MORNING SHIFT

18/06/2011
Dr. Ana, AM, TW, MW, SARTIKA, ITA

IN PATIENT

Room / ID Date In Diagnose Physician Vital Sign and Therapy Other

202 On 17/06/11
at 6pm
Fatty liver
GEA
Dr. JWL S: ptn feels better, no
stomach bloated, no
Patient came with chief comp
diarrhea. He has had the sympt
nausea, no diarhea, no since around 2 month prior. It
Stefanus Teja other complaint voiced watery, without any blood, but
Winata/ M/ 30 noticed minimal mucus on the stool.
yo/ INA O: vital sign at 12 pm: diarrhea has been 3 - 10 times /
BP: 110/70mmHg Accompanied with nausea, stom
P: 66 bpm bloated, weak, slight dizzy,
T: 360C abdominal pain. The quality of pain
Prudential
SpO2: 96% on RA like cramp sensation. Slightly decr
INS
RR : 18 x/min appetite. No fever, no numbn
Already taken some medicine for
- generally ptn condition, but no improvement.
looks good dr.Jaowenny visited in UGD advised
- BW: 105kgs - Check for labs (CBC, stool anal
SGOT, SGPT, SC, Na, K, Albumin
- IWL:
- Perform Upper-lower abdom
1575ml/24hrs
ultrasound
- Diarrhea 3x in the - IVFD RL 30 dpm
afternoon (at home), - Vomceran 8 mg, iv, TID
greenish colour, loose - Baquinor 200 mg, iv, BID, drip
consistency, no - Caprol 1 vial in NS 100 ml, iv, OD
diarhea since - Neokaolana syr, C II, TID
hospitalized.
- No vomiting On 17/6/11 At 10 PM informed lab
USG abdomen upper lower re
Lab result on 17/6/11: advised dr JWL:
CBC - Continue th/
WBC : 8.12
RBC : 5.78 On 18/6/11 at 09.50 AM Dr. JWL visit
HGB : 12.9 advised :
HCT : 39.8 - Rillus, BID
PLT : 209 - Urdahex 250 mg, BID
Lymph : 3.05 - Car-Q, BID
SGOT : 41 - Lapraz 30 mg, OD
SGPT : 81 - Baquinor 500mg, BID
SC : 0.8 - Ptn can be discharged
Na : 134 - Review on 4/7/11 at Dr. JWL pra
 K : 4.2
Albumin : 4.3 Ptn discharged on 18/6/11 at 12 pm.
Stool analysis  waiting
sample NOTE :
Ptn’s towel left at ptn room. Pls call p
USG abdomen upper this afternoon.
lower on 17/6/11 :
- Fatty liver ( ringan )
- Gall bladder,
pancreas, lien, ginjal
kanan kiri, buli,
prostat dan Mc
Burney normal

A: problem not solved

yet
P: continue NCP and th/
- Resite IVFD on
20/6/11

IVFD: RL 30 dpm
macro taken out IVFD
on 18/6/11 at 10.30 am

Th/
- Vomceran 8mg, IV,
TID
- Baquinor 500mg, IV,
 BID
- Caprol 1 vial drip in
NS 100ml, OD
- Neokaolana syr, C II,
TID
- Urdahex tab, BID
( during meal )
- Car Q tab, BID

DIET: LOW FIBER

204 On 17/6/11 at
9 PM
Observation of
subileus
Dr. Jaowenny
Lolo, Sp PD
S :feels weak, nausea,
stomach bloated, pain
Patient has been sufferring f
stomach pain since one week ago (
paralitik on lower abdoment on 10 2011). The pain is getting worse
Iin Elyawati/ F/22 and off, no other by day and since today she
YO/ INA complaint voiced. develops nausea. No fever. No vomi
No diarrhea.
O: She went to dr Jaowenny’s pra
Vital sign at 12 PM : yesterday but the pain still persist.
Prudential BP:100 /70 mmHg She never has the same problem befo
INS P: 60 bpm Called dr JWL on 17/4/11 at 9 PM
0
T: 36 C about th/ and inform ptn hospitalize
SpO2: 99 % on RA EXC,already have thorax X ray
RR : 18 x/min QUANTUM, not check blood
- Generally ptn advised :
condition look - Fasting until tomorrow morning
- Intake 6 hrs :730 ml - Tridex 27 B + Torasic 2 amp, 20 d
- Output 6 hrs : 1195 macro
 ml - Alinamin F 1 amp, TID, IV
- Fluid balance 6 hrs : - Broadced HP 1 gr or Broadced
(-)465 ml with IWL in NS 100 ml, BID, skin test first
- BW : 52 kgs - Nexium 40 mg in NS 100 ml, OD
- IWL/24 hrs : 780 ml - Check Lab : CBC, Na,K, AST,A
- Urine 9 hrs : 3 x (± Creatinin, Widal,IgM
600 cc ) salmonellya typhi –
- Ptn use abdominal
circumference Dr JWL visited on 17/6/11 at 9.30
- Performed IVFD on advised :
left hand on 17/6/11 - IVFD Tridex 27B + torasic 60 mg
at 9 PM with 20 dpm
abbocath 22 G. - broadced 1 gram,iv, BID
Abd.Circumference: - alinamin F ampul,iv,TID
On 17/6/11 at 10 PM : - vomceran 8 mg,iv, if needed
78,5 cm - nexium 1 vial in NS 100 ml,OD
On 17/6/11 at 6 AM : 75 - diet : fasting (can drink only wat
cm - observe : abdominal circumferen
On 17/6/11 at 12 pm : 77
cm On 17/6/11 At 10.30 PM called dr J
ptn request to check blood complete
Lab result on 17/6/11 : UL:
CBC - No need add check the other lab
WBC : 6.65 - Can check UL on 18/6/11 mornin
RBC : 4.38
HGB : 12.7 Dr JWL visited on 18/6/11 at 10.0
HCT : 38.4 advised:
PLT : 252 - Continue th/
Lymph : 1.86 - Diet: Liquid
RBS : 120.9
SGOT : 17
SGPT : 17
SC : 0.8
Na : 131
K : 4.2
Creatinin : 0,8
IgM anti salmonellya
typhi : negative scala 2

