DEPARTEMEN OBSTETRI DAN GINEKOLOGI

FAKULTAS KEDOKTERAN UNIVERSITAS INDONESIA

STATUS KHUSUS MAHASISWA

PEMERIKSAAN GINEKOLOGI

Nama Mahasiswa : …………………………………………………………………………………………………………………………………

Nomor pokok : …………………………………………………………………………………………………………………………………
Laporan nomor : …………………………………………………………………………………………………………………………………

I. IDENTITAS
Nama Nama suami
Umur Umur suami
Bangsa Bangsa
Agama Agama
Pendidikan Pendidikan
Pekerjaan Pekerjaan
Status pernikahan Belum menikah/
menikah...tahun/cerai
Alamat
Nomor register Masuk RSUPN. CM Tanggal :
Tanggal/jam pemeriksaan ………………………………… di: …………………………………………………………………………………

II Data Dasar

1. Keluhan utama :
…………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………
Keluhan tambahan (termasuk merinci berapa lama, pemeriksaan dan terapi yang dilaku-
kan)
…………………………………………………………………………………………………………………………………………………………………
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2. Siklus haid (3 bulan terakhir):
Tanggal hari pertama haid yang terakhir :.................................... lamanya: ......................... hari
Tanggal hari pertama hari haid sebelumnya: …………………………….. lamanya: ......................... hari
Tanggal hari pertama hari haid sebelumnya:................................. lamanya:........................... hari
Dapat dibuat menstrual diary. Contoh:
bulan

............ ............ ............

...... ....... ....... ....... ....... .......

Tgl awal Tgl
haid terakhir
haid

Siklus haid : …………………………………………………………………………hari.

Berapa banyak perdarahan haid: .........x ganti pembalut/hari
Nyeri haid: +/-, deksripsi nyeri haid: ringan/sedang/berat

3. Riwayat obstetri sebelumnya:

Para ....................... Abortus ........................

No. Jenis kelamin Umur BB Keterangan tentang

anak anak lahir operasi dan tindakan
yang lalu (indikasi, lama
perawatan), kuretase

1
2
3
4
5

Riwayat KB sebelumnya: ........................................................................................................................

4. Riwayat penyakit yang lampau

Diabetes mellitus: .............................................................
Penyakit jantung: ............................................................... Penyakit kelamin..................................
Penyakit paru-paru : ......................................................... Penyakit hati : .....................................
Penyakit lain : ..........................................................................................................................................
Riwayat pembedahan: .............................................................................................................................
......................................................................................................................................................................
......................................................................................................................... .............................................
Riwayat penyakit keluarga (termasuk riwayat keganasan dalam keluarga):
............................................................................................................................. .........................................
......................................................................................................................................................................

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5. Pemeriksaan fisik
6.1. Pemeriksaan fisik umum
Keadaan umum: .........................................
Kesadaran : ...............................................
Tekanan darah : ............................mmHg
Nadi : ..........................................................
Jantung : ....................................................
Paru-paru: ..................................................
Payudara : ..................................................
Perut : ........................................................
Ekstremitas : ............................................
Hal-hal penting lainnya: ..........................
.....................................................................
.....................................................................
.....................................................................
Tinngi bdan : ............................................. cm
Berat badan : ............................................ kg
Suhu : ......................................................... 0 C
Pernapasan : ....................................................
...........................................................................
...........................................................................
...........................................................................
...........................................................................
...........................................................................
...........................................................................
...........................................................................
...........................................................................
...........................................................................

5.2. Pemeriksaan ginekologi

6.2.1. Periksa luar
Inpeksi: Abdomen (dinding perut) .......................................................................................

Palpasi:
Massa : lokasi ................
Ukuran : ...x...x... cm
Batas : .......................
Mobilitas : mobile/ tidak
Nyeri : +/-

6.2.2 Periksa dalam: tanggal ................ jam ...................... oleh : ................................................

Inspeksi : Vulva ........................................ : Ostium uretra eksternum: ...........................

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 Inspekulo

Portio : ..........................................
Ostium: .........................................
Fluor : ..........................................
Fluksus : .......................................

V.T.: .........................................................................................................................................................
.........................................................................................................................................................
............................................................................................................................. ............................
..........................................................................................................................................................

6.3.Pemeriksaan laboratorik dasar

Hb : ......................................................... g% Golongan darah : ..............................................
Hematokrit : ......................................... vol% Faktor Rhesus: ..............................................
Leukosit : .............................................................................................................................. /m
Gula darah :
▪ puasa ............................................................................................................................. mg
▪ 2 jam postprandial ...................................................................................................... mg
Urin (rutin) : .............................................................................................................. .................
........................................................................................................................................................
....................................................................................................................... .................................

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III MASALAH
(Ungkapkanlah permasalahan/diagnosis yang dalam garis besarnya)
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IV. RENCANA PERMULAAN

1. Rencana diagnostik :
........................................................................................................................................................... ...........
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............................................................................................................................. .........................................
................................................................................................................................................................... ...

2. Rencana terapi:
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........................................................................................................................... ...........................................
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3. Rencana pendidikan:
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Mengetahui:

Dokter Jaga : ............................................... Paraf : ........................................ Tanggal: ..................................