RUMAH SAKIT UTAMA HUSADA

Jalan Manggar 134 Tegalsari – Ambulu

Telp. (0336) 881186, 881187

ASESMEN AWAL MEDIS OBSTETRI DAN

GYNEKOLOGI RAWAT INAP

Masuk ruangan : Tanggal....................................................Jam...............................

A. ANAMNESIS
a. Keluhan utama : .........................................................................................................
b. Riwayat penyakit sekarang : .............................................................................................................
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c. Riwayat penyakit dahulu : .........................................................................................................
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d. Riwayat penyakit dalam keluarga : ...................................................................................................
e. Riwayat Alergi : ..............................................................................................................................
f. Riwaat obstetri :.....................................................................................................................................
g. Riwayat KB:.............................................................................................................................. ……..
h. Riwayat menstruasi
Amenorhe : ..................................................
Menarche: ..................................................
Lama: ..................................................
Siklus: ..................................................
HPHT : ..................................................
I. Riwayat Kehamilan, Persalinan dan Nifas yang lalu

NO 1 2 3 4 5
TAHUN
PARTUS
TEMPAT
PARTUS
UMUR
HAMIL
JENIS
PERSALINAN
PENOLONG

PENYULIT

BB

TB

HIDUP/MATI

B. PEMERIKSAAN FISIK
1. Tanda Vital
Kesadaran : ....................... Tensi: ........mmHg Nadi: .......x/mnt RR: ........x/mnt Suhu: ........˚C
GCS : E...................... V...................... M.................... BB : ........Kg TB: ........cm
2. Status Generalis
A, Kepala

Rambut : Bersih Kotor Kusam Rontok

Mata : Konjungtiva merah muda Konjungtiva pucat Sklera ikterik
Telinga : Normal Infeksi Gangguan Pendengaran
Hidung : Normal Scret Polip
Mulut dan Ggi : Normal Mukosa kering Sianosis Reflek menelan (+) / (-)
Leher : Normal Pembesaran Kelenjar tiroid Distensi JVP
Lain-Lain :…………………………………
B. Dada
 Pergerakan dada : Simetris Asimetris
Paru: Vesikuler Ronkhi Whezing
Jantung : Reguler Murmur Galop
Payudara : Mennjol Masuk keadalam Data Hiperpigmentasi Pembengkakan Kolstrum/ASI
Lain-Lain :…………………………………
C. Abdomen
Luka bekas operasi Strie Linea Alba Linia lubra
Teraba Massa: Ya , Ukuran………Cm , Konsistensi………………………. Tidak
Palpasi
Leupod 1 :TFU:…………Cm
Leupod 2 : Puka Puki
Leupod 3 : Kepala Bokong
Leupod 4 : Konvergen Divergen
Lain-Lain :…………………………………
D. Genetalia
Vulva: bersih Kotor varises Edema
Servik : Pembukaan ……..…cm Belum ada Pembukaan
Hemoroi: Ada Tidak ada
Lain-Lain :…………………………………
E. Ektremitas

Ekstremitas Atas: Edema

Ekstremitas Bawah: Edema Varices
Lain-Lain :…………………………………

F. SKALA NYERI

G. PEMERIKSAAN
PENUNJANG
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H. DIAGNOSIS
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I. RENCANA PELAYANAN
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Ambulu, .......................Jam................
DPJP / Dokter Pemeriksa

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