Medical Report

MEDICAL RESUME

MEDICAL REPORTA. PATIENTS IDENTIFICATIONN a m e: Mrs. Michiko Takagi

A g e: 68 Years

S e x: Female

A d d r e s s: Herittage Hotel Rantepao Tana Toraja 91831

South Sulawesi Indonesia

Medical Record: 056829

Reg. No.: 08091019

Date of Exam: September 10th 2008

Period of Hospitalized: 10 11 September 2008Name of Hospital: ELIM Rantepao Hospital Tana Toraja

And address Jl. Ahmad Yani No. 68 Rantepao Telp. (0423) 21258/25572 Tana Toraja 91831 South Sulawesi IndonesiaAttending Physician: Dr. Yain PanggaloB. MEDICAL HISTORY

Anamneses : vomitus, diarrhea, anorexia and malaiseC. PHYSICAL EXAMINATION

Vital Sign : Tension = 130/90 ; HR = 84 times/min; RR = 16 times/min; T = 360 C

Abdomen : increased peristaltic, mild turgorD. LABORATORY TEST

Blood count : WBC 4900, Blood Presipitation Time : 60/hour

Titer WIDAL : normal

LFT: normal

RFT: normal

E. DIAGNOSIS : Gastroenteritis acuteF. TREATMENT : Rehidration, anti vomiting, antibiotic, loperamid, H2 receptors antagonist

G. PROGNOSIS :Bonam Rantepao, September 10th 2008

Dr. Yain Panggalo Name & Signature of Attending Physician with Hospital StampLAPORAN MEDIS SINGKATA. IDENTIFIKASI PASIENN a m a: Tn. GUSTAV RUDOLF TANAROU m u r: 51 TAHUNJenis Kelamin: LAKI-LAKI Alamat: JL. SERIGALA NO. 95 MAKASSAR

No. Medical Record: 059058Reg. No.: 08112243Tanggal Masuk: 22 NOVEMBER 2008 Pukul 20.00 WITALama Perawatan: 22 23 NOVEMBER 2008

Tempat Perawatan: RSU. ELIM Rantepao - Tana Toraja

Dan Alamat Jl. Ahmad Yani No. 68 Rantepao Telp. (0423) 21258/25572 Tana Toraja 91831 Sulawesi Selatan - Indonesia

Dokter Pemeriksa: Dr. Yain PanggaloB. ANAMNESIS (ALLOANAMNESIS)

Pasien masuk rumah sakit diantar oleh keluarga dalam keadaan kesadaran menurun akibat jatuh dari ketinggian lantai dua disertai perdarahan dari dahi, hidung dan kedua lengan bawah patahC. PEMERIKSAAN FISIS

Keadaan umum : GCS E1M5V1, sakit berat, gizi baik

Tanda Vital :Tensi = 80/Palpasi ; HR = 100 kali/menit; RR = 28 kali/menit; T = 36,60 C

Kepala

:luka robek pada dahi dan bibir atas, perdarahan aktif dari hidung

Ekstremitas

:patah kedua tulang lengan bawahD. PEMERIKSAAN PENUNJANG

Laboratorium: Golongan Darah A+, Hb : 11,7 mg%, Hm 35%

Rontgen: Tidak dilakukan karena pertimbangan kondisi pasienE. DIAGNOSIS KERJA: Cedera Kepala Berat + Patah Tulang Lengan Kiri dan Kanan + Syok hemoragikF. TINDAKAN : Penanganan kegawatdaruratan dan konsultasi Dokter Spesialis Neurologi, Bedah dan THT

G. PERJALANAN PENYAKIT :

Setelah dilakukan perawatan maksimal sesuai kondisi rumah sakit, pasien meninggal dihadapan keluarga, dokter jaga IRD dan perawat pada Hari Minggu tanggal 22 November 2008 Pukul 06.40 WITA

