MEDICAL REPORT

A. PATIENTS IDENTIFICATION
Name
: Mrs. Michiko Takagi
Age
: 68 Years
Sex
: Female
Address
: Herittage Hotel Rantepao Tana Toraja 91831
South Sulawesi Indonesia
Medical Record
: 056829
Reg. No.
: 08091019
Date of Exam
: September 10th 2008
Period of Hospitalized : 10 11 September 2008
Name of Hospital
: ELIM Rantepao Hospital Tana Toraja
And address
Jl. Ahmad Yani No. 68 Rantepao Telp. (0423)
21258/25572 Tana Toraja 91831 South Sulawesi
Indonesia
Attending Physician : Dr. Yain Panggalo
B. MEDICAL HISTORY
Anamneses : vomitus, diarrhea, anorexia and malaise
C. PHYSICAL EXAMINATION
Vital Sign
: Tension = 130/90 ; HR = 84 times/min; RR = 16 times/min;
T = 360 C
Abdomen
: increased peristaltic, mild turgor
D. LABORATORY TEST
Blood count : WBC 4900, Blood Presipitation Time : 60/hour
Titer WIDAL : normal
LFT
: normal
RFT
: normal
E. DIAGNOSIS
: Gastroenteritis acute
F. TREATMENT
: Rehidration, anti vomiting, antibiotic, loperamid, H2
receptors antagonist
G. PROGNOSIS
: Bonam
Rantepao, September 10th 2008

Dr. Yain Panggalo

Name & Signature of Attending Physician with Hospital Stamp

LAPORAN MEDIS SINGKAT

A. IDENTIFIKASI PASIEN
Nama
: Tn. GUSTAV RUDOLF TANARO
Umur
: 51 TAHUN
Jenis Kelamin
: LAKI-LAKI
Alamat
: JL. SERIGALA NO. 95 MAKASSAR
No. Medical Record
: 059058
Reg. No.
: 08112243
Tanggal Masuk
: 22 NOVEMBER 2008 Pukul 20.00 WITA
Lama Perawatan
: 22 23 NOVEMBER 2008
Tempat Perawatan
: RSU. ELIM Rantepao - Tana Toraja
Dan Alamat
Jl. Ahmad Yani No. 68 Rantepao Telp. (0423)
21258/25572 Tana Toraja 91831 Sulawesi Selatan Indonesia
Dokter Pemeriksa
: Dr. Yain Panggalo
B. ANAMNESIS (ALLOANAMNESIS)
Pasien masuk rumah sakit diantar oleh keluarga dalam keadaan kesadaran
menurun akibat jatuh dari ketinggian lantai dua disertai perdarahan dari dahi,
hidung dan kedua lengan bawah patah
C. PEMERIKSAAN FISIS
Keadaan umum : GCS E1M5V1, sakit berat, gizi baik
Tanda Vital
: Tensi = 80/Palpasi ; HR = 100 kali/menit; RR = 28
kali/menit;
T = 36,60 C
Kepala
: luka robek pada dahi dan bibir atas, perdarahan aktif dari
hidung
Ekstremitas
: patah kedua tulang lengan bawah
D. PEMERIKSAAN PENUNJANG
Laboratorium : Golongan Darah A+, Hb : 11,7 mg%, Hm 35%
Rontgen
: Tidak dilakukan karena pertimbangan kondisi pasien
E. DIAGNOSIS KERJA : Cedera Kepala Berat + Patah Tulang Lengan Kiri dan
Kanan + Syok hemoragik
F. TINDAKAN
: Penanganan kegawatdaruratan dan konsultasi Dokter
Spesialis Neurologi, Bedah dan THT
G. PERJALANAN PENYAKIT :
Setelah dilakukan perawatan maksimal sesuai kondisi rumah sakit, pasien
meninggal dihadapan keluarga, dokter jaga IRD dan perawat pada Hari Minggu
tanggal 22 November 2008 Pukul 06.40 WITA
Rantepao, 18 Desember 2008

