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BRIGADE INFANTERI 22/OTA MANASA

BATALYON INFANTERI 715/MOTULIATO


Gorontalo Utara, Juli 2017
Nomor :B/ /VII /2017
Klasifikasi : Biasa
Lampiran : 2( Dua ) Bundel
Perihal : Permohonan dukungan obat
Kepada

Yth. Kepala Dinas Kesehatan

Gorontalo Utara

di

Gorontalo Utara

1. Dasar :
a. Surat Edaran Kakesdam VII/Wrb Nomor : SE/24/X/2014 tanggal 28 Oktober
2014 tentang Petunjuk Pelaksanaan Pengelolaan Keuangan Dana Kapitasi dan
Non Kapitasi Pelaksanaan Pelayananan Kesehatan Tingkat Pertama ( PPK I ) di
Lingkungan Kemhan RI dan TNI

b. Pertimbangan Komando dan Staf Yonif 715/Motuliato.

2. Sehubungan dasar tersebut di atas, diajukan permohonan dukungan obat dan


kebutuhan Alkes di Klinik Pratama Motuliato Yonif 715/Mtl ( daftar terlampir ).
3. Demikian mohon menjadi maklum.

Komandan Batalyon Infanteri 715/Motuliato,

Gunarto,S.H
Letnan Kolonel Inf NRP 11990008840572
BRIGADE INFANTERI 22/OTA MANASA Lampiran Surat Danyonif 715/Motuliato
BATALYON INFANTERI 715/MOTULIATO Nomor : B / / VII / 2017
Tanggal, Juli 2017

DAFTAR NAMA OBAT

NO NAMA OBAT JUMLAH KET


OBAT
1. Antibiotik
a. Amoxilin 500 mg 3000 tab
b. Cefadroxil 500 mg 3000 caps
c. Cefixime 100 mg 1000 tab
d. Clindamicyne 150 mg 1000 caps
e. Cefadroxil dry syr 50 btl
f. Cefixime dry syr 50 btl
g. Ciproflaxasin 500 mg 1000 tab

2. Analgensik
a. Mefenamic acid 500 mg 2000 tab
b. Asam mefenamat 3000 tab
c. Piroxicam 10mg/20mg 1000 tab
d. Na diclofenac 25/50mg 1000 tab
e. Profenid/ketrofen supp 20 supp
f. Lidocain/pehacain inj. 50 amp

3. Antipiretik
a. Parasetamol syr 50 btl
b. Ibuprofen syr 50 Btl
c. Parasetamol supp 50 Supp

4. Obat flu [kombinasi]


a. Paratusin tab 1000 tab
b. Paratusin syr 50 btl

5. Mucolitik/expectorant
a. Bromhexin 50 syr
b. Ambroxol 50 Syr
c. Kombinasi 50 syr
d. Antitusive (codein 10/20mg) 1000 tablet

6. Bronchodilator
a. Salbutamol 2 mg 1000 tab
b. Aminofilin 1000 tab
c. Combivent/ventolin nebulizer 50 amp

7. Antidiare
a. Antalpugide 1000 tab
b. Loperamid 1000 tab
c. Lacto B /dialac 100 sacht
d. Buscopan inj/Gitas inj 150 Amp

8. Multivitamin
a. Multivitamin ( Panviton) 1000 tab
b. Neurotropic inj 150 amp

9. Anti hipertensi
a. Captopril 25 mg 1000 tab
b. Amlodipin 5 mg/10 mg 1000 tab

10. Obat Maag


a. Cimetidin 1000 tab
b. Antasida Syrup 100 Btl
c. Omeprazole 1000 tab
d. Ranitidin inj 150 amp

11. Antikejang
a. Stesolid supp 50 supp

12. Corticosteroid
a. Dexamethasone 1000 tab
b. Metilprednisolon 1000 tab
c. Dexamethasone inj 150 amp
d. Betason zalf 200 salep

