Gili Trawangan Lombok Indonesia 24 Hours Medical Service

Telp. +62370 6197510/ +6281805237373 On Call Doctor

gamed_clinic@yahoo.com
Pharmacy & Laboratory
info@blueislandclinic.com Land, Water and Air
Ambulance

DISCHARGE MEDICAL REPORT

Full Name : Francisco Javier Pollak Araya Sex : Male

Date of Birth : 19/07/1993 Nationality.................................:
Chile
Address in Lombok : Gili Trawangan

Main Complaint : High Fever + Weakness

Explanation in Details: Patient came to the clinic with main complaints of fever and weakness
today. He explains that the sudden high fever just started this morning, and goes up and down
throughout the day with headache, body ache and joint pain. He mention no diarrhea but had a
slight stomach cramps and feeling very nauseous. The patient has not been taking any medicine
to reduce the symptom. He felt tired, weak and is losing appetite since this morning.

While undergoing treatment at the clinic, the patient experiences vomiting and diarrhea. He
vomited just once, and had watery diarrhea followed by stomach cramps for 3 times in the past 6
hours. He was then given additional medicine.

Past Medical History : never had before

Past Traveling History: The patient have been traveling to Bali in past weeks.
Allergy : none
Vital Sign : BP = 100/70mmHg; HR = 120x/mnt; RR = 24 x/mnt T = 39,2 C;
Physical Examination .....................................................................................................................:
GCS : E4V5M6
Eye: pupil reflect +/+ isocor, anemic-/-, icteric-/-, sunken -/-
Neck & Mouth: T1/T1, crypta (-), hyperemi (-)
Thorax: Pulmo : Breath sound vesicular +/+, rhonchi -/-, wheezing
-/-.Cor : S1 S2 single regular, murmur (-), gallop (-)
Abdomen : Distension (-), bowel sound (+) N, tenderness (-), Hepar/ Lien
unpalpable, skin turgor normally, upper abdominal pain (+)

Laboratory Investigation: (Lab result attached)

Working Diagnosis : 1st day of Fever + dyspepsia + Gastroenteritis acute with mild-moderate
dehydration e.c bacterial infection

PT Medika Pulau Biru

Phone : +62 370 6197510
Fax : +62 370 6197511
Mobile : +62 81 805 237 373
Email : info@blueislandclinic.com
Website : www.blueislandclinic.com
 Gili Trawangan Lombok Indonesia 24 Hours Medical Service
Telp. +62370 6197510/ +6281805237373 On Call Doctor

gamed_clinic@yahoo.com
Pharmacy & Laboratory
info@blueislandclinic.com Land, Water and Air
Ambulance

Treatment/Medication
Maintenance Ringer Lactate intravenous drip 20 drops/mnt (Neurosanbe 1 ampule)
Initial Loading Ringer Lactate (1000cc)
Inj. Norages 3x1 amp
Inj. Omeprazole 1x40mg
Inj. Ceftriaxone 2x1 gr

Oral Medication: (Home medication)

Ciprofloxacyn 2x1 tab
Omeprazole 2x2 tab
Novagesic 3x1 tab

Additional Medicine:

Inj. Scopamine extra.

Inj. Ondansentron extra
Loperamide 3x1 tab
Diaform 3x2 tab

PT Medika Pulau Biru

Phone : +62 370 6197510
Fax : +62 370 6197511
Mobile : +62 81 805 237 373
Email : info@blueislandclinic.com
Website : www.blueislandclinic.com
 Gili Trawangan Lombok Indonesia 24 Hours Medical Service
Telp. +62370 6197510/ +6281805237373 On Call Doctor

gamed_clinic@yahoo.com
Pharmacy & Laboratory
info@blueislandclinic.com Land, Water and Air
Ambulance

Doctor Recommendation: - Bed rest 2-3 days - Drink a lot of water Inpatient
-
Avoid : Spicy food, alcohol, soda, milk Less fiber (juices/fruits) should
symptoms of diarrhea occur.

If the symptom worsens / should there be no improvement of condition in the next 3 days, go
see a doctor.

Patient Fit to Fly Yes [ No

[
Flight Recommendation [ Ordinary Seat [ Wheelchair Assistance [ Stretcher Case

Gili Trawangan 16th April 2017

Dr. Teuku Arie Hidayat

(Attending Physician)

PT Medika Pulau Biru

Phone : +62 370 6197510
Fax : +62 370 6197511
Mobile : +62 81 805 237 373
Email : info@blueislandclinic.com
Website : www.blueislandclinic.com