GILI MEDICAL SERVICE

GENERAL PRACTICIONER
DUSUN GILI AIR, GILI INDAH, PEMENANG, LOMBOK UTARA
Telp/WA : 087864353202 / 08170 991 991

MEDICAL REPORT : 231031

MEDICAL REPORT
Full name : Yvonne Stockler

Nationality : Osterreich

Sex : Female

Date Of Birth : 23.07.1991

Adresss in Lombok : Gili Trawangan

Principle Complaint : Left ear pain and fever

Detailed Explenation : The patient call to the clinic with complaints of, left ear pain, 1 feeling
fever, after snorkeling and diving since 3 days ago.
Past Medical history :
Allergy :-

Physhical examination :

Vital Sign

BP : 100/70 mmHg Respiration : 20 x / Min

Pulse : 82x/ Min SpO2 : 99% Temperature : 36,2°C

Glasgow coma scale (GCS) : e4v5m6

Eyes : Normal

Thorax : Cardio : S1 S2 normal

Pulmo : Vesikuler , Rhonki (-) wheezing (-)

Abdomen : Normal bowel sound

Acral : Warm +/+,crt <2s

Status localis :-

Diagnosis : Otitis media Acute interna

Other Possibellities : -

Doctor Recomendation : take medicine of tablet , and use ear drops.

 GILI MEDICAL SERVICE
GENERAL PRACTICIONER
DUSUN GILI AIR, GILI INDAH, PEMENANG, LOMBOK UTARA
Telp/WA : 087864353202 / 08170 991 991

Medication :
NO DESCRIPTION QTY
CONSULTATION AND VISIT
Physical examnation and consultation 1
PROCEDURE AND THERAPY

DRUGS
Reco ear drop 1
Cefford forte tablet 10
Faridexon forte tablet 10
CONSUMABLES AND MEDICAL SUPPLIES

OTHER SERVICE AND CHARGE

Call out service 1

Gili Air, 2023-10-31

dr. Lalu Syarif Ramdhani Akbar, MPH

Attending Physician