13. Cairan infuse


a. Normal saline 0,9% 200 flash
b. Ringer lactat 350 flash

14. Chlor ethil 10 btl

15. Obat tetes mata


a. Cendo xitrol 50 tube
Obat tetes telinga
a. Otopraff 50 tube

16. Bahan habis pakai yg di butuhkan


a. Kassa steril 100 pak
b. Sufratule/daryantule 25 pak
c. Disposible syringe 3 ml 3 pak
d. Kassa gulung 3 gulung
e. Benang cut gut no 4 150 sacht
f. Mess 10/20 150 sacht
g. Abocath no 20 /22 /18 150
h. Infusion set 50 set
i. Hipafix 10 pak
j. Handschren no 7 / 8 steril 50 pak

Komandan Batalyon Infanteri 715/Motuliato,

Jusriadi, S.Ag
Letnan Kolonel Inf NRP 11990008840572
BRIGADE INFANTERI 22/OTA MANASA Lampiran Surat Danyonif 715/Motuliato
BATALYON INFANTERI 715/MOTULIATO Nomor : B / / IV / 2016
Tanggal, April 2016

DAFTAR PASIEN UMUM RAWAT JALAN


KLINIK PRATAMA MOTULIATO

No Nama TTL Alamat Pekerjaan Diagnosa Terapi Jumlah


1 Irfan Umanto Tolongio,12-12-1982 Desa Ilodelungga Nelayan Ispa Amoxisilin 10 Tablet
Bronchifar 10 Tablet
2 Elias noe Ponelo,13-05-1988 Desa Ponelo Petani Susp.Kp Cefadroxsil 10 Tablet
Ambroxsol 10 Tablet
Ranitidin 10 Tablet
3 Windi anugraini D Tolongio,21-10-2015 Desa Tolongio - Dermatitis Atopi Gentamicin Salp 1 Tube
4 Darsono Ilangata,02-11-1955 Desa Ilangata Petani Reylagia Piroxsicam 10 Tablet
Nalget 10 Tablet
5 Dince Moningka Tolongio,07-06-1964 Desa Tolongio Petani LBP Piroxsicam 10 Tablet
6 Ance Tolongio,10-03-1986 Desa Tolongio Petani Psikosomatis Monalgin 10 Tablet
7 Aldi Modangu Ilodelunga,09-02-1995 Desa Ilodelungga Petani ISK Cefixcime 10 Tablet
Paracetamol 10 Tablet
8 Yamin Hasan Tolanggo,15-10-1982 Desa Tolanggo Petani KP - -
Anemia - -
9 Neni Potionua Tolongio,27-10-1987 Desa Ilodelungga Nelayan Ispa Cefadroxsil 10 Tablet
Ambroxsol 10 Tablet
10 Riswan Kaltili Manado,29-11-2006 Desa Ilodelungga - Ispa - -
Susp.KP - -
11 Suarni Tolongio,03-11-1955 Desa Tolongio Petani Ispa Demacolin 10 Tablet
Cefadroxsil 10 Tablet
12 Fasrin Kahar Ilodelunga,11-07-1971 Desa Ilodelungga Nelayan Luka Tangan Benang Cromic 1 Pack
Cefadroksil 10 Tablet
Asam mefenamat 10 Tablet
13 Inri Usman Tolongio,06-09-1999 Desa Tolongio IRT Tonsilitis Rr Eritromycin 10 Tablet
Dexamethasone 10 Tablet
Ambroxsol 10 Tablet
14 Faisal A nusi Limboto,31-05-1979 Desa Hodulungo Swasta Ispa Cefadroxsile 10 Tablet
Monalgin 10 Tablet
Bronchifar plus 10 Tablet
15 Moh.Zulham arsyat Sengkang,30-01-2006 Desa Embulodata Pelajar Ispa Eritromycin 10 Tablet
Bronchifar plus 10 Tablet
16 Unu Labano,13-10-1988 Desa Hellumo Petani Apendisitis Cefadroxsile 10 Tablet
Mefenamic Acid 10 Tablet
17 Mulyadi Tomu Ilodelunga,02-03-1973 Desa Ilodelungga Nelayan Tinea Pedis Cefadroxsile 10 Tablet
Mefenamic Acid 10 Tablet
18 Rabra Tadu Tolongio,05-05-1933 Desa Motillango Petani Diare Akut Metronidazole 10 Tablet
Omegdiar 10 Tablet
Pamol 10 Tablet
19 Rahmat Ilodelunga,06-08-2006 Desa Ilodelunga Petani Gr.Obstruksi Cefadroxsile 10 Tablet
Mefenamic Acid 10 Tablet
20 Arfan Tutuda Langge,06-01-1991 Desa Langge Petani Ispa Bronchifar plus 10 Tablet
Cefadroxsile 10 Tablet
Vit C 10 Tablet
22 Herlina Yasin Tolongio,23-05-1988 Desa Langge Nelayan Ispa Bronchifar plus 10 Tablet
Cefadroxsile 10 Tablet
Antasid 10 Tablet
23 Santy Yusuf Tolongio,30-10-1979 Desa Tolongio IRT Gastritis Akut Ranitidine 10 Tablet
Antasida 10 Tablet
24 Tri sukmo fajar Tolongio,25-02-2002 Desa Tolongio Pelajar Scabies Ctm 10 Tablet
Scabimite Salp 1 Tube
25 Angga Ramadan Tolongio,25-07-2014 Desa Tolongio - GEA Ranitidine 3 Tablet
Ondansetron 9 Tablet
Paracetamol 1 Tablet
Lakto B 4 Sacet
Cefadroxsile syrup 1 Botol
Omekdiar Syrp 1 Botol

