REQUEST FOR SPECIALIST CONSULTATION

PATIENT INFORMATION
International UN Staff
Locally recruited staff
Military Observer
Contractor
Troop √
Others
Patient Name
Endarto
(Last, first, middle)
UN ID No M-20003009

Date of Birth 27/9/1994

Rank / Title First Corporal

Nationality Indonesian

Duty Station REAR BASE NORTH SECTOR

Due to:
Illness √
Accident
Injury
Other
FROM:
Location/Hospital: NDROMO CAMP

Telephone and Fax Number: +243 997884225/ +6283 9966 6515

Attending Doctor: dr. Muh Fadlan Ramadhan/ IndoRDB Medical Doctor

Date: January 26th 2023
Signature:

(Attending Physician to kindly sign both pages of this document)

Peace it!
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Page 1 of 2
SOP / DMS/ Medical Services Section / Medical Case Management Unit / October 2019
MEDICAL CONFIDENTIAL

Patient’s Name Endarto

UN ID No M-20003009
Date of Birth 13 April 1984

The following additional medical information is confidential and should be treated as such.

How, where and when did the accident, injury or illness occur:
Tooth 17 there is Caries feels pain when exposed to cold stimulus and knocked. Patient
has difficult sleeping at night because the tooth feel pain and sick since 15 th January 2023.
The Treatment that have been given : Amoxcicillin 500 mg 3x1 tab, Dexamethasone 0,5 mg
2x1 tab, Diclofenac Sodium 25 mg 2x1 tab Medication : Temporer Filling

Current Diagnosis + ICD code :

Gangren Radix Tooth 17 (R02)

Specialist consultation: Dentist

Other comments/observations:
Composmentis; Tooth 17 Checked = Percusion test (knock) (+), Cold stimulation test pain
(+). There is not Allergic history of Medicine and food.

Attending Physician: dr. Muh Fadlan Ramadhan/ IndoRDB Medical Doctor

Date: January 26th 2023

Signature:

(Attending Physician to kindly sign both pages of this document)

Peace it!
facebook.com/monusco.org | twitter.com/monusco | flickr.com/monusco | www.monusco.org

Page 2 of 2
SOP / DMS/ Medical Services Section / Medical Case Management Unit / October 2019