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    Medical Report Simon Lund

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    biomedikaunicare
    1. Mr. Simon Sven Erik Lund, a 30-year-old Swedish man, presented with complaints of diarrhea more than 10 times in 24 hours starting the night before along with no vomiting, nausea, or loss of appetite. 2. His vital signs and physical examination were normal except for increased bowel sounds and no abdominal pain or distension. 3. He was diagnosed with acute gastroenteritis suspected to be bacterial infection or possibly viral infection. He was prescribed antibiotics, antiparasitics, antidiarrheals, and probiotics and advised to rest, avoid fruits and vegetables, drink plenty of water and return if symptoms worsen.

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    Medical Report Simon Lund

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    biomedikaunicare
    8 views1 page
    1. Mr. Simon Sven Erik Lund, a 30-year-old Swedish man, presented with complaints of diarrhea more than 10 times in 24 hours starting the night before along with no vomiting, nausea, or loss of appetite. 2. His vital signs and physical examination were normal except for increased bowel sounds and no abdominal pain or distension. 3. He was diagnosed with acute gastroenteritis suspected to be bacterial infection or possibly viral infection. He was prescribed antibiotics, antiparasitics, antidiarrheals, and probiotics and advised to rest, avoid fruits and vegetables, drink plenty of water and return if symptoms worsen.

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    1. Mr. Simon Sven Erik Lund, a 30-year-old Swedish man, presented with complaints of diarrhea more than 10 times in 24 hours starting the night before along with no vomiting, nausea, or loss of appetite. 2. His vital signs and physical examination were normal except for increased bowel sounds and no abdominal pain or distension. 3. He was diagnosed with acute gastroenteritis suspected to be bacterial infection or possibly viral infection. He was prescribed antibiotics, antiparasitics, antidiarrheals, and probiotics and advised to rest, avoid fruits and vegetables, drink plenty of water and return if symptoms worsen.

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    8 views1 page

    Medical Report Simon Lund

    Uploaded by

    biomedikaunicare
    1. Mr. Simon Sven Erik Lund, a 30-year-old Swedish man, presented with complaints of diarrhea more than 10 times in 24 hours starting the night before along with no vomiting, nausea, or loss of appetite. 2. His vital signs and physical examination were normal except for increased bowel sounds and no abdominal pain or distension. 3. He was diagnosed with acute gastroenteritis suspected to be bacterial infection or possibly viral infection. He was prescribed antibiotics, antiparasitics, antidiarrheals, and probiotics and advised to rest, avoid fruits and vegetables, drink plenty of water and return if symptoms worsen.

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    MEDICAL REPORT

    Medical Record Code


    Registry Number : 001-121154
    Date of Come : 15th October 2023
    Identity :
    Patient Name : Mr. Simon Sven Erik Lund SEX :
    Male
    Date Of Birth : 01st October 1993
    Address : Kuta - Lombok
    Nationality : Sweden
    Allergy History : None
    Medical Info
    Type Of Service : On call Time 11.10 AM
    Anamnesis: The patient came with complaints diarrhea more than 10 times in 24 hours. The patient complaint
    ever start from last night. Vomiting (-) Nausea (-) Good apetite and drink.

    Vital sign Blood Pressure : 110/80 mmHg Body Temperature : 37,5oC


    Pulse Rate : 88 x/minute SpO2 : 99 % room air
    Respiration Rate : 20 x/minute Conciusness : GCS E4V5M6

    Physical Examination
    General Examination:
    Eyes: not anemic, not icteric
    Heart: S1,S2 regular, single heart sound, no murmur
    Lung: vesicular sound, rhonchi -/-, no wheezing
    Abdomen : No mass, No distension, tymphany, normal bowel sound, no pain on palpation.
    Extremities: warm, CRT< 2 seconds, no cyanosis, no edematous

    Diagnosis :
    • Acute Gastroenteritis e.c susp. Bacterial Infection dd Viral Infection

    Treatment
    Medicine
    - Cefixime 100 mg 2x1 (Antibiotic oral)
    - Metronidazole (Antiparasyte oral)
    - Diagit 2 tablets every diarrhea ( Anti Diarrhea oral )
    - L-Bio Sachet 1 Sachet per day ( Probiotic Oral )
    - Scopma Plus ( Pain Killer Oral )

    Medical Advice
    • Avoid Vegetable & Fruit until the diarrhea are stop
    • Drink Water Plently at least 2 Litters Per Day
    • Take a rest for 2-3 Days and take the medicine as doctor recommended
    • If the complaint worsens immediately return to the medical service

    Kuta, 15 th October 2023


    Attending Physician Name & Signature
    Silvia
    dr. Silvia Irawan

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