TRAWANGAN MEDICAL SERVICE

GENERAL PRACTICIONER
GILI TRAWANGAN LOMBOK UTARA
Telp/WA : 0878 5894 1440 / 0878 6400 2433 / 08170 991 991

MEDICAL REPORT : 231017

MEDICAL REPORT
Full name : ZOE CORNELIS

Nationality : BELGIUM

Sex : Female

Date Of Birth : 08. 07. 1999

Adresss in Lombok : Gili Trawangan

Principle Complaint : ears feel uncomfortable, cough and runny nose

Detailed Explenation : The patient came with complaints of a hearing is reduced and the ears feel
closed, cough, runny nose since 3 days ago.
Past Medical history :
Allergy :-

Physhical examination :

Vital Sign

BP : 110/70 mmHg Respiration : 20 x / Min

Pulse : 82x/ Min SpO2 : 99% Temperature : 36,5°C

Glasgow coma scale (GCS) : e4v5m6

Eyes : Normal

Thorax : Cardio : S1 S2 normal

Pulmo : Vesikuler , Rhonki (-) wheezing (-)

Abdomen : bowel sound normal

Acral : Warm +/+,crt <2s

Status localis :-

Diagnosis : acute external otitis

Other Possibellities : -

Doctor Recomendation : do not swim

 TRAWANGAN MEDICAL SERVICE
GENERAL PRACTICIONER
GILI TRAWANGAN LOMBOK UTARA
Telp/WA : 0878 5894 1440 / 0878 6400 2433 / 08170 991 991

Medication :
NO DESCRIPTION QTY
CONSULTATION AND VISIT
Physical examnation and consultation 1
PROCEDURE AND THERAPY
spooling ear 2

DRUGS
cefford forte tablet 10

Brochifar tablet 10

reco tetes telinga (ear drops) 1

CONSUMABLES AND MEDICAL SUPPLIES

OTHER SERVICE AND CHARGE

Gili Trawangan, 2023-10-17

dr. Pandu Putera Anugerah

Attending Physician