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Status RSU FKUKI/Ilmu Obstetrii/Obgyn RSU FK UKI/10.
08
Page 1 of 8
No. MR
Bagian / SMF Obstetri Ginekologi

Fakultas Kedokteran / Rumah Sakit Umum FK UKI
Jl. Mayjen Sutoyo no. 2, Cawang, Jakarta 13630, Indonesia
Tel. ( 021 ) 8092317 ext. 205 / 108
GYNECOLOGIC STATUS
IDENTITY
PATIENT
HUSBAND/ PARENT / FAMILY
Name
: .......... Name
: ...........
Age
: .......... Age
: ...........
Education
: ..... Education
: ...........
Occupation
: ..... Occupation
: ...........
Religion
: ..... Religion
: ...........
Tribe
: ..... Tribe
: ...........
Address
: ..... Address
: ...........
.....
..........
.....
..........
.........................................
.....................................................
Date of Admition
: ..
Origin
: Self admitted
Time
: .
: ......................................................................................................................
I.
SUBJEKTIF ( Primary / Secondary)

1. Chief Complain :
2. Additional Complain
Status RSU FKUKI/Ilmu Obstetrii/Obgyn RSU FK UKI/10.08
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1.
2.
3.
4.
5.
3. Chronology of Complain/ Recent Illness
4. Menstruation History
First Period
: ............... years old
Cycle: Regular
: ................. days/ month
Length
: ............... days
Amount
: ..... changes / .......... cc
Period Pain ( desmenorrhea )
: ................
Last 3 month menstruation

Date
Month
Year
Length
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

a. Previous pregnancy : P .. A ..
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b. Count of child life

c.
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: .
The age of last child : .
7. Previous Illnesses
No.
1
2
3
4
5
6
7
8
System Based Abnormal

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

Central Nervous System
Cardiovascular
Respiratory Tract
Gastrointestinal Tract
Urogenital Tract
Haematology
Immunology / Metabolic
etc..
Explanation
9. Surgery History
No.
1
2
3
4
Genre Operation
Years
Explanation
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 gynecology)
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II.
OBJECTIVE
1.
GENERAL EXAMINATION
1. Vital Signs
General Condition
: ...
Consciousness
: ..
Blood Pressure
: ..................... mmHg
Pulse
: ..................... .time / mnt
Temperature
: ...................... C
Respiratory Rate
:.. .......................time/ mnt
Height
: ....................cm
Weight
: .................... kg
2. Head :
a. Eyes
i. Conjunctivae
: ..................
ii. Sclera
..................
b. Teeth
c. Ear Nose and Throat :

3. Neck
: .
4. Thorax :
a. Breasts
: ..
..
..
..
b. Heart
: ..
..
..
c.
Lungs
: ..
..
..
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5. Abdomen :
a. Inspection
: ......................................................................................
........................................................................................................
b. Palpation
: ........................................................................................................
........................................................................................................
c.
Percussion
: ........................................................................................................
........................................................................................................
d. Auscultation
: ........................................................................................................
........................................................................................................
6. Extremities :
a. Superior
:
.
.
b. Inferior
B. OBSTETRICAL EXAMINATION
1. Outer Examination
a. Face
..
..
..
b. Mammae
..
..
..
c.
Abdomen
..
..
..
d. External Genitalia
i. Pubic hair distribution
................
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ii. Fluksus
: ........................................
...................................................
Fluor
: ...........................................................................................
iii. Vulva
..............................
..............................
2.
Inner Examination
a.
Inspeculo (by
indication )
: ............................................................................................)
i.
Fluor
..
..
ii.
Fluxus
..
..
iii.
Vulva / urethra / vagina
.
.
...........................................................................................
iv.
Portio
...........................
ii.
Vaginal / Vaginal Toucher ( by indication : ......................)

i.
Vulva
ii.
vagina
........................................
iii.
Portio
.
..
..
iv.
Uterus
: ..
.
v.
Right Adnexa : ..
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...
vi. Left adnexa
: ..
..
vii.
Douglasy Cavity :..........................................................................................
3. Rectal Toucher / Rectovaginal touher (by indication : ................)
4. Spesific Examnination
Valsava Test
Other
..................
....................
5. Laboratory examination and next examination
III.
ASSESMENT
1.
WORKING DIAGNOSE
.
.
.
2.
DIFFERENTIAL DIAGNOSE
..
..
..
3.
PROGNOSIS
Ad vitam
: ......
Ad functionum
: ..
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Ad sanationum
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: ..
PROBLEM LISTS
4.
Active
1. .
IV.
2.
....
3.
....
4.
....
5.
....
6.
....
PLANNING
1. Diagnostic Planning
2. Management planning
3. Education Planning
Co assistant name
: .
Dokter Jaga / Dokter Konsulen Obgin

Jakarta, ........................................................
( ....................................................................)
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Status RSU FKUKI/Ilmu Obstetrii/Obgyn RSU FK UKI/10.

Bagian / SMF Obstetri Ginekologi

HUSBAND/ PARENT / FAMILY

SUBJEKTIF ( Primary / Secondary)

Status RSU FKUKI/Ilmu Obstetrii/Obgyn RSU FK UKI/10.08

Status RSU FKUKI/Ilmu Obstetrii/Obgyn RSU FK UKI/10.08

3. Chronology of Complain/ Recent Illness

: ............... years old

: ................. days/ month

: ..... changes / .......... cc

Period Pain ( desmenorrhea )

Last 3 month menstruation

: Married / Not Married / widow

6. Pregnancy, Labor, Parturition History

Status RSU FKUKI/Ilmu Obstetrii/Obgyn RSU FK UKI/10.08

b. Count of child life

The age of last child : .

System Based Abnormal

8. History disease in family

System Based Abnormal

10. Family Planning Method

Status RSU FKUKI/Ilmu Obstetrii/Obgyn RSU FK UKI/10.08

Status RSU FKUKI/Ilmu Obstetrii/Obgyn RSU FK UKI/10.08

: ..................... .time / mnt

:.. .......................time/ mnt

c. Ear Nose and Throat :

Status RSU FKUKI/Ilmu Obstetrii/Obgyn RSU FK UKI/10.08

Status RSU FKUKI/Ilmu Obstetrii/Obgyn RSU FK UKI/10.08

Status RSU FKUKI/Ilmu Obstetrii/Obgyn RSU FK UKI/10.08

Vulva / urethra / vagina

Vaginal / Vaginal Toucher ( by indication : ......................)

Status RSU FKUKI/Ilmu Obstetrii/Obgyn RSU FK UKI/10.08

Status RSU FKUKI/Ilmu Obstetrii/Obgyn RSU FK UKI/10.08

Douglasy Cavity :..........................................................................................

3. Rectal Toucher / Rectovaginal touher (by indication : ................)

Status RSU FKUKI/Ilmu Obstetrii/Obgyn RSU FK UKI/10.08

Status RSU FKUKI/Ilmu Obstetrii/Obgyn RSU FK UKI/10.08

Dokter Jaga / Dokter Konsulen Obgin

Status RSU FKUKI/Ilmu Obstetrii/Obgyn RSU FK UKI/10.08

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