Widal :
- S. Parathyphi C –O :
1/320
- S. Parathyphi B – H :
1/160

UL on 18/6/11 : WNL

A :Problem not solved

yet
P :Continue th/ and NCP
- Resite IVFD on
20/6/11

IVFD Tridex 27 B +
torasic 60 mg ( 2 amp )
 20 dpm macro
 Th/DOD:
- Vomceran 8 mg, IV,
statim

Th/ dr JWL :
- broadced 1 gram in
NS 100 ml,iv, BID
- Alinamin F
ampul,iv,TID
- Vomceran 8 mg,iv,
TID, PRN
- Nexium 1 vial in NS
100 ml,OD

Diet : liquid

DISCHARGED

Room / ID Date In Diagnose Physician Vital Sign and Therapy Other

202 In ptn On
13/6/11 at 9
DVT left leg
on sinistra
Dr. semadi Local State :
Left knee (back part) and
Patient came with chief complaint
on his left knee and calf. The sympt
pm femoralis vein calf : No swollen/edema, occur suddenly this morning when
(Partial no bruise, no redness, was walking down the stairs. The
Anthony Aver/
Occlusi) minimal pain on was like cramp sensation inside his
M/51
palpation, limited ROM knee and calf, getting worse when
yo/Australian Varicoses bend his knee, and better if he stretch
ankle bilateral Laboratory Result on leg. No numbness nor tingling sensa
Insurance 13/6/11: on his toes, no swollen, no redness
CBC : chest pain, no shortness of breath.
case WBC 6.10 Dr. Semadi Sp.BTKV visited on 14/
waiting LOG RBC 4.48 at 3.30 pm:
HGB 13.1 - Continue th/
HCT 40.4 - Dr will bring stocking on 15/6/11
PLT 185 ptn ( fee for stocking from dr
INR : 0.95 900.000 )
BT/PT : 2’00”/12.1 - Check lab (PT, APTT, INR, D-Dim
APTT : 30.1 after 2 days injection lovenox
D-dimer : 1.016 * 15/6/11 at 12 PM
- If ptn want can flight on Thursd
Lab result on 15/6/11 at 12 16/6/11??
pm :
INR : 1,01 Dr. Semadi Sp.BTKV visited on 15/
BT/PT :12,7 at 3.30 pm:
APTT : 32,6 - Continue th/
D-dimer : 473 - Performed Stocking DONE.
price from dr Semadi IDR 900
Uric Acid :7.3 As per bp. Raja + 10 %. Alre
input by TU
Imaging Result : - For deciced mobilization waitin
Doppler ultrasound : Dimer result
- Deep vein thrombosis - Check Uric Acid pls inform t
(partial non occluded if the D Dimer and Uric Acid re
thrombus) in the left if finish.
 proximal posterior
tibial vein At 7.30 PM, dr Ana called Dr. Sem
- No evidence of inform lab result advised :
superficial thrombosis - Recolvar tab, TID
- Competent valve of the - Voltaren SR, BID
left venous system - Warfarin (Simarc) 4mg, OD
- Arterial system : No - Continue Lovenox inj.
evidence of stenosis, no - Able to mobilization
evidence of - Can go home if pt asking
plaque/calcification.
- Right inferior extremity Called Dr. Semadi at 9 PM, to asking
: there are dilated of for Lovenox inj. And warfarin tab,
superficial veins on the asking about pt flight and for INR &
middle part of right Dimers result for flight suggestions a
medial femur and requested:
medial knee region, no - continue Lovenox inj. Until 5 d
evidence of thrombus. (10x injections) then do DOPP
These veins can USG to make sure the DVT
collapse completely improving
when compressed. - start giving warfarin 4 mg,
tonight (to accumulate with love
so on next 3 days hopefully can r
Th/: INR result in normal range)
- Lovenox inj 0,6cc, SC, - pt is fit to fly (whenever he w
BID (for 5 days) start tonight) even the INR result
- Recolvar tab, TID doesn’t in normal range due to
- Voltaren SR, BID Dimers result is in normal ra
- Warfarin (Simarc) already
 4mg, OD - pt able to walk in limit

