MEDICAL REPORT : 231115

MEDICAL REPORT
Full name : olivia lokomo

Nationality : ITALIANA

Sex : famale

Date Of Birth : 20 dec 2019

Adresss in Lombok : Gili Air

Principle Complaint : bleeding

Detailed Explenation : The patient complaint of bleeding and lacerations to the head after
falling down.
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 : lacerations on the head

Diagnosis : fulnus laceratum

Other Possibellities : -

Doctor Recomendation : give the stitches and take medicine.

Medication :
NO DESCRIPTION QTY
CONSULTATION AND VISIT
Physical examination and consultation 1
PROCEDURE AND THERAPY
 stitches 2
Lidocaine injection 1
DRUGS
Genoin cream 1
Lifadrox syrup 1
Farsifen syrup 1

OTHER SERVICE AND CHARGE

Call out service 1

Gili Air, 2023-12-25

dr. Lalu Syarif Ramdhani Akbar, MPH

Attending Physician