Medika Plaza

Health & Medical Service

HEALTH ASSESSMENT REPORT

Of

ABDUL RAHMAN 01032261

Wednesday, March 27, 2013

MEDIKA PLAZA CLINIC

Kartika Chandra - Office Tower 3rd Floor J1. Jend. Gatot Subroto, Kay. 18-20 Jakarta Selatan 12940 Tlp :(62-21) 525 1207, Fax :(62-21) 521 0815 Appointment Hotline (62-21) 528 80088 www.medikaplaza.com

MP Medical Center KC Clinic

Menara Kartika Chandra 3rd Floor 11. lend. Gatot Subroto Ka y. 18-20

Medika Plaza
Health & Medical Service

liatalE60 reip : -raz z1 szs

izor (hunting) Fax : +62 21 521 0815 www.medikaplaza.com

ABDUL RAHMAN

49 Years Old

INSPECTOR

RADIANT UTAMA INTERINSCO TBK

Fit for work to the job described Fit with Medical Note Unlit for work to the job described

April 03, 2013

Levi Piscianti, MD

No. Formulir No. Revisi Taxggal Terbir

: FM-DR-008-05 : 00 : 2 Mei 2011

MEDIKA PLAZA CLINIC

Kartika Chandra - Office Tower 3rd Floor J1. Jend. Gatot Subroto, Ka y . 18-20 Jakarta Selatan 12940 Tlp :(62-21) 525 1207, Fax :(62-21) 521 0815 Appointment Hotline (62-21) 528 80088 www.medikaplaza.com

Medika Plaza Health & Medical service

MR No. : NAME EMPLOYEE No. JOB TITLE COMP. NAME COMP. ADDR

: 01032261 : Abdul Rahman : INSPECTOR / : PT. RADIANT UTAMA rNTERINSCO TBK : Jakarta

EMPLOY. STATUS BIRTHDATE SEX STATUS NASIONALITY

: : 24 December 1963 : Male : Married : Indonesia

I. Dislipidemia with fatty liver USG : sugestive cholelithiasis DD/ polyp Obesity 4. Radix, calculus teeth Your fitness status is fit with medical note : Dislipidemia with fatty liver USG : sugestive cholelithiasis DD/ polyp

Low fat and carbohydrate diet, exercise regularly. See an internist for further evaluation of dislipidemia with fatty liver and sugestive cholelithiasis DD/ pot Reduce body weight gradually 0.5 Kgs/week, by doing regular exercise (aerobic/jogging), 3-4x/week, 30-45 minutes and reduce high calorie diet until maximal body weight is 73.96 Kgs (present body weight is 98 Kgs). See a nutritionist for further evaluation of obesity. 3. See a dentist for dental care

- Adolf Amahorseya, MD - Esther Poerwantoro, MD Levi Piscianti, MD Riko Yuniandri, MD Temmasonge, MD - A. Renowati, MD - Djuanda, MD

Cardiologist Clinical Patologist General Practitioner Opthalmologist Pulmonologist Radiologist Dentist

Lev

cianti MD

Notes: Should you eed the further information or consultation, please contact us via : : - kcdoctor01@medikaplaza.com Email - kcdoctor02@medikaplaza.com Clinic Number : (021) 5251207

Wednesday, April 03, 2013 / anisa

Page 1

MEDIKA PLAZA CLINIC

Kartika Chandra - Office Tower 3rd Floor J1. Jend. Gatot Subroto, Ka y. 18-20 Jakarta Selatan 12940 Tlp :(62-2 I ) 525 1207, Fax :(62-21) 521 0815 Appointment Hotline (62-21) 528 80088 www.medikaplaza.com

Medika Plaza & Mcdical'mice

MR No. :
NAME EMPLOYEE No.

: 01032261
: Abdul Rahman : : INSPECTOR / : PT. RADIANT UTAMA INTERINSCO TBK : Jakarta

EMPLOY. STATUS
BIRTHDATE SEX STATUS NASIONALITY

:
: 24 December 1963 : Male : Married : Indonesia

JOB TITLE
COMP. NAME COMP. ADDR

I. Dislipidemia with fatty liver USG : sugestive cholelithiasis DD/ polyp Obesity 4. Radix, calculus teeth Your fitness status is fit with medical note : Dislipidemia with fatty liver USG : sugestive cholelithiasis DD/ polyp

Adolf Amahorseya, MD - Esther Poerwantoro, MD - Levi Piscianti, MI) - Riko Yuniandri, MD Temmasonge, MD - A. Renowati, MD - Djuanda, MD