called dr Semadi on 16/06/11 at 12.30

reported that ptn requested
discharged, advised:
- dr can’t visit now
- ptn can be discharged with
waiting dr visit
- prepare meds untill ptn flight bac

Ptn discharged on 16/6/11 at 2.30 PM

202 On 2/6/11 at
8 pm
ALL Dr. IB Mudita, Th/ :
SpA - cortidex sac continue
Patient came brought referal letter f
dr. Mudhita Sp.A. He came to h
Pro MTX chemotherapy ( metotrexate intrath
Intratechal with general anasthesia. The proced
Chemotherap will be done on June 3, 2011at 10
I.B Dharma
y No complaint at this moment.
Yoga/M/5 YO/
Sent ptn to Ok on 3/6/11 at 10.00
INA
Finished OK at 11.00

Therapy dr. Mudita post OK :

- continue th/
- continue cortidex sach

dr Mudita visited on 4/6/11 at 1

 advised :
- ptn can be discharged today
- continue cortidex sachet
- next chemotherapy on 29/7/11
not confirm yet, as dr. Mudita
need to come one day before
28/7/11 but ptn ‘s mother reques
come on 29/7/11 morning,
confirm to dr yet

202 On 30/5/11
at 4 pm
B24 on ART Dr.Kris
Prof.Tuti.P
CBC resulted on 11/6/11:
WBC : 6.40
Patient came with chief complaint
rash all over his body. He had
Pneumonia RBC :4.12 symptoms since around 1 hour prio
Salim/M/25 HGB : 14.6 the hospital after took some antif
yo/INA Allergic HCT : 44.2 medicine (Sumagesic). No itchy,
reaction PLT : 415 nausea nor vomiting, no SOB. He
Lymph : 2.47 weak, slight dizzy, and had chest
sometimes on his right chest. He
X-ray thorax : bronchitis has been suffering from high fever s
chronis, dengan last night. Got productive coug
perselubungan tipis pada since about two weeks ago with phle
paracardial kanan, kesan s colour is yellow. Sore throat (+).
disertai sekunder infeksi took chinese medicine but
improvement.
Medication Currently used :
ART
Ptn came on 12/6/11 to have review
Prof Tuti adviced:
 - nislev 500 mg tab OD
- Becombion Forte tab TID
- Need to have review on 22/6/11
need Check lab & X-Ray.
Franken Jacob On 20/9/10 Canal Stenosis Dr. Tjok Thorax X-Ray on 20/9/10: Home physiotherapy’s schedule by
Cornelis/ 78 y.o/ at 10.00 Lumbalis Mahadewa Sri Kandhyawati every Wednesday
Netherlands
- Mild
Saturday until 8 des 2011
Pn moved Compressive Cardiomegaly.
Pls call him “ Mr. from fracture L1-2 - Lungs, soft tissue
Jack” intermediat JUNE
and bones are normal.
e to 203 on Osteoporotic On 1/6/11  DONE, MR give on Frid
LOG received 23/9/10 at 9 spine Chest X-Ray on 12/1/11: 3rd 2011 already input the fees
until 12/10/10 am bronchitis chronis with On 4/6/11 th DONE, MR give
Cervical canal fibrotic process on the Saturday, 4 2011 already input
stenosis C 5-7 right paracardial fees.
Organized left pleural On 11/6/11 DONE, MR already typ
POST effusion and bill already input
Laminectomy Cardiomegali On 15/6/11  DONE, MR alre
day 16th typed, and bill already input
Echocardiography result
on 22/9/10 : On 14/5/11 at 3 PM dr Yeni advised :
LV Hypertrofi - Triatec 2.5mg tab, 1-0-0 for 10 day
LV Diastolic Dysfunction - Plavix tab, 1-0-0 for 10 days
LV fs ( S )normal - Carpiaton 50mg tab, 1 -0-0 for
days
Th/ dr Purwa : - Truvaz 10 mg tab, OD night
- Meticobal tab, TID - Fluimucil tab, TID
- Review Saturday on 11/6/11
 Check lab first: DL, BSN, T
dr KBN therapy : cholesterol, Direct LDL choleste
- Cedocard 5 mg tab, HDL cholesterol and Trigliseride.
TID Pls remind dr and ptn 1 day bef
- Trizedon MR, tab, BID to fasting 12 hours  pls ask
- Carpiaton 50 mg tab, want to see dr or notalready ca
1-0-0 decreased to bli wayan, ptn refused to see
25mg 1-0-0 Internistwell notify to Dr.Yeni
- Cordaron 200mg tab,
1-0-0 decreased to On 23/5/11 at 6 pm ptn saw dr.Tjo
100mg 1-0-0 per dr.Tjok :
- Rechol 0-0-1 - Neurontin tab ,OD
- No need review
Lab result on 5/2/11: - From dr.Tjok FOC
Bun: 18.9
Sc: 0.9 On 28/5/11 at 6 pm ptn saw dr.KBN,
Advised:
Thorax CT-scan with - Plavix 30 mg OD( Night )
contrass at prima medika - Carpiaton 50 mg OD
on 5/2/11: - Approvel 150 mg OD
Elongation of ascending - Mucofect R BID
aorta with calsification at - Trizedon MR 60 mg BID
walls of aorta thoracalis. - Review 28/6/11
There are no mass at
mediastinal and lungs NOTE:
parenchyma, - For dr Yeni, Pls reservation 1
Lymphadenopaty at before then put tracer on fron
paratrachea and left hilar, room dr Yeni practice
degenerative changes of - Pls charge the item below everyt
thoracal spine. dr. Sri visit the ptn
physiotherapy: Kon
MRI on 10/2/11 at KIH : physiatrist specialist (Sp.R
- Compressive facture at
IDR. 1.075.000, do not inp
anterior superior
aspect of L1 and L2 specialist exc A or B beca
body sipne ,with honor will different to give to dr
internal PLS..PLS..BE AWARE
fixatiob,posterior part - Administrasi IDR 50.000
displced,stenosis - Fisiotherapy out ptn IDR 600.00
anterior thecal sac.
- Protrusion disk
herniation at L3 – 4 to
postero medial, right –
left para medial,slight
anterior thecal
sav,stenosis nerve root
exiting L# right –left.
- Slight bulging disc L4-
5 and L5-S1 to postero
medial , slight stenosis
anterior thecal sac,no
stenosis nerve root.
- Canal spinal stenosis at
level L3-4 and L4-5

