CONFIDENTIAL MEDICAL REPORT

Date: 16/3/2019 Time: 10.30 pm

File No. : 321/SBKR/2019

Name :
Sex : FEMALE
Age :
Nationality : INDIAN
Current Address in Bali : BeachWalk Shoping Mall

Present history:
Patient complained of headaches since yesterday, patient had taken medication but the head still felt pain.
Patient comes to the clinic just want to ask for a prescription and not buy medicine at the clinic

Allergic history : None

Past medical history : None
Medication currently used : None
Treatment so far : none

Physical Examination:
Level of consciousness : Compos mentis Respiratory rate : 24 times per
(E4V5M6) Blood pressure: 120/80 mmHg minute Temperature : 36,50 C
Pulse rate : 88 beat per minute O2 saturation : 98% on room air

General State
Patient looked slightly unwell
Eyes : no sunken eyes, no anemic or yellow sclera, no redness at both
eyes Mouth : dry lip (-)
Throat : redness on pharynx wall (-), exudate (-)
Chest : Heart : heart sound S1 S2, single, regular, and no
murmur Lung : vesicular sound (+/+), no wheezing,
no rhonchi
Abdomen : normal bowel sound, slightly bloated (-), tenderness on epigastric area (-), skin turgor (+)
normal, no enlargement of liver or spleen
Limb : warm on all extremities, no edema, CRT < 2 seconds

Additional examination (Radiology, Lab, ECG, CT Scan, Ultra Sound, MRI, etc.): -

Diagnosis:
Common Cold

Treatment/Medication

None
Doctor’s Recommendation:
Patient Request Repatriation: Yes No V

In Doctor’s Opinion This Patient Requires Repatriation / Medical Evacuation: Yes No V

Patient Can Be Transported: Yes V No

If Yes, with:

V Normal Transportation

Ambulance

Patient’s fit to fly: Yes V No

If Yes, with:
V
Normal Flight
V
Non Escorted In Economic

Class Non Escorted In Business

Class

Non Medical Escorted In Business

Class Medical Escort in Business

Class Stretcher Medical Escort

Team

Charter Flight / Air Ambulance Team

Comment:
- Avoid eating any spicy, greasy, and acid food; avoid drinking soda, alcohol, coffee, or tea.
- Further examination such as blood test should be done if fever persists within the next three days.
- Take the medicine as prescribed.
- If anything issues, please call us.

Kuta, 16-3-2019

dr. dewa prasatya