MEDICAL EXAMINATION REPORT

NO : 300.A / XI /MCUREPORT/K.UTAMAPIPMKS-2021

Name : Muhammad Fajri

Place Date of Birth : Sinangkala/October 18,1994

Nationality : Indonesia

Position : THIRD ENGINER

MR. Number : 20212510
Examination For Duty As : Duty Engine Department

MEDICAL HISTROY
No Yes No Yes No Yes
- Problem Of Vision √ - Allergy √ - Epilepsy √
- Colour Perception √ - Diabetes √ - Haemorrhoid √
- Problem of Hearing √ - Tuberculosis √ - Fear of Darkness √
- Hypertension √ - Shortness of Breath √ - Fear of Heights √
- Chest Pain √ - Kidney Disease √ - Fear Of Fire √
- Asthma √ - Fever √ - Other Illnes √
PHYSICAL EXAMINATION
- Blood Pressure - Respiration 20 x/min - Visual Acuity
Systolic Uncorrected
130/80 mm/Hg **
Diastolic - Hearing Normal OD 6/6
No Yes OS 6/6
- Pulse Right Ear √ Corrected
Rate 80 bpm Left Ear √ OD 6/6
- Temperature 36,5 ◦c OS 6/6
Regular Normal - Weight 62 Kg - Pupil Normal
No Yes - Height 172 cm - Visual Field Normal
√ - BMI 20,96 kg/m² Colour Perception Normal
F NF No Yes
Anemis √ Ishihara Book 38 Plate √
Ikterik √ Romberg Test √
Sianosis √
Normal Normal Normal
No Yes No Yes No Yes
- Head √ - Liver √ - Lower extremity √
- Neck √ - Spleen √ - Hernia √
- Teeth √ - Genito urinary system √ - Spine √
- Chest and lung √ - Rectum √ - Neurologic reflexes √
- Abdomen √ - Upper extremity √ - Pathologic Reflex √
- Range Of Motions √ - Fisiologis Reflex √
LABORATORY : WITHIN NORMAL LIMITS
Blood Type :
CHEST X-RAY : NORMAL
ECG EXAMINATION : NORMAL
CONCLUSION : FIT TO WORK WITH MEDICAL SURVEILLANCE
ADVICE :
VALID UNTIL : OCTOBER 25,2023

Makassar, 02 November 2021

MEDICAL
MedicalEXAMINER
Examiner

dr. Mulyani Mus

dr. MULYANI MUS
Hasil Pengujian Kesehatan yang dikirm melalui whatsapp/email telah divalidasi dokter penguji tanpa menggunakan tanda tangan
Name : MUHAMMAD FAJRI
Sex : MALE
Place / Date Of Birth : SINANGKALA/OCTOBER 18,1994

RINGKASAN HASIL PEMERIKSAAN

Resume of examination
1. WAWANCARA
Anamnese : COMPOS MENTIS

2. PEMERIKSAAN FISIK
Physical Diagnostic
- Weight : 62 Kg
- Blood Pressure : 130/80 mmHg
- Height : 172 Cm
- Pulse : 80 X/i
- Respiratory : 20 X/i
- Temperature : 37 ◦C
- Head and neck : NORMAL
- Chest / Thorax : NORMAL
- Abdomen : NORMAL
- Extremity : NORMAL
- Others : NORMAL

3. PEMERIKSAAN THT
ENT Examination
a. Ear : NORMAL
b. Nose : NORMAL
c. Throat : NORMAL
d.d.Audiometri
Audiometri(Right
(Left &
/ Right
Left) : NORMAL HEARING

4. PEMERIKSAAN MATA
Eye Examination
a. Vision distance (OD, OS) : 6/6 6/6 BV 6/6 6/6
b. Colour Perception : NORMAL
c. Visual Field : NORMAL
d. Others : -

5. PEMERIKSAAN GIGI
Dental Examination
a. Pro extraction : 25,46
b. Pro conservation : -
c. Pro Scalling : -
d. Pro Prothesis : 36
e. Others : -
f. Conclusion : MODERATE
6. PEMERIKSAAN KELAMIN LUAR : NORMAL
Genitalia externa Examination

7. PEMERIKSAAN KANDUNGAN : (Woman Only)

Gyneacological examination
8. LABORATORIUM :
Laboratory findings

URINE Reference Value

Protein : NEGATIVE Negative
Glucosa : NEGATIVE Negative
Billirubin : NEGATIVE Negative
Ph : 6,0
Sg : 1,025
Leucocyte : NEGATIVE Negative
Nitrit : NEGATIVE Negative
Urobilinogen : NEGATIVE
Blood : NEGATIVE
Keton : NEGATIVE
Sedimen Lekosit : 2-3 Sel/lbp
Sedimen Eritrosit : 2-3 Sel/lbp
Sedimen Epitel Sel : 2-3 Sel/lbp
Planotest : - (woman Only)
BLOOD CELLS Reference Value
BSR : 9 mm/h
Haemoglobine : 17,1 g/dl 10,0 - 16,5
Leucocyte : 10,98 10³/mm³ 4,00 - 10,00
Trombocite : 271 10³/mm³ 150 - 400
Blood Group : 0
RBC : 5,96 10³/Ul 4,70 - 6,10
HCT : 48,0 % 42,0 - 52,0
MCV : 80,5 fL 80,0 - 100,0
MCH : 28,7 pg 27,0 - 35,0
MCHC : 35,6 g/dL 30,0 - 40,0
RDW-SD : 39,6 fL 30,0 - 40,0
RDW-CV : 13,9 % 11,5 - 14,5
PDW : 12,0 fL 9,0 - 17,0
MPV : 10,4 fL 6,8 - 10,0
P-LCR : 27,8 % 13,0 - 43,0
PCT : 0,26 % 0,10 - 0,50
NEUT# : 4,23 10³/Ul 1,00 - 7,00
LYMPH# : 4,70 10³/Ul 1,00 - 3,70
MONO# : 0,58 10³/Ul 0,00 - 0,70
EO# : 1,40 10³/Ul 0,00 - 0,40
BASO# : 0,07 10³/Ul 0,00 - 0,10
Neut % : 38,5 % 50,0 - 70,0
Lymph % : 42,8 % 20,0 - 40,0
Mono % : 5,3 % 2,0 - 8,0
EO % : 12,8 % 1,0 - 5,0
Baso % : 0,6 % 0,0 - 1,0