Lab result on 15/4/11 at

06.00 pm
WBC: 9,61
HGB : 13.00
HCT: 40.0
PLT: 278
Lymp: 2.03
RBS : 93.78
BUN: 12,03
SC: 0.92
SGOT: 10.03
SGPT: 12.32
Total cholsterol: 210.59
HDL cholesterol: 46.43
LDL cholesterol:150.58
Triglyceride:75.82
Uric Acid:7.40
Albumin: 4.40
Natrium:134
Kalium:4.5
Urinalysis: WNL

USG Abdomen upper

lower on 15/4/11 :
- Simple cyst in the left
kidney
- Small hyperechoic
nodule in the right
liver lobe suspect liver
 hemangioma
- Prostate enlargement
- Suspicous of
abdominal aorta
abdominalis in the
level of supraumbilical
region with thrombus
inside the aortic lumen.

Lab resulted on 14/5/11 at

2 pm:
Total cholestrol : 139.20
HDL Cholestrol : 45
LDL Cholestrol : 94
Triglceride : 96.37

OUT PATIENT

Room / ID Date In Diagnose Physician Vital Sign and Therapy Other

Lee Annette Policlinic on Left cerumen Dr nuarsa Vital sign: Patient came bring referal letter f
R/F/51 yo/ 18/6/11 at obturan BP:120/80 mmHg doctor inhouse clinic Bali Padma H
australian 12.30 P: 66 bpm with diagnose cerumen obturan
T: 36 0C sinistra, consult to ENT spesia
SpO2: 95% RA Patient complaint feels earblock s
 Rr: 18 x/mnt yesterday.
Left ear : ear blocked by wax.
As per dr. Nuarsa, Sp.THT ( E
spesialist)
- Spooling on left ear
- No need medication
- No need CC and review