26 Ramli Moda Gorontalo,03-03-1998 Desa Tolongio Pelajar Ispa Paracetamol 10 Tablet


Dexamethasone 10 Tablet
Panviton 10 Tablet
27 Ainun Kahar Langge,01-11-2006 Desa Langge Pelajar Scabies Amoxcilin syr 1 Botol
Dexamethasone 10 Tablet
Vit C 10 Tablet
27 Zanal Kahar Langge, 23-08-2008 Desa langge Petani Sekabies Amocicillin Syrp 1 botol
Dexamethasone 10 tablet
Vit. C 10 tablet
28 Muh. Afan Langge, 10-05-2014 Desa Langge - Sekabies Amocicillin Syrp 1 botol
Dexamethasone 3 tablet
Vit. C 5 tablet
29 Nomi Pomanto Tolongio, 19-02-1952 Desa Tolongio Petani Bronghitis Kronis Ambroxol 10 tablet
Dexamethasone 10 tablet
30 Nori Tolongio, 03-07-1952 Desa Tolongio Petani Bronghitis Kronis Amoxicillin 10 tablet
Ambroxol 10 tablet
Dexamethasone 10 tablet
31 Hadija Pakari Tolongio, 21-12-1970 Desa Tolongio Petani Bronghitis asma Salbotamol 10 tablet
Ambroxol 10 tablet
Dexamethasone 10 tablet
32 Boki Tolongio, 08-01-1955 Desa Tolongio Petani Susp.Katarak Panviton 10 tablet
Dermatitis Dexamethasone 10 tablet

