Gili Trawangan Lombok Indonesia 24 Hours Medical Service

Telp. +62370 6197510/ +6281805237373 On Call Doctor

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

DISCHARGE MEDICAL REPORT

Full Name : Thomas Bakkan Sex : Male

Date of Birth : 22/07/1987 Nationality: Norway
Address in Lombok : Gili Trawangan

Main Complaint : High Fever + Joint Pain

Explanation in Details : Patient came to the clinic with main complaints high fever and joint pain
since 2 days ago. He explains that fever goes up and down throughout the day due to the
consumption of paracetamol and ibuprofen. He also mentions several periods of sweating. He
also experiences body ache, joint pain, and headache. He experiences no diarrhea, nor stomach
cramps and vomiting. He felt tired, weak and is losing appetite since yesterday.

(01/07/2017)

As per this morning the patient felt a lot better. He mentioned no periods of fever nor shivering.
He also stated that he did not experienced any body ache nor joint pain. He has gained his
appetite and felt energetic.

(02/07/2017)

The patient came for a follow up of his medical condition. As per this morning he mentioned no
fever, body ache nor joint pain. He felt a lot more energetic and has gained his appetite. The
patient is then discharged.

Past Medical History : never had before

Past Traveling History: The patient have been traveling to Bali in past weeks.
Allergy : none
Vital Sign : BP = 110/70mmHg; HR = 96x/mnt; RR = 24 x/mnt T = 36,2 C;
Physical Examination : GCS : E4V5M6
Eye: pupil reflect +/+ isocor, anemic-/-, icteric-/-, sunken -/-
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 (-)

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
Pharmacy & Laboratory
gamed_clinic@yahoo.com info@blueislandclinic.com Land, Water and Air Ambulance
Laboratory Investigation: (Lab result attached)

Working Diagnosis : Obs. 4th day of fever with mild-moderate dehydration

Differential Diagnosis 1: Unspecified viral infection
Differential Diagnosis 2: Susp. Dengue Fever

Treatment/Medication :

Continue oral medication

Novagesic 3x1 tab

Dehaf 3x1 Sacch.
Ramolit 3 x 1 Sacch.

Doctor Recommendation: - Drink a lot of water Inpatient treatment

Avoid: Spicy food, alcohol, soda, milk Less fiber (juices/fruits)

- Should the symptoms re appear go see a doctor

- No follow up visit is required due to the positive trends of thrombocyte levels and the
patient shows a good clinical sign of recovery.

Patient Fit to Fly Yes [

No
[
Flight Recommendation T Ordinary Seat T
[ [ Wheelchair Assistance [ Stretcher Case
y y
T T T
p p
y y y
e e
p p Gili Trawangan 2nd July p2017
a a
e e e
q q
a a a
u u
q q q
o o
u u u
t t
o o o
e e Dr. Teuku Arie Hidayat
t t t
f f (Attending Physician)
e e e
r r
f f f
o o
PT Medika Pulau Biru r r r
Phone : +62 370 6197510 m m
o o o
Fax : +62 370 6197511
t t
Mobile : +62 81 805 237 373 m m m
Email : info@blueislandclinic.com h h
Website : www.blueislandclinic.com t t t
e e
h h h
d d
e e e
 Gili Trawangan Lombok Indonesia 24 Hours Medical Service
Telp. +62370 6197510/ +6281805237373 On Call Doctor
Pharmacy & Laboratory
gamed_clinic@yahoo.com info@blueislandclinic.com Land, Water and Air Ambulance

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