Cardiologist Clinical Patologist General Practitioner Opthalmologist Pulmonologist Radiologist Dentist

Notes: Should ou need the further information or consultation, please contact us via : : - kcdoctor01@medikaplaza.com Emai - kcdoctor02@medikaplaza.com Clinic Number : (021) 5251207

Wednesday, April 03, 2013 / anisa

Page 1

Name : Abdul Rahman Comp : RADIANT UTAMA INTERINSCO TBK

Sex :Male

MR No. : 01032261

Visit : 27-Mar-2013

DOB : December 24, 1963

PHYSICAL EXAMINATION MEDICAL HISTORY - Present Complaint PAST MEDICAL HISTORY - Surgery - Disease - Inpatient - Alergy History - Imunization recently FAMILY MEDICAL HISTORY - Diabetes Melitus - Hypertension - Heart Disease - Lung Disease/TBC - Kidney Disease - Asthma Bronchial - Mental Disorder - Epilepsy - Chronic Skin - Cancer - Color Blindness - Stroke/CVA - Disgestive/Liver - Muscle - Bone and Joint - Others disease HABITS - Appetite - Drink Alcohol - Smoking - Exercise MEASUREMENT - Body Weight - Body Height - Normal Weight - Body Mass Index ( BMI) - BMI Impression - Blood Pressure - Pulse
Wednesday, April 03, 2013

None

No No No No No

None None None None None None None None None None None None None None None No

Good No No No

98 Kg 172 Cm 54.73 - 73.96 Kg 33.13 kg/m2 Obesity 120/80 mmHg 82 x per menit
Page 1/3

Name : Abdul Rahman

Sex :Male

MR No. : 01032261

Visit : 27-Mar-2013

Comp :RADIANT UTAMA INTERINSCO TBK

DOB : December 24, 1963

GENERAL APPEARANCE - Pallor Jaundice - Skin EAR, NOSE, THROAT - Auricle Nose (Septum, Conchae) - Sinuses Pharynx - Tonsil EYE - Left - Right MOUTH - Tounge - Gum - Dentition NECK - General - Thyroid Gland / Thracea LYMPHE SYSTEM - Neck Gland - Armpit Gland CHEST (INSPECTION, PALPATION, PERCUSSION, AUSCULTATION) - Form - Expansi - Lung (Breath Sound, Stem Fremitus) - Heart (Sound, Ictus, Form) - Breast ABDOMEN - General - Palpation Liver (Enlargement, Consistency) Spleen (Enlargement, Consistency) - Kidney (Ballotement) Hernia Inguinal RECTAL EXAM - Haemorrhoids
Wednesday, April 03, 2013 No

No Normal

Normal Normal Normal Normal Normal

Normal Normal

Normal Normal Abnormal Radix, calculus teeth

Normal Normal

Normal Normal

Normal Normal Normal Normal Normal

Globular Supple Not palpable Not palpable No ballotement Negative

Negative
Pager 2/3

Name : Abdul Rahman Comp : RADIANT UTAMA INTERINSCO TBK

Sex :Male

MR No. : 01032261

Visit : 27-Mar-2013

DOB : December 24, 1963

- Rectum/Anus/Perianal UPPER AND LOWER EXTREMITIES Bones / Joint - Muscles / Tonus Finger / Nails - Hand Foot NEUROLOGICAL EXAMINATION Motoric Function - Sensoric Function Coordination Function - Physiologic Reflex - Patologic Reflex - Extra - Pyramidal Function WORK EXPOSURE - Toxic or irritant chemicals - Heavy Manual handling - Solvents, oils, greases - Noise - Silica dust - Other Dust - Shift Work - Vibration - UV Radiation - Heat Stress - Working at height - Confined space work - Cold Stress - lritating Fluid - Fumes Working arround rotating machinery - Requires color vision - Clerical/Administration/Office work Handling food products

Normal

Normal Normal Normal Normal Normal

Normal Normal Normal Normal Negative Normal

No No No Yes No No No No No No No No No No No Yes No No No

Wednesday, April 03, 2013

Page : 3/3

Name : ABDUL RAHMAN Comp : RADIANT UTAMA INTERINSCO TBK

Sex : Male

MR No. :01032261

Visit : 27-Mar-2013

DOB: 24 December 1963 / Age : 49

DESCRIPTION Previous Glasses Distant Without Glasses Near

Distant Correction Near

Right
Add S+1,75

Left
Add S+1,75

1,0 J1

1,0
II

Tonometry Funduscopy
I Good Good

Colour Blind Test

Normal

Wednesday, March 27, 2013 / dian fajar utama

Page : 1 of 1

Name : ABDUL RAHMAN

Sex : Male

DOB : 24 December 1963 / Age : 49 Rad/Reg. No. :D 01032261-1

MR No. : 01032261 Visit : 27-Mar-2013

Comp : RADIANT UTAMA INTERINSCO TBK Examt

Thorax PA

No abnormality seen in both lungs. Normal bronchovascular markings in both hili. The heart is normal in size and shape. The mediastinum is not widened. Both sinus and diaphragms are good. No evidence of pleural effusion.

