Discharge Medical Report TGL 17 Fransisco Javier [PDF]

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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



DISCHARGE MEDICAL REPORT Full Name Date of Birth Address in Lombok



: Francisco Javier Pollak Araya : 19/07/1993 : Gili Trawangan



Main Complaint



: High Fever + Weakness



Sex : Male Nationality: Chile



Explanation in Details : Patient came to the clinic with main complaints of fever and weakness today. He explains that the sudden high fever just started this morning, and goes up and down throughout the day with headache, body ache and joint pain. He mention no diarrhea but had a slight stomach cramps and feeling very nauseous. The patient has not been taking any medicine to reduce the symptom. He felt tired, weak and is losing appetite since this morning. While undergoing treatment at the clinic, the patient experiences vomiting and diarrhea. He vomited just once, and had watery diarrhea followed by stomach cramps for 3 times in the past 6 hours. He was then given additional medicine. As per this afternoon, the patient felt a lot better. There was no more diarrhea, stomach cramps, nor nausea and weakness. The patient is the 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 = 100/70mmHg; HR = 86x/mnt; RR = 24 x/mnt T = 36,4 C; Physical Examination : GCS : E4V5M6 Eye: pupil reflect +/+ isocor, anemic-/-, icteric-/-, sunken -/Neck & Mouth: T1/T1, crypta (-), hyperemi (-) 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 (+)



Laboratory Investigation: (Lab result attached) Working Diagnosis 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



: 2nd day of Fever + dyspepsia + Gastroenteritis acute with mild-moderate dehydration e.c bacterial infection



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



Treatment/Medication  Maintenance Ringer Lactate intravenous drip 20 drops/mnt (Neurosanbe 1 ampule)  Initial Loading Ringer Lactate (1000cc)  Inj. Norages 3x1 amp  Inj. Omeprazole 1x40mg  Inj. Ceftriaxone 2x1 gr



Oral Medication: (Home medication)  Ciprofloxacyn 2x1 tab  Omeprazole 2x2 tab  Novagesic 3x1 tab



Additional Medicine:    



Inj. Scopamine extra. Inj. Ondansentron extra Loperamide 3x1 tab Diaform 3x2 tab



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]



Doctor Recommendation: - Bed rest 2-3 days



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



- Drink a lot of water –Inpatient



Avoid : Spicy food, alcohol, soda, milk –Less fiber (juices/fruits) should symptoms of diarrhea occur. If the symptom worsens / should there be no improvement of condition in the next 3 days, go see a doctor. 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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