Rolf Soedjak On 17/6/11 Observation Dr. GWK Vital sign: Patient came with referral letter f
/ 61 YO / M/ at 8 PM of RR : 18 x/min International SOS to have consulta
Netherlands hematospermia B P : 130/80 mmHg and further treatment with dr G W
ec prostat T : 36.0 °C Kusuma Duarsa,SpU (urologist).
inflammation P : 67 x/min Patient noticed blood in his sperm (a
SpO2: 97 % on RA he had sexual intercourse) since
week ago. No pain on urination.
UL at SOS on 17/6/11 : genital discharge. No urine frequenc
Bacteria : pos Th/ dr G Wirya Kusuma Duarsa,S
Crystal : Ca carbonate ( +) (urologist) :
pos - nonflamin capsule,TID
Others : Hyaline pos - ceftix 200 mg tablet, OD
- Kalnex tablet,TID
Th/ : - ultracet tablet,TID
- nonflamin capsule,TID - not have sexual intercourse fo
- ceftix 200 mg tablet, weeks. Need to have regular P
OD check at home country.
- Kalnex tablet,TID
- ultracet tablet,TID No need CC and review
Seo Royng Policlinic on Suspect non Dr kris Vital Sign : Patient came with chief comp
Kang/44 yo/M/ 17/6/11 at spesific BP : 110/70 mmHg discharge his penis. He noticed
korean 3.30 pm urethritis P : 88 x/mnt symptoms since yesterday.
T : 36°C discharge's colour was white (pus-l
RR : 18 x/mnt accompanied with itchy sensation
SpO2 : 95% in RA his penis. No redness, no swollen
stinging or burning during urination
fever, no stomach pain.
UL on 17/6/11: WNL As per dr kris advised:
- Check UL
Th/: - Zithromax 1 gr, tab, OD (single
- Zithromax 1 gr, tab, OD dose)
(single dose) - Ozen tab, OD
- Ozen tab, OD
CC on 21/6/11
Mr.Roland Policlinic on GERD Prof.Wibawa Vital Sign at 12 pm : Patient came brought referal letter f
Zauner/ 47 years / 17/6/11 at 12 Dr.Widi Sp.An BP : 120/80 mmHg Kasih Ibu Hospital for endosc
Male pm P : 60 x/mnt procedure under General anastesia
/France T : 36°C diagnose Abdominal colic due
INS RR : 18 x/mnt duadenal ulcer.
SpO2 : 97% in RA PMH :GERD

Allergy : Treatment in Kasih Ibu Hspital:

Augmentin, Cefadroxil - Pariet 20mg, OD
- Inpepsa syr 15 ml, QID
RBS on 17/6/11 at 12 pm : - vometa tab, TID
106 mg/dl
Dr Widi Sp.An visited on 17/6/11 a
Chest X-Ray resulted on pm,advised;
17/6/11 : - ACC endoscopy with GA
- Heart,lungs are normal - Fasting 6 hour
- Old fracture of anterior - Agreement form
left rib,Union fracture - ECG
of left clavicle with - RBS
internal fixation - Thorax X-Ray as per ptn reque
- Put VenflonPerform in endosc
Endoscopy result on
17/06/11: Ptn move to endoscopy at 1 pm
- reflux esophagitis Finished endoscopy at 2 PM
- anthral type superficial
gastritis As per prof wib advised:
- bulbitis/duodenitis - Perform UGI Endoscopy under
today (June 17th,2011)
PA on 17/6/11 at Sentra - Nexium 20 mg tab, BID
Diagnostik: pls f/up on - Motilium tab, BID
20/6/11 - Acitral syr, 15 ml, TID
- Ptn said prefer to come back to
hospital to get next consulta
with prof wib
Ms Vanessa Policlinic on Nail avulsion Dr.Kris Vital Sign : Patient came with chief comp
Redl 16/6/11 at 5 BP : 110/60mmHg detached nail. She got the sympt
/Germany/F/19 pm P : 66 x/mnt after had an rafting accident aroun
yo/ T : 36 hour prior to the hospital. She
SpO2 :98% doing rafting then suddenly her r
RR :18x/mnt big toe hit the boat and made her
SOBEK detached. No active bleeding, no nu
Therapy: nor tingling sensation on her toes,
- Claneksi 500 mg tab, able to move the toe, she only felt sl
TID pain on the affected area.
- Mefinal 500 mg tab, Th/ dr. Kris :
TID (If needed) - Removed the detached nail,
wound dressing with NaCl
0.9% then covered with
cuticell and sterile gauze
- Claneksi 500 mg tab, TID
- Mefinal 500 mg tab, TID (If neede

Ptn came on 17/6/11 at 12.30 saw D

for Wound dressing, advised :
- Wound dressing with Nacl 0.9
then covered with cuticell and ste
gauze.
- Right big toe :Pus (-), clot
discharge (-) , dry lesion (+)
- Need to have review for WT with
days on Tuesday June 21 2011,
remind ptn one day before
 c/n Hard Rock Hotel Bali #6411

NOTE :
- Ptn still have cuticell classic
betadine 5 ml. Kept at # 205 #

Ms.Ekatrina Policlinic on Obsv.of Soft Dr.Kris Vital Sign : Patient came with chief complaint
Malova/F/26 16/6/11 at 4 tissue swelling BP : 100/60mmHg on her left thigh and left knee. She
yo/Russian pm on left knee P : 66 x/mnt the symptoms after had an acci
T : 36 around 3 hour prior to the hospital.
Excoriation SpO2 :98% was doing rafting then suddenly
TELAGA WAJA wound on left RR :18x/mnt boat was flip over, made her fell d
and right leg and bumped the stone. After that
X-Ray Left femur and left felt pain on her left leg, difficult to
knee Resulted : No up her thigh and bend her knee.
evidence of fracture nor numb nor tingling sensation that
dislocation on the left knee felt, no head injury (patient w
region. helmet), still able to move her ankle
toes, able to walk limping.
Therapy From Dr.Kris :
- Perform Left femur and left kne
ray pls call Telaga waja to take
result Telaga waja will pick
this afternoon,the result keep
cuboard 205 DONE
 - Nonflamin caps, TID
- Mefinal 500 mg tab, TID
- Flamar gel, apply on the affe
area 2-3 times/day
- No need CC and review, bec
ptn’s can’t speak english

