RUMAH SAKIT UMUM BHAKTI RAHAYU

JL. GATOT SUBROTO II NO. 11 DENPASAR – BALI

TELP : (0361) 430270, 430245 FAX : (0361) 263371, 430833
EMAIL : bhakti_rahayu_dps@yahoo.co.id
ihcghbbhaksena@gmail.com

INITIAL MEDICAL ASSESSMENT

IN-HOUSE CLINIC GRAND HYATT BALI

Date : 24/09/2022 Time : 16.30 GMT+8

Surname : Cox First Name : Lucy
D.O.B : 20/04/2016 Address : GHB room 3204
Sex/Gender : Female Medical Record : 220025
Nationality : Australia Attending Physician :

Patient Complaint / Medical History:

The child suffered a cut to the chin after slipping in the pool and hitting the tiles. There is no
history of unconsciousness.

Allergy:
Denied

Past Medical History:

Denied

Physical Examination:
Vital Sign
GCS Score : E4V5M6 VAS : 1-2
Blood Pressure : NE mmHg Respiration : 20 x/min
Pulse : 60 x/min regular Body Temp. : 36.3 o
C
O2 Saturation : 98 % Body weight : NE kg

Physical Findings:
Eye : Anemic (-/-), pupil equals and reaction (+/+)
ENT : NE
Thorax : NE
Abdomen : NE
Extremities : Warm, CRT <2”, skin turgor normal
Regio chin: v. appertum 1 cm in length, bleeding (-)
 RUMAH SAKIT UMUM BHAKTI RAHAYU
JL. GATOT SUBROTO II NO. 11 DENPASAR – BALI
TELP : (0361) 430270, 430245 FAX : (0361) 263371, 430833
EMAIL : bhakti_rahayu_dps@yahoo.co.id
ihcghbbhaksena@gmail.com

Laboratory Test / Diagnostic Procedure / Imaging:

n/a

Diagnosis:
Vulnus appertum regio chin (ICD-X S01.80XA)

Differential Diagnosis:
None

Treatment / Management:
- Skin suture (refused by patient’s parent because the patient was uncooperative)
- Butterly bandage + Framycetin tulle
- Cefaclor syr (owned)
- Nurofen syr (owned)

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:

- Follow up every 2 days
- Keep the wound clean and dry

Patient Disposition Outpatient c

Inpatient c
ICU

Bali, 24/09/2022
The Attending Physician