………...........
Address : …………………………..... Address : ………………………………...........
…………………………..... ………………………………..........
…………………………..... ………………………………..........
......................................... .....................................................

Date of Admition : ……………………………………….. Time : …………………….

Origin : Self admitted
: ......................................................................................................................

I. SUBJECTIVE ( Primary / Secondary)

1. Chief Complain :
………………………………………………………………………………………………………………

2. Additional Complain
1. …………………………………………………………………………………………………………
2. …………………………………………………………………………………………………………
3. …………………………………………………………………………………………………………
4. …………………………………………………………………………………………………………
5. …………………………………………………………………………………………………………

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 3. Chronology of Complain/ Recent Illness
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4. Menstruation History
First Period : …………………………………..............………. years old
Cycle: Regular : ………………………………...............…….. days/ month
Length : ……………………………………...............………… days
Amount : ……………….....… changes / ……………..........…… cc
1st Day of Last Period : ……………………………………................………………
Length : …………………………………...............…………… days
Amount : ………………....... changes / ……………….............. cc
Estimated Date of Labor : .......................................................................................
Period Pain ( desmenorrhea ) : ………………………………………………...............…….
Menstrual Period in last 3 months :
Date Month Year Lenght Amount

5. Marital History
a. Marital Status : Married / Not Married / Widow
: 1 / 2 / 3 / 4 / 5 time
b. Last Marriage : ……………………..................................…month / years

6. Pregnancy, Labor, Parturition History

Birth
No. Age of Pregnancy Type of Labor Sex Current Age
Weight
1
2
3
4

7. Previous Illnesses

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 No. System Based Abnormal Explanation
1 Central Nervous System
2 Cardiovascular
3 Respiratory Tract
4 Gastrointestinal Tract
5 Urogenital Tract
6 Haematology
7 Immunology / Metabolic
8 etc …………………………..

8. History Disease in Family

No. System Based Abnormal Explanation

1 Central Nervous System
2 Cardiovascular
3 Respiratory Tract
4 Gastrointestinal Tract
5 Urogenital Tract
6 Haematology
7 Immunology / Metabolic
8 etc……………………………..

9. Surgery History

No. Genre Operation Years Explanation

1
2
3
4

10. Family Planning Method

Genre Years
Not use KB
Hormonal ( tablet, inject , susuk )
IUD ( lipe loops, cooper T, … )
Condom
Natural ( calendar, interuptus )
Kontap
Etc ……………………………….

11. Others Data ( others secondary data / information associated with obstetric and gynecology)
…………………………………………………………………………………………………………………………
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II. OBJECTIVE
A. GENERAL EXAMINATION
1. Vital Signs
General Condition : ……………………………………………………………………..…….
Consciousness : ……………………………………………………………………………
Blood Pressure : ……………………………………….....................…………… mmHg
Pulse : ……………………………………………....................…. .time / mnt
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 Temperature : ……………………………………….....................………………. º C
Respiratory Rate : ……....……………………………………....................……...time/ mnt
Height : ………………………....................…………………………………cm
Weight : …………………………....................……………………………… kg

2. Head :
Eyes :
i. Conjunctivae : ……………………………………………………..................…………
ii. Sclera : ………………………………………………………..................………
Teeth : ……………………………………………………………………………………….………

Ear Nose and Throat :

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

3. Neck : ………………………………………………………………………………………..……..
………………………………………………………………………………………………

4. Thorax :
a. Heart : …………………………………………………………………………….……….
………………………………………………………..……………………………
…………………………………..…………………………………………………
……………………………………………………………………………………...
b. Lungs : ………………………………………..……………………………………………
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5. Abdomen :
a. Inspection : ……………......................................................................................
........................................................................................................
b. Palpation : ........................................................................................................
........................................................................................................
c. Percussion : ........................................................................................................
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d. Auscultation : ........................................................................................................
........................................................................................................

6. Extremities :
a. Superior : …………………………………………………………………………………
………………………………………………………………………………….

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 ………………………………………………………………………………….
b. Inferior : …………………………………………………………………………………
…………………………………………………………………………………
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B. GYNECOLOGY EXAMINATION
1. Outer Examination
a. Face
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b. Breast
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c. Abdomen
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d. External genitalia
i. Pubic hair distribution :
…………………………………………………………………
ii. Fluor :
…………………………………………………………………
iii. Fluxus :
…………………………………………………………………
iv. Vulva :
………………………………………………………………….
………………………………………………………………….
2. Internal Examination
a. Inspeculo
i. Fluxus : …………………………………………………………………
ii. Fluor : …………………………………………………………………
iii. Vulva : …………………………………………………………………
iv. Vagina : ………………………………………………………………….
v. Portio : ………………………………………………………………….

b. Vaginal Toucher ( by indication : …………………….....................…….)

i. Vulva / vagina : ……………………………………………..............................
...........................................................................................
ii. Portio : ……………………………………………..............................
iii. Uterus : ……………………………………………..............................
iv. Right Adnexa : ……………………………………………..............................
v. Left Adnexa : ……………………………………………..............................
vi. Rectouterine pouch : ……………………………………………..............................

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 c. Rectal Toucher ( by indication : .........................................................)
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
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3. Laboratory Examination and Next examination

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III. ASSESMENT
A. WORKING DIAGNOSE
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B. DIFERRENTIAL DIAGNOSE
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C. PROGNOSES
Ad Vitam : …………………………………………………………………...................................…..
Ad Funtionam : …………………………………………………………………...................................…..
Ad Sanationum : …………………………………………………………………...................................…..

D. PROBLEM LISTS
1. ………………………………………………………………………………….………………………
2. ……………………………………………………………………………………...………………….
3. …………………………………………………………………………………………...…………….
4. ………………………………………………………………………………………………...……….

IV. PLANNING
1. Diagnostic Planning
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2. Management planning

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 …………………………………………………………………………………………………………………………
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3. Education Planning
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Co assistant Name : ………………………………………….

Night Shift doctor / Obstetric-Gynecologist
Jakarta, ........................................................

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

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