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Status RSU FKUKI/Ilmu Obstetrii/Obgyn RSU FK UKI/10.

08

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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

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

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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