GRACIA CLINIC

Jl. Gatot Subroto Tengah No. 100 K

Email : gracia.clinic.bali@gmail.com

MEDICAL CERTIFICATE
Name : Helga CM Mordente Sex : Female
Age : 45 years old Nationality : Brazil
Address at Bali : Hilton Bali Resort Room Number : 2423

ANAMNESIS :
Patient complain fever since yesterday, and she also complain whole body ache, history of allergy to
medicine was denied

PHYSICAL EXAMINATION
 VITAL SIGN
Blood Pressure : 110/80 mmhg Temperature : 37,5 c
Pulse : 100 x/min SpO2 : 98 %
Respiration Rate : 20x/min
 GENERAL EXAMINATION
o Head : Anemia (-/-), Anikterik (-/-)
o Thorax : Vesicular (+/+), Wheezing (-/-), Rhonchi (-/-)
o Abdomen : Distention (-/-), Bowel sounds (+/+) normal
o Extremities : Warm, CRT < 2 sec
 LOCAL EXAMINATION
The tonsil seems no matter , the pharynx is normal

DIAGNOSA : Common cold

THERAPY : Demacoline (3x1)
Dexamethason 0,5 mg (3x1)
Imboost (2x1)
PLANNING : -
SUGGESTION : Take a bed rest.
Drink water (8 glass in a day)

Bali, 6 Januari 2018

dr. Jesika
GRACIA CLINIC
Jl. Gatot Subroto Tengah No. 100 K
Email : gracia.clinic.bali@gmail.com