Rantepao, 18 Desember 2008Dr. Yain Panggalo

DOKTER JAGA IRDMEDICAL REPORTA. PATIENTS IDENTIFICATIONN a m e: MISS. SARI HAAVISTOA g e: 26 YEARS OLDS e x: FEMALEA d d r e s s: INDRA HOTEL RANTEPAO NORTH TORAJA 91831

SOUTH SULAWESI INDONESIA

Medical Record: 067241Date of Exam: JULY 29th 2009Name of Hospital: ELIM RANTEPAO HOSPITAL NORTH TORAJAAnd address Jl. AHMAD YANI No. 68 RANTEPAO

TELP. (0423) 21258/25572 NORTH TORAJA

POSTAL CODE 91831

SOUTH SULAWESI INDONESIAAttending Physician: Dr. YAIN PANGGALOB. HISTORY

Motorcycle injured in collision with carC. PHYSICAL EXAMINATION

General Condition: Composmentis, In pain

Upper Limb

: Excoriation wound on left upper arm, elbow, forearm, palmar, bone intaq.

Abdomen

: Excoriation wound on lower left quadrant

Lower Limb

: Excoriation wound on left thigh, knee, and both toes. Laceration wound on medial left heel, size 2 x 3 cm, bone intaq.D. DIAGNOSIS

: Multiple Excoriation Wound with Laceration wound on left heelE. TREATMENT

: Clean the wound with NaCl 0,9% solution, betadine and suturing, Intermoxyl 3x500 mg, Coditam 3x1 tablet

F. PROGNOSIS

:Bonam

RANTEPAO, JULY 29th 2009

Dr. Yain Panggalo

Name & Signature of Attending PhysicianMEDICAL REPORTA. PATIENTS IDENTIFICATIONN a m e: Mr. HENRIK TIITTANENA g e: 26 YEARS OLDS e x: MALEA d d r e s s: INDRA HOTEL RANTEPAO NORTH TORAJA 91831

SOUTH SULAWESIi INDONESIA

Medical Record: 067239Date of Exam: JULY 29th 2009Name of Hospital: ELIM RANTEPAO HOSPITAL NORTH TORAJAAnd address Jl. AHMAD YANI No. 68 RANTEPAO


POSTAL CODE 91831

SOUTH SULAWESI INDONESIAAttending Physician: Dr. LONASIS CABUSLAYB. HISTORY

Motorcycle injured in collision with carC. PHYSICAL EXAMINATION


Upper Limb

: Excoriation wound on elbow, palmar, bone intaq.

Lower back

: Tenderness

Lower Limb

: Excoriation wound on the right cruris, knee, and left toes. bone intaq.D. INVESTIGATION

: X-RAY THORACOLUMBAL- (nothing abnormal detected)E. DIAGNOSIS

: Multiple Excoriation Wound

F. TREATMENT

: Clean the wound with NaCl 0,9% solution, betadine and suturing, Intermoxyl 3x500 mg, Coditam 3x1 tablet

G. PROGNOSIS

:Bonam

RANTEPAO, JULY 29th 2009

Dr. LONASIS CABUSLAY

Name & Signature of Attending PhysicianMEDICAL REPORTA. PATIENTS IDENTIFICATIONN a m e: MR. HENDRIKSA g e: 62 YEARS OLDS e x: MALEA d d r e s s: INDRA HOTEL RANTEPAO NORTH TORAJA 91831

SOUTH SULAWESIi INDONESIA

Medical Record: 067465Date of Exam: AUGUST 3th 2009Name of Hospital: ELIM RANTEPAO HOSPITAL NORTH TORAJAAnd address Jl. AHMAD YANI No. 68 RANTEPAO


POSTAL CODE 91831

SOUTH SULAWESI INDONESIAAttending Physician: Dr. LONASIS CABUSLAYB. HISTORY

Accidental fall from the high 2 days agoC. PHYSICAL EXAMINATION


Lower Limb

: Swelling on the right ankle, tenderness, bone intaq.D. INVESTIGATION

:X-RAY CRURIS DEXTER (nothing abnormal detected)