Robert Ralph On 16/6/11 Susp. Dr. Kris Vital Sign : Patient complain of coughing s
Wildman/ M/ 64 At 01.30 PM Bronchitis BP : 130/80 mmHg around 1 week ago. It was produc
YO/ USA P : 65 bpm cough, with thick greenish-co
T : 360 C phlegm (no blood notic
SPO2 : 95% RA Accompanied with slight sore sensa
RR :18 x/mnt on his chest when he cough and sl
sore throat. No chest pain, no fever
runny nose, no abnormal breat
sound.
Th/ Dr Kris :
- Cravit 500 mg tab, OD
- Mucopect 30 mg syr, 5 ml,
TID
- Mix caps (Meptin mini,
Hexilon, Vit B1), BID

CC 19/6/11
Kamimura On 16/6/11 Bronchitis Dr. Wirajaya Vital Sign : Patient came to have consultation w
Chimako/ F/ 67 At 10.53 am allergy BP : 110/70 mmhg internist. She has been suffering f
y.o/ Japanese P : 74 bpm fever and cough since 3 week
T : 36 C Coughing with few pleghm. Sore th
SPO2 : 96% RA since 1 week ago.
RR :18 x/mnt Since yesterday morning, she not
swollen on her face and h
Lab result on 16/6/11 : accompanied with urinary more o
WBC : 5.60 than usual.
RBC : 3.79 as per dr. Wirajaya Sp.PD:
HGB : 11.7 - chest XR
HCT : 36.0 - check lab test (CBC, ESR, LFT, R
PLT : 157 anti-HCV)
Lymph:1.31 - Mucopect syr, 15 ml, TID
- Mix caps (Meptin mini, Vit
RBS:96.1 Hexilon 4 mg), BID
ESR: 26
CC on 20/06/11
Anti HCV :0.214 (non
reaktiv) already
informed by ibu sakura.

Chest XR:
- Aorta knob sclerotic
- Scoliosis thoracalis
- heart, lungs and soft
tissue of chest region
are normal
Aisaku Fujiyama / On 16/6/11 Osteoarthitis Dr. Wirajaya Vital Sign : Patient came to have consultation w
M / 74 yo / At 10.53 am of the right and BP : 100/60 mmHg internist. He have complaint swo
Japanese left ankle P : 82 bpm and pain on both of hand and bot
.. T : 36 C ankle since 1 week ago. stiffness bot
Rheumatoid SPO2 : 96% RA hand, dificult to walking due to pai
arthritis RR : 18x/mnt both ankle.
Patient had history head injury 1 m
Lab result on 16/6/11 : ago. headache (+).
CBC : As per dr. Wirajaya Sp.PD
WBC : 8.60 - check lab (CBC, BUN, SC,
RBC : 4.64 ASTO, RF)
HGB : 13.3 - XR ankle D et S AP/ lat: XR Ma
HCT : 42.1 D/ S
PLT : 266 - Head CT scan without contrast
LYMP : 1.01 - Mexpharm 15 mg tab, BID
- Hexillon 4 mg tab, BID
Blood Chemistry : - Feldene gel
BUN : 25.5
Creatinine : 1.1 CC on 20/06/11

Blood Immuno Serology NOTE:

Rheumatid Factor : Ptn will come on 17/06/11 mornin
negative check Uric Acid  already input on
ASTO : negative no need arrival and transfer to lab
per ibu Sakura she will check
UA: awaiting japan,and never mind for charge for
sample bill
 Head CT scan without
contrast:
No abnormality in the
brain parenchyme.
Mild brain atrophy
Exudate density in the
right and left maxillaries
sinuses, suggest sinusitis

XR ankle D et S:
- osteoarthitis of the right
and left ankle
- no evidence of fracture
nor bone destruction

XR Manus Hand D
et S:
- Rheumatoid arthritis of
right and left hand
- No evidence of fracture
nor bone destruction

