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    Confidential Medical Report 2

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    tahuchubby sesetan
    The medical report documents a female Indian patient's visit to the clinic complaining of headaches. On examination, the patient looked slightly unwell but had normal vital signs. The diagnosis was a common cold. The doctor recommended the patient avoid spicy foods, get blood tests if fever persists, take prescribed medication, and call if any issues arise. The doctor deemed the patient fit to fly commercially without escort.

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    Confidential Medical Report 2

    Uploaded by

    tahuchubby sesetan
    57 views2 pages
    The medical report documents a female Indian patient's visit to the clinic complaining of headaches. On examination, the patient looked slightly unwell but had normal vital signs. The diagnosis was a common cold. The doctor recommended the patient avoid spicy foods, get blood tests if fever persists, take prescribed medication, and call if any issues arise. The doctor deemed the patient fit to fly commercially without escort.

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    CONFIDENTIAL MEDICAL REPORT 2

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    The medical report documents a female Indian patient's visit to the clinic complaining of headaches. On examination, the patient looked slightly unwell but had normal vital signs. The diagnosis was a common cold. The doctor recommended the patient avoid spicy foods, get blood tests if fever persists, take prescribed medication, and call if any issues arise. The doctor deemed the patient fit to fly commercially without escort.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    57 views2 pages

    Confidential Medical Report 2

    Uploaded by

    tahuchubby sesetan
    The medical report documents a female Indian patient's visit to the clinic complaining of headaches. On examination, the patient looked slightly unwell but had normal vital signs. The diagnosis was a common cold. The doctor recommended the patient avoid spicy foods, get blood tests if fever persists, take prescribed medication, and call if any issues arise. The doctor deemed the patient fit to fly commercially without escort.

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    CONFIDENTIAL MEDICAL REPORT

    Date: 16/3/2019 Time: 10.30 pm

    File No. : 321/SBKR/2019


    Name :
    Sex : FEMALE
    Age :
    Nationality : INDIAN
    Current Address in Bali : BeachWalk Shoping Mall

    Present history:
    Patient complained of headaches since yesterday, patient had taken medication but the head still felt pain.
    Patient comes to the clinic just want to ask for a prescription and not buy medicine at the clinic

    Allergic history : None


    Past medical history : None
    Medication currently used : None
    Treatment so far : none

    Physical Examination:
    Level of consciousness : Compos mentis Respiratory rate : 24 times per
    (E4V5M6) Blood pressure: 120/80 mmHg minute Temperature : 36,50 C
    Pulse rate : 88 beat per minute O2 saturation : 98% on room air

    General State
    Patient looked slightly unwell
    Eyes : no sunken eyes, no anemic or yellow sclera, no redness at both
    eyes Mouth : dry lip (-)
    Throat : redness on pharynx wall (-), exudate (-)
    Chest : Heart : heart sound S1 S2, single, regular, and no
    murmur Lung : vesicular sound (+/+), no wheezing,
    no rhonchi
    Abdomen : normal bowel sound, slightly bloated (-), tenderness on epigastric area (-), skin turgor (+)
    normal, no enlargement of liver or spleen
    Limb : warm on all extremities, no edema, CRT < 2 seconds

    Additional examination (Radiology, Lab, ECG, CT Scan, Ultra Sound, MRI, etc.): -

    Diagnosis:
    Common Cold

    Treatment/Medication

    None
    Doctor’s Recommendation:
    Patient Request Repatriation: Yes No V

    In Doctor’s Opinion This Patient Requires Repatriation / Medical Evacuation: Yes No V

    Patient Can Be Transported: Yes V No

    If Yes, with:

    V Normal Transportation

    Ambulance

    Patient’s fit to fly: Yes V No

    If Yes, with:
    V
    Normal Flight
    V
    Non Escorted In Economic

    Class Non Escorted In Business

    Class

    Non Medical Escorted In Business

    Class Medical Escort in Business

    Class Stretcher Medical Escort

    Team

    Charter Flight / Air Ambulance Team

    Comment:
    - Avoid eating any spicy, greasy, and acid food; avoid drinking soda, alcohol, coffee, or tea.
    - Further examination such as blood test should be done if fever persists within the next three days.
    - Take the medicine as prescribed.
    - If anything issues, please call us.

    Kuta, 16-3-2019

    dr. dewa prasatya

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