Impression : Normal chest. No evidence of specific process in both lungs.

Examining Physician

: A. Renowati Sp.Rad

Wednesday, Arch 27, 2013 /

Page : 1 of I

Name : A- 'JL RAHMAN

Sex : Male

DOB: 24 December 1963 / Age : 49 Rad/Reg. No. :D 01032261-1

MR No. : 01032261 Visit : 27-Mar-2013

Como : RADIANT UTAMA INTERINSCO TBK Examination g m

UP PERLOWER ABDOMEN SONOGRAPHY

LIVER: Liver tip is blunt, there are increase attenuation echoes structure parenchyme which are homogenous. No sign of SOL. Intrahepatic vascularity and billiary tract are normal. GALL BLADDER: Normal in size, contour and surface. Multiple hyperechoic lesion was seen without shadowing at lumen gall bladder,diameter 7,6 mm BOTH KIDNEYS: Normal in size, contour and surface. No sign of obstruction/ stone/ SOL. PANCREAS: Normal in size, contour and surface. No sign of SOL. LIEN: Normal in size and contour, the echoes are homogenous. No sign of SOL. URINARY BLADDER: Normal in size, contour and surface. No sign of stone/ SOL. PROSTATE AND VESICULA SEMINALIS: Normal in size and contour which are homogenous echoes and no sign of focal lesion/ SOL. Impression : Fatty liver Sugestive Cholelithiasis DD/Polyp

Examining Physician

: A. Renowati Sp.Rad

Page : 2 of 1
Wednesday (larch 27, 2013 /

wirdiPiftit r .Latztv
Kartika Chandra - Office Tower 3rd Floor Jend. Gatot Subroto, Kay. 18-20 Jakarta Selatan 12940 Tlp :(62-21) 525 1207, Fax :(62-2I) 521 0815 Appointment Hotline (62-21) 528 80088 www.medikaplaza.com

Medika Plaza Health Medical Service

Name : ABDUL RAHMAN

Sex : Male

DOB : 24 December 1963 / Age : 49 Lab/Reg. No. :C.2703019D

MR No. : 01032261 Visit : 27-Mar-2013

Comp : RADIANT UTAMA INTERINSCO TBK

HEMATOLOGI Automated Blood Count - WBC - RBC - Hemoglobin - Hematocrit - Thrombocytes - MCV - MCH - MCHC L ESR Diff Count - Basophils - Eosinophils - Bands / Stab - Neutrophils - Lymphocytes - Monocytes BLOOD CHEMISTRY LIPID PROFILE - Total Cholesterol - HDL Cholesterol - LDL Cholesterol - Ttyglicerides RENAL FUNCTION - Ureum - Creatinine - Uric Acid LIVER FUNCTION - SGOT - SGPT DIABETES Glucose Fasting - Glucose urine - Keton urine Glucose 2PP - Glucose urine - Keton urine 109 Negative Negative 94 Negative Negative < 110 mg/c11 Negative Negative < 140 mg/di Negative Negative 6.0495 Negative Negative 5.217 Negative Negative < 6.1 mmo1/1 Negative Negative < 6.7 mmo1/1 Negative Negative 13 32 13 - 45 IU/L 13-50 IU/L 13 32 13 - 45 IU/L 13-50 IU/L 19 1.3 7.4 * 10 - 50 mg/dl 0.6 - 1.3 mg/dl 3.5 - 7.2 mg/dl 6.783 114.92 440.152 3.5 - 17.8 !ninon 53 - 115 umol/L 120-420 umol/L 222 * 43 * 122 280 * < 200 mg / dl >45 mg/di < 130 mg/di 70 - 140 mg /d1 5.7498 1.1137 3.1598 44.072 < 5.18 mmol/L > 1.16 mmol/L < 3.37 mmol/L 11.0 - 22.0 umol/L 1 2 1* 57 31 8 0- 1% 2- 4% 3-5% 50 - 70 % 25 - 40 % 2-8% 1 2 t 57 31 8 0- 1% 2- 4% 3-5% 50 - 70 % 25 - 40 % 2-8% 6.3 5.6 15.5 46 314 82 28 33.4 14* 3.8 - 11.0 IC/u1 4.4 - 5.9 Mini 13.2 - 17.3 g/d1 40 - 52 % 150 - 440 KJul 80 - 100 fl 26 - 34 pg 32 - 36 g/dI 0 - 10 min/h 6.3 5.6 15.5 0.46 314 82 28 334 14 3.8 - 11.0 K/ul 4.4 - 5.9 MA11 132 - 173 g/L 0.4 - 0.52 150 -440 K/ul 80 - 100 fl 26 - 34 pg 32 - 36 g/d1 0 - 10 min/h

