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