Dr. Yain Panggalo

DOKTER JAGA IRD

MEDICAL REPORT
A. PATIENTS IDENTIFICATION
Name
: MISS. SARI HAAVISTO
Age
: 26 YEARS OLD
Sex
: FEMALE
Address
: INDRA HOTEL RANTEPAO NORTH TORAJA 91831
SOUTH SULAWESI INDONESIA
Medical Record
: 067241
Date of Exam
: JULY 29th 2009
Name of Hospital
: ELIM RANTEPAO HOSPITAL NORTH TORAJA
And address
Jl. AHMAD YANI No. 68 RANTEPAO
TELP. (0423) 21258/25572 NORTH TORAJA
POSTAL CODE 91831
SOUTH SULAWESI INDONESIA
Attending Physician : Dr. YAIN PANGGALO
B. HISTORY
Motorcycle injured in collision with car
C. PHYSICAL EXAMINATION
General Condition : Composmentis, In pain
Upper Limb
: Excoriation wound on left upper arm, elbow, forearm,
palmar, bone intaq.
Abdomen
: Excoriation wound on lower left quadrant
Lower Limb
: Excoriation wound on left thigh, knee, and both toes.
Laceration wound on medial left heel, size 2 x 3 cm,
bone intaq.
D. DIAGNOSIS
: Multiple Excoriation Wound with Laceration wound
on left heel
E. TREATMENT
: Clean the wound with NaCl 0,9% solution, betadine
and suturing, Intermoxyl 3x500 mg, Coditam 3x1
tablet
F. PROGNOSIS
: Bonam
RANTEPAO, JULY 29th 2009

Dr. Yain Panggalo

Name & Signature of Attending Physician

MEDICAL REPORT
A. PATIENTS IDENTIFICATION
Name
: Mr. HENRIK TIITTANEN
Age
: 26 YEARS OLD
Sex
: MALE
Address
: INDRA HOTEL RANTEPAO NORTH TORAJA 91831
SOUTH SULAWESIi INDONESIA
Medical Record
: 067239
Date of Exam
: JULY 29th 2009
Name of Hospital
: ELIM RANTEPAO HOSPITAL NORTH TORAJA
And address
Jl. AHMAD YANI No. 68 RANTEPAO
TELP. (0423) 21258/25572 NORTH TORAJA
POSTAL CODE 91831
SOUTH SULAWESI INDONESIA
Attending Physician : Dr. LONASIS CABUSLAY
B. HISTORY
Motorcycle injured in collision with car
C. PHYSICAL EXAMINATION
General Condition : Composmentis, In pain
Upper Limb
: Excoriation wound on elbow, palmar, bone intaq.
Lower back
: Tenderness
Lower Limb
: Excoriation wound on the right cruris, knee, and left
toes. bone intaq.
D. INVESTIGATION
: X-RAY THORACOLUMBAL- (nothing abnormal
detected)
E. DIAGNOSIS
: Multiple Excoriation Wound
F. TREATMENT
: Clean the wound with NaCl 0,9% solution, betadine
and suturing, Intermoxyl 3x500 mg, Coditam 3x1
tablet
G. PROGNOSIS
: Bonam
RANTEPAO, JULY 29th 2009

Dr. LONASIS CABUSLAY

Name & Signature of Attending Physician

MEDICAL REPORT
A. PATIENTS IDENTIFICATION
Name
: MR. HENDRIKS
Age
: 62 YEARS OLD
Sex
: MALE
Address
: INDRA HOTEL RANTEPAO NORTH TORAJA 91831
SOUTH SULAWESIi INDONESIA
Medical Record
: 067465
Date of Exam
: AUGUST 3th 2009
Name of Hospital
: ELIM RANTEPAO HOSPITAL NORTH TORAJA
And address
Jl. AHMAD YANI No. 68 RANTEPAO
TELP. (0423) 21258/25572 NORTH TORAJA
POSTAL CODE 91831
SOUTH SULAWESI INDONESIA
Attending Physician : Dr. LONASIS CABUSLAY
B. HISTORY
Accidental fall from the high 2 days ago
C. PHYSICAL EXAMINATION
General Condition : Composmentis, In pain
Lower Limb
: Swelling on the right ankle, tenderness, bone intaq.
D. INVESTIGATION
: X-RAY CRURIS DEXTER (nothing abnormal
detected)
E. DIAGNOSIS
: Sprain and strain of the right ankle
F. TREATMENT
: Ibuprofen 3 x 400 mg, metilprednisolon 3 x 4 mg,
Intermoxyl 3x500 mg,
G. PROGNOSIS
: Bonam
RANTEPAO, AUGUST 3th 2009