Wednesday, March 27, 2013 / rika andriani

Page : 1

 Name : ABDUL RAHMAN

Sex : Male

DOB : 24 December 1963 / Age : 49 Lab/Reg. No. :C.2703019D

MR No. : 01032261 Visit : 27-Mar-2013

Comp : RADIANT UTAMA INTERINSCO TBK

URINALYSIS MACROSCOPIC - Colour - Turbidity - Sp. Gravity -pH - Leucocytes ( Enzymatic ) - Glucose - Nitrites - Bilirubin - Blood - Urobilinogen - Proteins - Keton IICROSCOPIC - WBC - RBC - Ephitels Squamous - Cylinder - Crystals - Bacteria - Others 1-2 0-1 1-3 Negative Negative Negative Negative 0-4 cell IIIPP 0-1 cell /HPF 5-15 /LPF Negative Negative Negative Negative 1 0 1-3 Negative Negative Negative Negative Yellow Clear 1.015 6.5 Negative Negative Negative Negative Negative Normal Negative Negative 1.015 - 1.025 4.8 - 7.4 Negative Negative Negative Negative Negative Normal Negative / <10 mg/dl Negative Yellow Clear 1.015 6.5 Negative Negative Negative Negative Negative Normal Negative Negative

Examining Physician : Esther oerwantoro, Sp.PK

Wednesday, March 27, 2013 / rika andriani

Page : 2

Name : ABDUL RAHMAN Comp : RADIANT UTAMA INTERINSCO TBK

Sex : Male

MR No. : 01032261

Visit : 27-Mar-2013

DOB : 24 December 1963 / Age : 49

FVC Result FEV1 Result FEV1/FVC Result PEF Result Index Spirometry Result

: : : :

3.36 L---> 88.2 % 2.96 L---> 89.7 % 88.10 %---> 119.9 % 10.20 L/S---> 99.4 %

Indonesian Standart Result : : Normal Spirometry

Impression : -

-lasonge Sp.P
N

r-
01 r-

00

N N (.0

1.0
cn

00 01

co co
C.) . C) 0SC

r- CD r- r.-mcneimr7-

1 CD-C!!'4
`

CM CD C)

CD CD uJ CC

,-

CD

r-

r-

OD

un CD -Nu) C)

CO OD

LO r- (4 CO of roc CD r- ul

o ol
CI
(L)

0 ,r r4C

, 0 0

-S s 8
C

0-

tO

(.0

o0 uJ

OD m

cv00

CD (.0 CD '4- 00 03 CO '7 CV m ,- 00 (0 ,-- CD N UD - (ID CD m . . . ol0 CD ,r CD OD ,r CD CD uD

I W.,

IIIII

CC 411
C U.11-_-_

co
un _1 ___J _1 i.p

r-

_ __i _i __i_.12.:1 .._i

.43

U) (77 ., ID CD

co 0 w -J

_..1 _I &,,. co co

H ".
7ti Z

_i

_.:1

Cn
c,4

1 !...._n li

uJ

gl

C> F-4

000a c"5

=l ocs4c0 p cz,g/NoN(..,2r-s:

001,

i Nu `D x8 r" ini
A

>5

as
Page : I of I

II I

II I
77

il
QD LL

"
;>
NIO NN wwwww LL w tw

01

CL)

SPIROMETRY TEST REPORT Name ID No. Sex Age Height Weight BSA Predicted Cal. Date Physician Comment ITEM UNIT MEAS PRED %PRED ABDUL RAHMAN 1 3 Male 49 172 0 cm 98 0 kg 2. 10 m2 ASIA2 27/ 3/2013 7:25 AM

Date Race Room temp Humidity Atm Pr

- :