Mrs Karin On 16/6/11 Obs Prof suastika Vital sign : Patient came brought referal lette
Weber/F/69 y.o/ at 9am Unexplained BP : 150/90 mmhg have consultation with Prof. Suas
germany Body weight P : 95 bpm Sp.PD. She complaint about b
Loss T : 36 C weight loss 12 kgs around one year
SPO2 : 99% other complaint voiced, normal bo
RR :18 x/mnt movement, good appetite, eat and d
enough and regular, no stress,
Lab result on October 21, coughing.
2011 As per Prof. Suastika Sp.PD
CBC: (internist)
WBC:5.01 - chest x-ray
HGB:10.5 - USG abdomen upper and lower
HCT:31.9 - no medication
PLT:252 - Observed body weight 3 month,
AST:21 no improvement suggest to perf
ALT:22 whole body scanning
gamma gt:38
alkaline
phospatase:104
tot bilirubin: 0.38
direct bil:0.15
BSN:92
BUN:9
SC:0.7
UL:amor urat
crystal (+)
FT3:2.31
FT4:0.86
TSHs:2.86

stool analysis: WNL

cytology
 ginecology:
satisfactory for
evaluation, atrophy
CEA: 0.8

Imaging Result :
Jan 20, 2011
endoscopy: mild
gastritis

chest x-ray result on

16/06/11:
Aorta Knob sclerotic
Heart,Lungs,Soft Tissue
and bones of chest region
are normal.

USG abdomen upper and

lower result on 16/06/11:
Simple cyst of right
Kidney
Thickening of gall Bladder
wall,suggest cholecystitis.
Others was nornal

Peter Wood/ M/ on 15/6/11 Pro Prof. Wibawa Vital sign : Ptn came on 14/6/11 at 11.00 as
65 y.o/ australian at 12.00 consultation BP : 130/90 mmhg about the endoscopy procedure,
and endoscopy P : 77bpm available in our hospital or not.
with GA T : 36,5C The ptn was diagnose with reflux ?
Hiatal hernia + RR :18x/mnt H pylori positif ? 6 -7 years ago.
reflux SPO2 : 92% had the endoscopy in his country.
esofagitis BS : 111 under medication : anti aci
.. Antral (omeprazole 40mg ?).
gastritis ECG kept on file Since few days ago he feels at nigh
mouth dry, smell acidity as his prev
Upper GI endoscopy result symtoms .
(june 15 2011) : - Called prof. Wibawa to make
- hiatal hernia + reflux appointment  already agree
esofagitis 13.00
- anthral type superficial - Already confirm with dr. W
gastritis (anesthesiologist), will come
15/6/11 at 12.00
- Already confirmed with Handay
Ig Anti Hpylori at Dewani - Eta FO already informed the pric
on 15/6/11 : equivocal, ptn agree
indeks : 0.82 (well notify to
Prof.Wib)
Patient came to have consultation
PA 1 sample at Sentra GI tract endoscopy with
Medika on 15/6/11 : Wibawa,SpPD,KGEH.
waiting result. Will finish He has been suffering from ga
around 17/6/11 in the reflux since 3-4 weeks ago. I
afternoon.Pls f/u!!! Then accompanied with uncomfort feelin
send via email his mouth. He has the same sympt
before (reflux esofagitis) and now w
to confirm the symptoms
endoscopy.

Advised prof Wibawa post endoscop

- nexium 40 mg tablet,OD (in
morning), own med  ptn di
take the medication due
expensive
- Regit (domperidon) tablet,BID
- need to have IgG anti H.pylor
DONE, pls inform Prof Wibaw
finish

On 17/6/11 at 1 pm,reported Ig G A
H Pylori,advised:
- Repeat Ig G Anti-H Pylori ne
week (29/7/11)
- continue prev th/

Note :
- Pls call Prof Wibawa and ptn ,e
to ptn if the Ig G anti H-pylori
For Ig G anti H pylory pls call
ASAP. Ptn will flight on Sunday
PM , 18/6/11 already inform to
by dr kris and send via emai
17/6/11 at 19.00
Nicole Samm / 42 On 14/6/11 Pro tubectomy Dr. Darmayasa, Vital sign : Patient came to see Obstetric
yo / F / Australian at 10.40 AM Sp. OG BP : 130/80 mmhg Gynecologist specialist. She wants t
P : 80 bpm tubectomie procedure (sterilize
contraseption indication)  as
No need Med request
Lab test on 14/6/11 Ptn came to saw dr Darmayasa advi
Faal hemostasis - planning tubectomy on Monday
BT : 1’30’’ june 2011 at 9 Am with GA
PT : 13.2 darmayasa reschedule on
INR : 1.06
june 2011 at 11.30 am,
APTT :28.9
inform to ptn when
tomorrow on 19/6/11
- Check FH  DONE
- pls arrange one day be
(Sunday) for all preperation
remind ptn and doctor
- Pls remind ptn to shave her p
area at home

Preparation of Tubectemy :
- Fasting 6 hrs
- Shave the pubic area
- Lab CBC last may can use
preparation tubectomyposs
 No need to check CBC again.
- Agreement form
- Co/ with Anasthesy
- Booking OK
- ECG and x-ray pls confirm
anasthesy

