Discharge Medical Report [PDF]

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Gili Trawangan – Lombok – Indonesia Telp. +62370 6197510/ +6281805237373 [email protected] – [email protected]



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24 Hours Medical Service On Call Doctor Pharmacy & Laboratory Land, Water and Air Ambulance



DISCHARGE MEDICAL REPORT Full Name Date of Birth Address in Lombok



: Thomas Bakkan : 22/07/1987 : Gili Trawangan



Main Complaint



: High Fever + Joint Pain



Sex : Male Nationality: Norway



Explanation in Details : Patient came to the clinic with main complaints high fever and joint pain since 2 days ago. He explains that fever goes up and down throughout the day due to the consumption of paracetamol and ibuprofen. He also mentions several periods of sweating. He also experiences body ache, joint pain, and headache. He experiences no diarrhea, nor stomach cramps and vomiting. He felt tired, weak and is losing appetite since yesterday. (01/07/2017) As per this morning the patient felt a lot better. He mentioned no periods of fever nor shivering. He also stated that he did not experienced any body ache nor joint pain. He has gained his appetite and felt energetic.



(02/07/2017) The patient came for a follow up of his medical condition. As per this morning he mentioned no fever, body ache nor joint pain. He felt a lot more energetic and has gained his appetite. The patient is then discharged. Past Medical History : never had before Past Traveling History: The patient have been traveling to Bali in past weeks. Allergy : none Vital Sign : BP = 110/70mmHg; HR = 96x/mnt; RR = 24 x/mnt T = 36,2 C; Physical Examination : GCS : E4V5M6 Eye: pupil reflect +/+ isocor, anemic-/-, icteric-/-, sunken -/Thorax: Pulmo : Breath sound vesicular +/+, rhonchi -/-, wheezing -/.Cor : S1 S2 single regular, murmur (-), gallop (-) Abdomen : Distension (-), bowel sound (+) N, tenderness (-), Hepar/ Lien unpalpable, skin turgor normally, upper abdominal pain (-)



PT Medika Pulau Biru Phone : +62 370 6197510 Fax : +62 370 6197511 Mobile : +62 81 805 237 373 Email : [email protected] Website : www.blueislandclinic.com



Gili Trawangan – Lombok – Indonesia Telp. +62370 6197510/ +6281805237373 [email protected] – [email protected]



   



24 Hours Medical Service On Call Doctor Pharmacy & Laboratory Land, Water and Air Ambulance



Laboratory Investigation: (Lab result attached) Working Diagnosis : Obs. 4th day of fever with mild-moderate dehydration Differential Diagnosis 1: Unspecified viral infection Differential Diagnosis 2: Susp. Dengue Fever



Treatment/Medication :



Continue oral medication  Novagesic 3x1 tab  Dehaf 3x1 Sacch.  Ramolit 3 x 1 Sacch.



Doctor Recommendation: - Drink a lot of water – Inpatient treatment Avoid: Spicy food, alcohol, soda, milk –Less fiber (juices/fruits) -



Should the symptoms re appear go see a doctor No follow up visit is required due to the positive trends of thrombocyte levels and the patient shows a good clinical sign of recovery.



Patient Fit to Fly Flight Recommendation



PT Medika Pulau Biru Phone : +62 370 6197510 Fax : +62 370 6197511 Mobile : +62 81 805 237 373 Email : [email protected] Website : www.blueislandclinic.com



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Yes



[ T Ordinary Seat [ y T p y e p a e q a u q o u t o e t f e r f o r m o t m h t e h d e



No



[ T [ Wheelchair Assistance [ Stretcher Case y T T p y y e p Gili Trawangan 2nd July p2017 a e e q a a u q q o u u t o o Dr. Teuku Arie Hidayat e t t (Attending Physician) f e e r f f o r r m o o t m m h t t e h h d e e



Gili Trawangan – Lombok – Indonesia Telp. +62370 6197510/ +6281805237373 [email protected] – [email protected]



PT Medika Pulau Biru Phone : +62 370 6197510 Fax : +62 370 6197511 Mobile : +62 81 805 237 373 Email : [email protected] Website : www.blueislandclinic.com



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24 Hours Medical Service On Call Doctor Pharmacy & Laboratory Land, Water and Air Ambulance