MEDICAL REPORT : 090324

MEDICAL REPORT
Full name : Buster Kondrup Meyer

Nationality : Dansk/ Danish/Danoise

Sex : Male

Date Of Birth : 19 06 1993

Adresss in Lombok : Gili Air

Principle Complaint : Have wound

Detailed Explenation : The patient come to the clinic complaints of have wound on foot.
Past Medical history :
Allergy :-

Physhical examination :

Vital Sign

BP : 110/70 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 : Vulnus Excoriasi

Other Possibellities : -

Doctor Recomendation : clean everyday and take the medicine

Medication :
 NO DESCRIPTION QTY
CONSULTATION AND VISIT

PROCEDURE AND THERAPY

Wound care 1

Yusimox 10
Bioplacenton 1
Nacl 1

CONSUMABLES AND MEDICAL SUPPLIES

Hyfafix 1
Sterile gauze 1
Infused macro 1

OTHER SERVICE AND CHARGE

Gili Air, 2024-03-09

dr. Lalu Syarif Ramdhani Akbar, MPH

Attending Physician