33 Farida Ovi Tolongio, 03-03-1963 Desa Tolongio Petani Rematoit Atritis Piroxicam 10 tablet
Vit. B comp 10 tablet
34 Maryam Tolongio, 26-05-1978 Desa Tolongio IRT Ispa + Alergi Amoxicillin 10 tablet
Paracetamol 10 tablet
Methyiprednisolon 10 tablet
35 Vita D. Ani Tolongio, 06-03-1986 Desa Tolongio IRT KP Cefadroxil 10 tablet
CandidasisOral
Susp. HIV Ranitidine 10 tablet
36 Ajrin Tolongio, 27-10- 2015 Desa Tolongio - Ispa Amocicillin Syrp 1 botol
Dexamethasone 5 tablet
Pamol 1 tablet
Bromixin 1 tablet
37 Rian Pranata Tolongio, 21-06-1990 Desa Tolongio Wiraswasta Ispa Amoxicillin 10 tablet
Vit. B comp 10 tablet
Paracetamol 10 tablet
GG 10 tablet
38 Radit Jailani Langge, 05 – 09 -2010 Desa Langge Pelajar Skabies Amocicillin Syrp 1 botol
Tiafen Syrp 1 botol
39 Ishak Tolongio, 03-05-1982 Desa Tolongio Petani Ispa Paracetamol 10 tablet
Panviton 10 tablet
40 Latif Palowa Anggrek, 09-09-1975 Anggrek Petani Rematoit Atritis Piroxicam 10 tablet
Paracetamol 10 tablet
41 Muliadi Tomu Tolinggula, 02-03-1973 Desa Ilodulunga Nelayan Preterigicum Dex Erlamicyn 1 tub
42 Martin Pakaya Tolongio, 04-02-1965 Desa Ilodulunga IRT Ganggren Dex Ciprofloxasyn 10 tablet
43 Ibrahim Opaladu Kwandang,25-01-1967 Desa Alata Karya PNS Ambeyen + Cefadroxil 10 tablet
Stomatitis Mefenamid Acid 10 tablet
Vit. C 10 tablet
Vit. B comp. 10 tablet
Panviton 10 tablet
44 Revan Langge,06-12- 2013 Desa Langge - Skabies Amocicillin Syrp 1 botol
Vit. C 2 tablet
Vit. B comp. 2 tablet
Dexamethasone 2 tablet
45 Hafni Tolongio,12 -03 -1974 Desa Tolongio IRT LBP + Sakit Gigi Dexamethasone 10 tablet
Amoxicillin 10 tablet
Natrium Dilapenat 10 tablet
46 Rahim Dampu Ilodulunga, 09-07-1985 Desa Ilodulunga Petani Apendisitis Cefadroxil 10 tablet
Mefenamid Acid 10 tablet
47 Selvi Pakaya Ilangata,19-09-1989 Desa Ilangata IRT Migran Mefenamid Acid 10 tablet
Diazepam 10 tablet
48 Hendrik Layya Ilangata, 01-02-1985 Desa Ilangata Petani Gea Ranitidine 10 tablet
Domperidone 10 tablet
49 Yunus Tolongio, 26-04-1978 Desa Tolongio Petani Rematoit Atritis Piroxicam 10 tablet
50 Abd. Labido Helumo, 16-09-1939 Desa Helumo Petani Ispa Captopril 10 tablet
Paracetamol 10 tablet
Vit. B comp. 10 tablet