E. DIAGNOSIS

: Sprain and strain of the right ankle

F. TREATMENT

: Ibuprofen 3 x 400 mg, metilprednisolon 3 x 4 mg, Intermoxyl 3x500 mg,

G. PROGNOSIS

:Bonam

RANTEPAO, AUGUST 3th 2009

Dr. LONASIS CABUSLAY

Name & Signature of Attending PhysicianMEDICAL REPORTA. PATIENTS IDENTIFICATIONN a m e: MS.LINAA g e: 47 YEARS OLDS e x: FEMALEA d d r e s s: POPIES INN RANTEPAO NORTH TORAJA 91831


Medical Record: 071538Date of Exam: NOVEMBER 14th 2009Name of Hospital: ELIM RANTEPAO HOSPITAL NORTH TORAJAAnd address Jl. AHMAD YANI No. 68 RANTEPAO


POSTAL CODE 91831


Accidental felt down into canalC. PHYSICAL EXAMINATION


Lower Limb

: Swelling on the anterior cruris dextra, laceration through into muscle, excoriation, tenderness, bone intaq.D. INVESTIGATION

:X-RAY CRURIS DEXTRA (nothing abnormal detected, no fracture)

E. DIAGNOSIS

: VULNUS LACERATUM CRURIS DEXTRA

F. TREATMENT

: Explorer and wash the wound with NaCl 0,9% solution, betadine and suturing, Claneksi 3 x 500 mg Coditam 3x1 tablet, Nonflamin 3 x 1 tablet, ImobilizationG. PROGNOSIS

:Bonam

RANTEPAO, NOVEMBER 18th 2009

Dr. YAIN PANGGALO

Name & Signature of Attending PhysicianMEDICAL REPORTA. PATIENTS IDENTIFICATIONN a m e: Mr. ESTEBAN MUJICA ARZAA g e: 49 YEARS OLDS e x: MALEA d d r e s s: LUTHA HOTEL RANTEPAO NORTH TORAJA 91831


Passport: BF275984

Medical Reg.:02435Date of Exam: AUGUST 16th 2014Name of Clinic: RANTEPAO MEDICAL CENTRE NORTH TORAJAAnd address Jl. PONGTIKU MISILIANA

TELP. 085255009811 NORTH TORAJA

POSTAL CODE 91831


Diarhea, fever and faint, since yesterdayC. PHYSICAL EXAMINATION

General Condition: Composmentis, fatique

Physical Examination : BP = 129/72 mmHg; HR = 102 times/minute;

T = 37,80 C

Abdomen

: Inreased peristaltic, turgor mediumD. DIAGNOSIS

: Enteritis acute + Mild Dedydration

E. TREATMENT

: Rehidration, antibiotic, antipireticF. PROGNOSIS

:Bonam

RANTEPAO, August 16th 2014

Dr. YAIN PANGGALO

Name & Signature of Attending PhysicianMEDICAL REPORTA. PATIENTS IDENTIFICATIONN a m e: Mrs. BRIGITTE BONNAUDA g e: 55 YEARS OLDS e x: FEMALEA d d r e s s: LUTHA HOTEL RANTEPAO NORTH TORAJA 91831


Date of Exam: SEPTEMBER 18th 2014Name of Clinic: RANTEPAO MEDICAL CENTRE NORTH TORAJAAnd address Jl. PONGTIKU MISILIANA

TELP. 085255009811 NORTH TORAJA

POSTAL CODE 91831


Epigastric pain, Nausea dan vomitus, since yesterdayC. PHYSICAL EXAMINATION

General Condition: Composmentis, fatique

Physical Examination : BP = 130/80 mmHg; HR = 86 times/minute;

T = 36,40 C

Abdomen

: Inreased peristalticD. DIAGNOSIS

: Gastroenteritis acute

E. TREATMENT

: Antibiotic, antispasme/analgetikF. PROGNOSIS

:Bonam

RANTEPAO, September 18th 2014

Dr. YAIN PANGGALO

Name & Signature of Attending Physician

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Medical Report