RUMAH SAKIT UMUM BHAKTI RAHAYU

JL. GATOT SUBROTO II NO. 11 DENPASAR – BALI

TELP : (0361) 430270, 430245 FAX : (0361) 263371, 430833
EMAIL : bhakti_rahayu_dps@yahoo.co.id
ihcghbbhaksena@gmail.com

INITIAL MEDICAL ASSESSMENT

IN-HOUSE CLINIC GRAND HYATT BALI

Date : 27/09/2022 Time : 09.35 GMT+8

Surname : Kronborg First Name : Phoebe
D.O.B : 04/12/2014 Address : GHB Room 4355
Sex/Gender : Female Medical Record : 220027
Nationality : Australia Attending Physician :

Patient Complaint / Medical History:

The child complained of pain in both ears since 3 days ago, the right ear feels more painful. The
child has complaints of cough and runny nose but no fever.

Allergy:
Denied

Past Medical History:

Denied

Physical Examination:
Vital Sign
GCS Score : E4V5M6 VAS : 2-3
Blood Pressure : NE mmHg Respiration : 28 x/min
Pulse : 116 x/min regular Body Temp. : 37.1 o
C
O2 Saturation : 98 % Body weight : 35 kg

Physical Findings:
Eye : Anemic (-/-), edema (-/-), pupil equals and reaction (+/+)
ENT : Ear : Tragus pain (+/+), ear canal hyperemic (+), tympanic membrane
intact (+/+)
Nose : Rhinorea (-/-), nasal obstruction (-/+)
Throat : Tonsils T1/T1 exudate (-/-), pharinx hyperemic (-/-)
Thorax : Pulmo : Vesiculer +/+, Rhonki -/-, Wheezing -/-
Cor : S1S2 single regular, murmur (-)
Abdomen : Distension (-), bowel movement (+) normal, hepatomegaly (-),
 RUMAH SAKIT UMUM BHAKTI RAHAYU
JL. GATOT SUBROTO II NO. 11 DENPASAR – BALI
TELP : (0361) 430270, 430245 FAX : (0361) 263371, 430833
EMAIL : bhakti_rahayu_dps@yahoo.co.id
ihcghbbhaksena@gmail.com

splenomegaly (-)
Extremities : Warm, CRT <2”, numbness (-), skin turgor normal

Laboratory Test / Diagnostic Procedure / Imaging:

n/a

Diagnosis:
Otitis externa auricular dextra et sinistra (ICD-X H60.90)

Differential Diagnosis:
- Otitis media
- Ear canal furuncle

Treatment / Management:
- Cefixime syr (100 mg/5 mL) 2 x 5 mL po
- Hufabethamin syr 3 x 5 mL po
- Otopain ear drop 4 x 1 drop on both ear
- Nurofen syr if needed (owned)

Patient Monitoring:
Monitoring patient vital sign and symptom improvement/worsening.

Complication:
Is there any complication of disease found? YES / NO
If yes, please describe:

Recommendation / Doctor’s Note:

- Bed rest
- Do not swim
- Drink more water to prevent fever

Patient Disposition Outpatient c

Inpatient c
ICU

Bali, 27/09/2022
The Attending Physician