Dr. LONASIS CABUSLAY

Name & Signature of Attending Physician

MEDICAL REPORT
A. PATIENTS IDENTIFICATION
Name
: MS.LINA
Age
: 47 YEARS OLD
Sex
: FEMALE
Address
: POPIES INN RANTEPAO NORTH TORAJA 91831
SOUTH SULAWESI INDONESIA
Medical Record
: 071538
Date of Exam
: NOVEMBER 14th 2009
Name of Hospital
: ELIM RANTEPAO HOSPITAL NORTH TORAJA
And address
Jl. AHMAD YANI No. 68 RANTEPAO
TELP. (0423) 21258/25572 NORTH TORAJA
POSTAL CODE 91831
SOUTH SULAWESI INDONESIA
Attending Physician : Dr. YAIN PANGGALO
B. HISTORY
Accidental felt down into canal
C. PHYSICAL EXAMINATION
General Condition : Composmentis, In pain
Lower Limb
: Swelling on the anterior cruris dextra, laceration
through into muscle, excoriation, tenderness, bone
intaq.
D. INVESTIGATION
: X-RAY CRURIS DEXTRA (nothing abnormal
detected, no fracture)
E. DIAGNOSIS
: VULNUS LACERATUM CRURIS DEXTRA
F. TREATMENT
: Explorer and wash the wound with NaCl 0,9%
solution, betadine and suturing, Claneksi 3 x 500 mg
Coditam 3x1 tablet, Nonflamin 3 x 1 tablet,
Imobilization
G. PROGNOSIS
: Bonam
RANTEPAO, NOVEMBER 18th 2009

Dr. YAIN PANGGALO

Name & Signature of Attending Physician

MEDICAL REPORT
A. PATIENTS IDENTIFICATION
Name
: Mr. ESTEBAN MUJICA ARZA
Age
: 49 YEARS OLD
Sex
: MALE
Address
: LUTHA HOTEL RANTEPAO NORTH TORAJA 91831
SOUTH SULAWESI INDONESIA
Passport
: BF275984
Medical Reg.
: 02435
Date of Exam
: AUGUST 16th 2014
Name of Clinic
: RANTEPAO MEDICAL CENTRE NORTH TORAJA
And address
Jl. PONGTIKU MISILIANA
TELP. 085255009811 NORTH TORAJA
POSTAL CODE 91831
SOUTH SULAWESI INDONESIA
Attending Physician : Dr. YAIN PANGGALO
B. HISTORY
Diarhea, fever and faint, since yesterday
C. PHYSICAL EXAMINATION
General Condition : Composmentis, fatique
Physical Examination : BP = 129/72 mmHg; HR = 102 times/minute;
T = 37,80 C
Abdomen
: Inreased peristaltic, turgor medium
D. DIAGNOSIS
: Enteritis acute + Mild Dedydration
E. TREATMENT
: Rehidration, antibiotic, antipiretic
F. PROGNOSIS
: Bonam
RANTEPAO, August 16th 2014

Dr. YAIN PANGGALO

Name & Signature of Attending Physician

MEDICAL REPORT
A. PATIENTS IDENTIFICATION
Name
: Mrs. BRIGITTE BONNAUD
Age
: 55 YEARS OLD
Sex
: FEMALE
Address
: LUTHA HOTEL RANTEPAO NORTH TORAJA 91831
SOUTH SULAWESI INDONESIA
Date of Exam
: SEPTEMBER 18th 2014
Name of Clinic
: RANTEPAO MEDICAL CENTRE NORTH TORAJA
And address
Jl. PONGTIKU MISILIANA
TELP. 085255009811 NORTH TORAJA
POSTAL CODE 91831
SOUTH SULAWESI INDONESIA
Attending Physician : Dr. YAIN PANGGALO
B. HISTORY
Epigastric pain, Nausea dan vomitus, since yesterday
C. PHYSICAL EXAMINATION
General Condition : Composmentis, fatique
Physical Examination : BP = 130/80 mmHg; HR = 86 times/minute;
T = 36,40 C
Abdomen
: Inreased peristaltic
D. DIAGNOSIS
: Gastroenteritis acute
E. TREATMENT
: Antibiotic, antispasme/analgetik
F. PROGNOSIS
: Bonam
RANTEPAO, September 18th 2014

Dr. YAIN PANGGALO

Name & Signature of Attending Physician