KLINIK BHAKSENA TRAGIA

Jl. Bypass Ngurah Rai, Komplek Pertokoan Tragia

Blok D21-22, Kuta Selatan
Telp. (+62) 8113986396
Email : klinikbhaksenatragianusadua@gmail.com

INITIAL MEDICAL ASSESSMENT

IN-HOUSE CLINIC GRAND HYATT BALI

Date :
Surname : First Name :
D.O.B : Address :
Sex/Gender : Attending Physician : dr. Andre Kristanto
Nationality :

Patient Complaint / Medical History:

Allergy:

Past Medical History:

Physical Examination:
Vital Sign
GCS Score : EVM VAS :
Blood Pressure : mmHg Respiration : x/min
o
Pulse : x/min regular Body Temp. : C
O2 Saturation : %

Physical Findings
Eye : Anemic (-/-), edema (-/-), pupil equals and reaction (+/+)
ENT : Tragus pain (-), tympanic membrane intact (+/+)
Thorax : Pulmo : Ves +/+, Rh -/-, Wh -/-
Cor : S1S2 single regular, murmur (-)
Abdomen : Distension (-), bowel movement (+) normal, pain in palpation RLQ (-),
hepatomegaly (-), splenomegaly (-)
Extremities : Warm, CRT <2”, numbness (-), skin turgor normal

Laboratory Test / Diagnostic Procedure / Imaging:

Diagnosis:

Differential Diagnosis:

Treatment / Management:
Patient Monitoring:
Monitoring patient vital sign and symptom improvement/worsening.

Complication:
Is there any complication of disease found? YES / NO
If yes, please describe:

Recommendation / Doctor’s Note:

Patient Disposition Outpatient Inpatient ICU

c c

Bali,
The Attending Physician

dr. Andre Kristanto_

SIP : 446/1142/VIII/2018/DIKES