DISCHARGED SUMMARY REPORT

Patient Name : Bae Sung Wan MR. No. : 11.25.95

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Date Consultation : 25 August 2017 Time : 09.00 WITA
Age/ Gender : 31 y.o / Male
Nationality : Korean
Address in Bali : Kuta, Bali
First Date of symptom : 24th August 2017
Admission date : 24th August 2017

Diagnosis :
Post debridement multiple vulnus appertum region antebrachii dextra with rupture vena Cephalica
distal + partial rupture musculus abductor policis longus dextra and multiple vulnus appertum region
manus sinistra et causa Monkey bite

History Of Recent Illness :

Patient come to Emergency Room at Surya Husadha Nusa Dua Hospital with chief complaint wound
on his right lower arm and left hand caused by monkey bite. Patient had been done debridement by
dr. Edy Widyanto sp.B (Surgeon) for repair the vena rupture and the muscle rupture.

Allergy:
Medicine allergy (-)

Past Medical History:

N/A

Medication currently used:

 IVFD RL 28 macro dpm
 Terfacet 2x 1 gr (IV)
 Verorab Injection (I & II ) (Im) continued at day VII (7) and XXI (21)
 Ondancentron 4 mg (IV) (if needed)
 Sanmol 3x 1 gram (IV)
 Ondancentron 4 mg (if needed)
 Fentanyl Drip 300mcq/24 hours on 500cc Nacl 0,9% speed of titration 2,1 cc/hours

Physical Examination :
Vital Sign :
Level of Consciousnes : CM Respiratory Rate : 20 x/min
Blood Pressure : 120/70 mmHg Temperature : 36,6 °C
Pulse : 90 beats/min Oxygen Saturation : 99%

General State:
Eyes : no anemic, no icteric, pupil isokor
Lung : Cor : s1s2 single regular murmur (-)
Pulmo : ves +/+ rales -/- wheezing -/-

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Abdomen : distension (-), normal bowel sound
Extremity : Warm (+)
Localized state
 Region antebrachii Dextra post debridement : swelling (+), pain(+), active bleeding
(-), AVN good
 Region manus sinistra post debridement : swelling (+), pain(+), active bleeding (-),
AVN good

Lab/Imaging Result :
Laboratory result attached

Disposition:
Outpatient

Discharge Treatment :
- Cefspan 200 mg every 12 hours after meal (PO)
- Oxyneo 10 mg tablet. Every 12 hours after meal. (PO)

Recommendation
- Continued Verorab injection on day VII and XXI
- Control for Wound Dressing 3 days again

Fit To Fly Statement :

Patient is fit to flight

Nusa Dua, 25st August 2017

The Attending Physician

dr. Ni Wayan Eka Karisma S (General Practitioner)

For: Dr. Edy Widyanto Sp.B (General Surgeon)
For Dr. Srinami Sp.AN (Anesthesia Specialist)

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