THE SUMMARY OF MEDICAL RECARD

Patient, mr. Mun jay yub, 64 years old come to emergency room unit on October 2015 at 7
am with complaints the left of head feels pain and left chest pain after car accident. The left head is
bruises and the left cheast is pain.

VITAL SIGN

Blood pressure : 130/80 mmHg

Pulses : 92x/minutes

Respiratory rate: 20x/minutes

Temperature : 36,8◦C

LABORATORY

Haemoglobin : 14,4 g/dl

Hematokrit : 38,7%

Trombosit : 117.000cell/mm3

SGOT : 31 u/i

SGPT : 49 u/i

Kreatinin : 0,5 mg/dl

BUN : 21 mg/dl

Tendon blood sugar : 211 mg/dl

Profil lipid : 214 mg/dl

Because in this hospital is nothink MRI and CT SCAN, and according to me as a general doctor
the patients needs CT SCAN and MRI for final diagnostic, so we refers patients by ambulance to the
biggers hospital for MRI and CT SCAN.

Thereby i write this summary of medical record in order to use as well.

Pasuruan, October, 17, 2015

Dr. Bayu Nizar Fathoni