Documente Academic
Documente Profesional
Documente Cultură
08
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No. MR
GYNECOLOGIC STATUS
IDENTITY
PATIENT
Name
: .......... Name
: ...........
Age
: .......... Age
: ...........
Education
: ..... Education
: ...........
Occupation
: ..... Occupation
: ...........
Religion
: ..... Religion
: ...........
Tribe
: ..... Tribe
: ...........
Address
: ..... Address
: ...........
.....
..........
.....
..........
.........................................
.....................................................
Date of Admition
: ..
Origin
: Self admitted
Time
: .
: ......................................................................................................................
I.
2. Additional Complain
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1.
2.
3.
4.
5.
4. Menstruation History
First Period
Cycle: Regular
Length
: ............... days
Amount
: ................
Month
Year
Length
Amount
5. Marital History
a. Marital Status
b. Last Marriage
: ..................................month / years
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: .
7. Previous Illnesses
No.
1
2
3
4
5
6
7
8
Explanation
No.
1
2
3
4
5
6
7
8
Explanation
9. Surgery History
No.
1
2
3
4
Genre Operation
Years
Explanation
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
Temperature
: ...................... C
Respiratory Rate
Height
: ....................cm
Weight
: .................... kg
2. Head :
a. Eyes
i. Conjunctivae
: ..................
ii. Sclera
..................
b. Teeth
: .
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
................
Status RSU FKUKI/Ilmu Obstetrii/Obgyn RSU FK UKI/10.08
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ii. Fluksus
: ........................................
...................................................
Fluor
: ...........................................................................................
iii. Vulva
..............................
..............................
2.
Inner Examination
a.
Inspeculo (by
indication )
: ............................................................................................)
i.
Fluor
..
..
ii.
Fluxus
..
..
iii.
.
.
...........................................................................................
iv.
Portio
...........................
ii.
Vulva
ii.
vagina
........................................
iii.
Portio
.
..
..
iv.
Uterus
: ..
.
v.
Right Adnexa : ..
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...
vi. Left adnexa
: ..
..
vii.
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
: .
( ....................................................................)
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