Post on 27-Jan-2016
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LAPORAN KASUS OBGYN
STATUS PASIEN
I. IDENTITAS PASIEN
Nama : .............................................
Jenis Kelamin : .............................................
Umur : .............................................
Alamat : .............................................
Agama : .............................................
Pekerjaan : .............................................
Pendidikan : .............................................
Tanggal Masuk : .............................................
Mondok di bangsal : .............................................
Nomor CM : .............................................
Nama suami : .............................................
Pendidikan : .............................................
II. ANAMNESIS
Keluhan Utama
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Riwayat Penyakit Sekarang
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Riwayat Penyakit Dahulu : .............................................
Riwayat penyakit Keluarga : .............................................
Riwayat Psikososial dan ekonomi : .............................................
Riwayat perkawinan
Kawin : .............................................
Umur waktu kawin : .............................................
Umur suami waktu kawin : .............................................
Lama perkawinan : .............................................
Riwayat Menstruasi
Menarche : .............................................
Menstruasi : .............................................
Jumlah darah menstruasi : .............................................
Rasa sakit saat menstruasi : .............................................
Perdarahan diluar siklus : .............................................
HPM : .............................................
Riwayat fertilitas : .............................................
Riwayat kehamilan sekarang : .............................................
HPM : .............................................
HPL : .............................................
Mual-mualan : .............................................
Sesak nafas : .............................................
Gangguan BAK/BAB : .............................................
Hipertensi : .............................................
Kejang : .............................................
Riwayat keluarga berencana : .............................................
III. PEMERIKSAAN FISIK
Status generalis
KU : .............................................
Vital sign : TD : .............................................
Suhu : .............................................
Nadi : .............................................
Respirasi : .............................................
Berat badan : .............................................
Gizi : .............................................
Kepala : .............................................
Leher : .............................................
Dada : .............................................
Abdomen : Status Obstetrik
Extremitas : .............................................
Status obstetri
Inspeksi : .............................................
Palpasi : .............................................
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Leopold I : .............................................
Leopold II : .............................................
Leopold III : .............................................
Leopold IV : .............................................
Auskultasi : .............................................
Lain-lain His : .............................................
TBJ : .............................................
Periksa I
Umur kehamilan (minggu)
TFU
Presentasi
Letak anak dan turunnya bagian bawah
Punggung
DJJ
Edema
Tekanan darah (mmHg)
Berat badan (kg)
Status Genitalia
Inspeksi :V/U : .............................................
Inspekulo : vagina : .............................................
Portio : .............................................
VT bimanual
Vagina : .............................................
Portio : .............................................
IV. PEMERIKSAAN PENUNJANG
Laboratorium
Hb : Bilirubin Total :
leukosit : Bilirubin Direk :
Hmt : Bilirubin Indirek :
eritrosit : Protein Total :
trombosit : Albumin :
Masa pendarahan (duke) : Globulin :
Masa pembekuan : SGOT :
HJL Eosinophyl : SGPT :
Staf : Alkali phosphatase :
Segmen : Ureum :
Lymphocyte : Creatinin :
Monocyte : Uric :
Malaria :
Golongan darah :
Rhesus :
Urin :
pH :
Albumin :
Gula :
Urobilin :
BJ :
Keton :
Darah samar :
Epithel :
Leucocyte :
Erythrocyte :
USG :
Radiologi :
V. DIAGNOSIS
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VI. DIAGNOSA BANDING
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VII. TERAPI
Non farmakologis : ............................................. .............................................
Farmakologis :
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VIII. EDUKASI
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IX. PROGNOSIS
Quo ad vitam : Ad .......................
Quo ad fungtionam : Ad .......................
Quo ad sanationam : Ad........................