51 Isahole Helumo,18-09-1949 Desa Helumo Petani Hipertensi Captopril 10 tablet


52 Hadijah M. Agus Baina Ale, 09-10-1961 Desa Baina Ale Petani Rematoit Atritis Cefadroxil 10 tablet
Paracetamol 10 tablet
Vit. B comp. 10 tablet
53 Aisyah Tutuwoto, 26-12-1961 Desa Tutuwoto IRT Kolic ABD + Mefenamit Acid 10 tablet
Susp.
Hidroneprhosis
54 Riston Akuba Paguyaman,11-10-1982 Desa Tolongio Petani Ispa Nalget 10 tablet
Brochon 10 tablet
Neuralgin 10 tablet
56 Raden Husain Gorontalo,16-07-1939 Desa Tolongio Petani Rematoit Atritis Nalget 10 tablet
Piroxicam 10 tablet
57 Marjan Pakaya Ilangata, 29-06-1978 Desa Ilangata Petani Fetrigo + Susp. Simpastatin 10 tablet
dislipidimi Upalgin 10 tablet
58 Harianto Yusup Tolongio, 05-05-1996 Desa Tolongio Pelajar APP Acut - -
59 Aziz Langge, 09-02-1976 Desa Langge Petani Gea Ranitidine 10 tablet
Domperidone 10 tablet
60 Suarni Bungio Tolongio, 06-02-1962 Desa Tolongio Petani Ispa Paracetamol 10 tablet
Cefadroxil 10 tablet
Vit. B comp. 10 tablet
61 Neni Yusuf Tolongio, 19-11-1966 Desa Tolongio Petani Luka Kaki Cefadroxil 10 tablet
Mefenamit Acid 10 tablet
62 Roni Gorontalo, 19-09-1976 Desa Mondinelo Wiraswasta Cabut Kuku Amoxicillin 10 tablet
Mefenamit Acid 10 tablet
63 Siti Nurbaya.U Mulingkapoto,05-03-1998 Desa Butungo Pelajar Utikaria Methyiprednisolon 10 tablet
Bungo Vit. C 10 tablet
64 Maryam Ahlul Tolongio, 09-01-1970 Desa Tolongio IRT Ispa Brochon 10 tablet
65 Ismail Klinau Tolongio, 10-05-1973 Desa Tolongio Petani ISK Cefadroxil 10 tablet
66 Yustine Sangihe, 07-01-1943 Desa Monano IRT Osteoporosis Piroxicam 10 tablet
Vit. B comp 10 tablet
67 Nestor Sangihe, 05-11-1975 Desa Monano Petani Bronghitis Acut Cefadroxil 10 tablet
Demacolin 10 tablet
GG 10 tablet
68 Zanal Kahar Langge, 23-08-2008 Desa langge Petani Sekabies Amocicillin Syrp 1 botol
Dexamethasone 10 tablet
Vit. C 10 tablet
69 Masdayanti Tanah tengah, 12-06-1993 Tolongio Pelajar Obs. Otalgia CC3 Mefenamat Acid 10 tablet
Susp. M3
70 M. Fauzan Mustafa Helumo, 21-08-2004 Helumo Pelajar Tonsilofar Akut Amoxicillin 10 tablet
Paracetamol 10 tablet
71 Uyan M Daiko Tolongio, 23-01-1977 Tolongio Petani Epilepsi Amoxicillin 10 tablet
Vit. B comp 10 tablet
72 Kartin Ise Tolongio,21-04-1964 Tolongio IRT Caries Denitis Amoxicillin 10 tablet
Celibenclamid 10 tablet
73 Marni Doki Tolongio, 12-06-1988 Tolongio IRT LBP Mefenamat Acid 10 tablet
Amoxicillin 10 tablet
74 Wisnu Pakaya Ilangata, 27-06-1971 Ilangata Wiraswasta ISPA Amoxicillin 10 tablet
Brochon 10 tablet
75 Idah Tolongio, 23-02-1955 Tolongio IRT Hipertensi Amlodiphine 10 tablet
Piroxicam 10 tablet
76 Sairah Sude Tolongio,07-01-1962 Tolongio IRT OA Piroxicam 10 tablet
Vit. B comp 10 tablet
77 Maya Yunus Potiana,13-09-1983 Potiana IRT Obs. Varicella Amoxicillin 10 tablet
Dermitis Konak CTM 10 tablet
Allergica Acyclovir 10 tablet
78 Muh. Mofili Pontiana,03-07-2015 Potiana - Abces Amoxicillin 3 tablet
Dexamethasone 3 tablet
79 Husni Tolongio,23-09-1984 Tolongio IRT Hipertensi + Captopril 10 tablet
Gastritis Ranitidine 10 tablet
Antasida 10 tablet
80 Hsan Abbas Molunggota,14-04-1990 Molunggota Petani LBP Mefenamat Acid 10 tablet
Amoxicillin 10 tablet
81 Sulaiman Ladiku Gentuma,12-04-1974 Gentuma raya Petani LBP Mefenamat Acid 10 tablet
Amoxicillin 10 tablet
82 Nuko Maliju Ilodulungata,01-12-1930 Ilodulungata Petani Hipertensi Captopril 10 tablet
Mefenamat Acid 10 tablet
Amoxicillin 10 tablet
Scabimat slp 1 tube
83 Arlin Uluto Ilodulungata,01-08-1988 Ilodulungata Petani Limfoma Amoxicillin 10 tablet
Meloxicam 10 tablet
Paracetamol 10 tablet
84 Aldin Nusi Tolongio,22-09-1997 Tolongio Pelajar CC Amoxicillin 10 tablet
Paracetamol 10 tablet
Ambroxol 10 tablet
85 Imelda Potionoa Popalo,21-11-2015 Langge - CC Amoxicillin 5 tablet
Paracetamol 1 botol
Ambroxol 5 tablet
86 Fajrin Ertaif Tolongio,17-06-2010 Tolongio - CC Amoxicillin 5 tablet
Paracetamol 5 tablet
Ambroxol 5 tablet
Metoclopramide 5 tablet
87 Rumi Tomu Tolinggula,25-12-1965 Tolinggula IRT Susp. Pneumonia Ciprofloxasim 10 tablet
Paracetamol 10 tablet
Ambroxol 10 tablet
Neuralgin 10 tablet
88 Vicky Hasan Tolongio,23-04-2002 Tolongio Pelajar Gastritis Amoxicillin 10 tablet
Ranitidine 10 tablet
Paracetamol 10 tablet
89 Adi Putra Mofili Potiana,23-01-2014 Potiana - ISPA Amoxicillin 3 tablet
Paracetamol 5 tablet
Dexamethasone 5 tablet
Pimacillin syr 1 botol