BLOOD CHEMISTRY
GDP : 92 mg/dl 70 - 110
2hpp : - mg/dl
SGOT : 26 µ/l 0 - 37
SGPT : 28 µ/l 0 - 42
GGT : - µ/l
Ureum : 13 mg/dl 10 - 50
Creatinine : 0,6 mg/dl 0,7 - 1,3
Urid acid : 7,8 mg/dl 3,7 - 7
 Cholesterol : 190 mg/dl 0 - 200
HDL : 27 mg/dl
LDL : 108 mg/dl
Trigliseride : 407 mg/dl 0 - 150
HBsAg : NON REAKTIVE Non Reaktive
HBeAg : - Non Reaktive
VDRL : NON REAKTIVE Non Reaktive
HbA1c : - %

9. PEMERIKSAAN ELEKTRO KARDIOGRAFI

ECG Examination : NORMAL
10. Treadmill : -

11. PEMERIKSAAN RADIOLOGI : NORMAL

X-Ray Examination
12. SPIROMETRI : NOT PERFORMANCE

Spyrometry :
13. HASIL RUJUKAN : -

Referral Summary :

14. KESIMPULAN
Conclusion : FIT TO WORK WITH MEDICAL SURVEILLANCE

SUBJECT TO MEDICAL SURVEILLANCE

MEDICAL
Medical EXAMINER
Examiner

dr. Mulyani Mus

dr. MULYANI MUS

0
 Name : MUHAMMAD FAJRI
Sex : MALE
Place /Date Of Birth : SINANGKALA/OCTOBER 18,1994

PHISICAL EXAMINATION

Height : 20212510Cm Pulse : 80 X/i

Weight : 62 Kg Resp : 20 X/i
TD : 130/80 mmHg Rhythm : Regularly

NO GENARAL APPEARANCE NORMAL ABNORMAL

1 Head √
2 Eyes √
3 Pupils √
4 Eye Movement √
5 Nose, Sinus, Throat √
6 Ear ( in general) √
7 Tympani membrane √
8 Chest and lungs √
9 Breast examination √
10 Heart √
11 Skin √
12 Varicose veins √
13 Abdomen and viscera √
14 Hernia √
15 Anus √
16 Genital √
17 Upper and lower extremites √
18 Spine √
19 Neurologic reflexes √

dr. MULYANI MUS

Medical Examination Result Sent By Whatsapp/email has been Validation by Medical Examiner without sign in
 Name : MUHAMMAD FAJRI
Sex : MALE
Place / Date Of Birth : SINANGKALA/OCTOBER 18,1994

EYES EXAMINATION

1. Vision Distance
OD : 6/6 OD : 6/6
CORRECTION
OS : 6/6 OS : 6/6
2. Colour Perception : NORMAL
3. Other : -

EAR EXAMINATION
1. Audiometri
500 HZ 1000 HZ 2000 HZ 3000 HZ 4000 HZ
Right : 40 30 20 15 10

Left : 30 30 25 5 5

2. Whisper : NORMAL

dr. SHINTIYA DJAJAKUSLI, Sp.M

dr. INDAH HAMRIANI, Sp.THT
Medical Examination Result Sent By Whatsapp/email has been Validation by Medical Examiner without sign in
 Name : MUHAMMAD FAJRI
Sex : MALE
Place / Date Of Birth : SINANGKALA/OCTOBER 18,1994

DENTAL EXAMINATION

Pro Extraction : 25,46

Pro Conservation : -
Pro Scalling : -
Pro Prothesis : 36
Others : -

CONCLUSION : MODERATE

drg. ROBERT ROBBY P.

Medical Examination Result Sent By Whatsapp/email has been Validation by Medical Examiner without sign in
 Name : MUHAMMAD FAJRI
Sex : MALE
Place / Date Of Birth : SINANGKALA/OCTOBER 18,1994

RADIOLOGI

FOTO THORAX PA

BRONCHOVASKULER NORMAL

COR : NORMAL

SINUS AND DIAFRAGMA NORMAL

OS INTAK
`

KONCLUTION : NORMAL

dr. ANDI ROMPEGADING, Sp.Rad

Medical Examination Result Sent By Whatsapp/email has been Validation by Medical Examiner without sign in
Name : MUHAMMAD FAJRI
Sex : MALE
Place / Date Of Birth : SINANGKALA/OCTOBER 18,1994

ELEKTROCARDIOGRAPH