27/ 3/2013 9 : 33 MI Asian (100 %) 2510 '0 50.0 % 1013. 1 hPa

FVC F EV1. 0 F EV6. 0 F EV1/FVC MME F F F25 EF50 EF75 EF75 8 5

E F200-1200

L L L % Lis L's Us L/s

L/s

EF TIME s ET L xtra p V
xtrapV%

3.36 2. 96 3.36 88.10 4 06 10. 20 9 54 5. 18 1.68 1.08 8. 94 0.22 4 94 0 13 3. 87

3.81 3.30 73.51 4 15 10. 26 7 87 5 33 2.38

88.2 89.7 119.9 97.8 99 4 121 2 97.2 70.6

I VC I V1 0
I V1 0/ FVC

I F I F50 ITEM
Diagnosis Stage BD Improvement FEV1/FVC

Lis L/s [I NT ERPRETAT I ON]

EVALUAT I ON (IC Normal

Restrictive

Normal

70
Mixed Obstructive

80

100 %FVC

[COPD CLASSIFICATION] FEV1/FVC 94/F EV1 0 88. 10 oft 89 70 46

Normal Stag e Recommended treatment by GOLD

[ FVC 12
Pred curve

LC 8 :j

8 L

L-5

ttr) RI n3

Name : ABDUL RAHMAN Comp : RADIANT UTAMA INTERINSCO TBK

Sex : Male

MR No. :01032261

Visit : 27-Mar-2013

IDOB : 24 December 1963 / Age : 49

TREADMILL

Sinus Rythm axis ( N ), P wave ( N ), PR int 0.16" ST - T segment ( N ), aritmia (-)

Treadmill Exercise Test : Negative Cardiopulmonary Fitness Classsification : Good METs : 10.1

Examining Physician : Adolf Amahorseya DSJP

Wednesday, March 27, 2013 / afni octavia

Page : 1 of 1

Medika Plaza
Health & Medical Service

MP Medical Center KC Clinic

Menara Kartika Chandra 3rd Floor JI. lend. Gatot Subroto Ka y . 18-20, Jakarta 12060 Telp : +62 21 525 1207 (hunting), Fax : +62 21 521 0815

www.medikaplaza.com

TREADMILL EXERCISE TEST REPORT

Date Name No. MR. Phone

Referred by Indication of test Resting ECG :

: : tbk)1/4 LA VA\ M .
:

Age : Weight : Previous test

yrs g kg

F/M

Height : riAm Date/Result :

LtO ec\-46%-ez-e-> .."L-r,zs2z----p-e----4----c_c2_.9)/

Treadmill exercise test :

Exercise potokol : BRUCE Test terminated after /Pninutes Reason Completed stage lb stage? ( nutes of stage ) f '16--predicted Maximal heart rate achievq inappropriate. Maximal heart rate), response : Maximal ST change *: * During exercise : mm in leads , in stage mm in leads , minutes at rest * Post exercise . Arrhythmias : .rte Bloodpressure Chest doscomfort (if nitroglycerine is given, state when and note ECG changes): (*+ : elevation, - : depression, J : J tyoe B : Borderline H : Horizontal, S : Sickle shaped-down slope).
Conclusion :

egati / Positive / Equivocal treadmill exercise test. (Ischemic Response) - Excellent verage / Low Cardioopulmonary Fitness Classification. - Duke Score :
Other remarks :

Cardiologist

No. Formulir : FM-Lab-006-02 No. Revisi : 00 Tanggal Terbit : 2 Mei 2011

STAGE / GRADE /
SPEED REST HYPERVENTILATION

MIN

H.R bpm u

mmHg 12A 174 No

B.P.

level

S.T.

SIMPROMS /SIGNS / ARRHYTHMIAS

I.

10% 2.74 mph

II.

12%4.02 4.02 mph

1 2 3 4 : 7 8 9 10 11 12 13 14 15 16 17 18

1 10 1.15 13 1-24 l% tkleI-A _ 1 1 re* 1

,_, I ,bl.MC

III.

14 % 5.47 mph

1.k1 (V

IV.

16% 6.76 mph

V.

18%8.05 8.05 mph

VI.

20 % 8.85 mph

POST EXERCISE :
MIN 1 2 3 4 5 6 7 8 9 10 11 12 No. Formulir : FM-Lab-006-01 No. Revisi : 00 Tanggal Terbit : 2 Mei 2011 H.R bpm
mmHg

B.P.

S.T. level

SIMPROMS / SIGNS / ARRHYTHMIAS