90 Muh. Akbar Lahiya Potiana,28-12-2015 Potiana - ISPA Amoxicillin 5 tablet


Paracetamol 5 tablet
CTM 3 tablet
91 Rasia Madi Tolongio,03-07-2015 Tolongio - ISPA Amoxicillin Syr 1 botol
Paracetamol 2 tablet
CTM 2 tablet
Vit. B comp 2 tablet
92 Rahman Imran Hialohile,29-03-2003 Hialohile Pelajar Cepal Hematome Amoxicillin 10 tablet
Mefenamat Acid 10 tablet
93 Irwan Popalo,27-01-1983 Popalo Wiraswasta App. R. Frontalis Amoxicillin 10 tablet
Mefenamat Acid 10 tablet
94 Sulaiman Exan Tolongio,21-03-2012 Tolongio - Cont. Mosulorum Amoxicillin 10 tablet
Piroxicam 10 tablet
95 Adrian Sirajak Tolongio,27-12-2010 Tolongio - ISPA Amoxicillin 5 tablet
Brochon 3 tablet
Dexamethasone 5 tablet
96 Yusni Olii Ilodulunga,20-08-1983 Ilodulunga IRT Asma Br Ambroxol 10 tablet
Metilprednisolone 10 tablet
Salbutamol 10 tablet
97 Hadia Isa Tolongia, 21-03-1960 Tolongio Petani Tensiol Meadical Piroxicam 10 tablet
Vit. B comp 10 tablet
98 Rahman Motanu Malingkapoto,11-02-1977 Malingkapoto Petani Arthitis Allopurinal 10 tablet
Piroxicam 10 tablet
99 Yanto Halalang Helumo,11-11-1981 Helumo Petani ISPA Mionalgin 10 tablet
Brochon 10 tablet
Vit. C 10 tablet
100 Indah Makassar,27-12-2015 Makassar - ISPA Amoxicillin 3 tablet
Dexamethasone 5 tablet
Paracetamol 5 tablet
Pimacillin syr 1 botol
101 Rehan Mahidin Popalo,17-12-2009 Popalo - ISK Amoxicillin 5 tablet
Paracetamol 5 tablet
Ranitidine 5 tablet
102 Salman Ibrahim Popalo,28-11-1985 Popalo Nelayan O.Febris Paracetamol 10 tablet
Vit.B Complek 10 tablet
103 Rusman Pakaya Ilodulunga,20-10-1984 Ilodulunga Nelayan Asam Urat Piroxsicam 10 tablet
Allopurinol 10 tablet

Penangung Jawab Klinik,

dr.Agustini Diah Anggraini


NIP 197308182007122001