Note :
- Ptn will come on 20/6/11 at 8 AM
- Already inform price by Eta
- Ptn prefer room 205
Peter On 13/06/11 Susp. fracture Dr. Ana Vital sign: Patient came to hospital with c
Murphy/M/44yo/ At 10.00am vertebra BP: 120/80 mmHg complaint pain on left back area
AUS P:84bpm playing footbal 3 days ago and o
T:36 0C friend accidentally kicked with the k
SpO2: 97 % RA on back area. No head injury.
headache. No nausea nor vomi
X-Ray lumbosacral AP Normal urination and defecation.
lateral on 13/6/2011 unconsious state. No Numbness
No eviedence of vertebral back area
compression nor As per dr Ana :
spondylolisthesis - XR Lumbosacral Ap/lateral
Spondylosis lumbalis with USG Lower Abdomen
narrowing of - Nonflamin, caps, TID
intervertebral space 5 - Ponstelax, 500mg, tab, TID
lumbal -1 sacral spine - Voltaren cream, apply on back
twice daily.
 Lower abdominal USG on
13/6/11: CC on 17/6/11 by dr. Intan : nobody
Rigth and left kidney’s pick up the phone
Urrinary bladder prostate
are normal
No eviedence of free fluid NOTE :
in the abdominal cavity - Ptn charge EXC B just for D
because lack of money

Philip On 13/06/11 Pancreas Dr. Ana Vital sign: Patient came to hospital with c
Carral/M/60 yo At 08.00am Adenocarcino Dr Jaoweny Vital sign: complaint painfull on upper abdo
ma Lolo Sp PD BP: 140/80 mmHg since yesterday, and this morning
Observation 4 On 16/6/11 P:70bpm more worst. Patient said that yester
hours. 9.00 am- at 11.30am Erosive T:36 0C he had vomiting twice, nausea.
01.00 pm obsv for 2 Esophagitis SpO2: 97 % RA fever . Patient need to see internist.
hrs As per dr ana advised :
Gastric IVFD : - IVFD RL-- > 20 dpm
Submucosal RL flasing 400ml - Nexium 40mg in NS 100ml,
Varices RL + pethidine 100 statim
mg+torasic 3 amp(90 mg) - Vomceran 8mg, IV, Statim
20 dpm - observation

Th/: As per dr Jaowenny Lolo, Sp.PD :

- Vomceran 8 mg statim - IVFD RL + Torasic 90 mg, via
- Continue vomceran 4 Pethidine 100mg, vial --> 20dpm
mg TID - Nexium 40mg in NS 100ml, BID
- Nexium 40 mg in NS - Vomceran 4 mg, IV , TID
0.9 % - hospitalized --> sign refused form
 Called dr JWL on 13/6/11 at 12 am
Advised :
- Used durogesic path  the ptn o
get 2 pcs of duragesic patch
- Review on on 21/6/11 at 09.00 w
dr JWL. pls remind dr and patien
one day before
- On 22/6/11 until 1 july 2011 dr. J
go to America.

Ptn come on 16/6/11 at 10.45am with

complaint pain on his stomach, and
dr JWL:
- Obsv for 2 hrs untill 2pm
- IVFD: tridex 27B +Fentanyl 100m
+ Torasic 90mg drip 20dpm
- MST cont 30mg TID
- Torasic tab TID
- Nexium 20mg OD
- Review on 20 or 21/6/11 at 9-12 p
with Dr.JWL,pls Remind both be

Barry Malcolm On 13/06/11 Observation of Dr. Iin Vital sign: Patient is transferred from KMCA
Curnow/M/ 60yo/ At 5.45am chest pain BP: 120/73mmHg observation of chest pain suspec
Australian suspect ec Dr. Gunadi P: 55-70bpm miocard infark.
Acute T:36 0C He has got pain on his left chest
Coronary SpO2: 98% with 3lpm O2,
Syndrome NC
Lab result on June 13 2011:
RBS (in ER ) : 114 mg/dL
ECG on 13/6/11 at KMCA,
5 AM : at file
ECG on 13/6/11 at 5.30 M
stairs : at file
ECG on 13/6/11 at 8 AM :
at file
ECG on 13/6/11 at 13
PM :NSR
suddenly at 4 am today (june 13 20
The pain was like heavy thing comp
his chest. Not noticed referred pai
left arm nor jaw. No shortness of bre
No headache. No nausea. No vomiti
Patient had the same symptom m
years ago (he forgot how many y
ago) and had cardiologist consultati
He does not take any medicines
heart problem nor high blood pres
problem. No lungs problem before.
No diabetes mellitus.
He only takes nexium 40 mg tablet o
a day for his stomach.

CBC, When he arrived (at 5.30 am) in S

WBC: 13.03 Husadha Hospital Emerge
HGB : 13.6 Department, he feels better. No m
HCT: 41.0 chest pain. No shortness of breath.
PLT: 296 headache. No nausea.
Lymp: 1.10
RBS : 119,6 Past Medical History :
BUN: 11.4 Chest pain (many years ago)
SC: 0.7
SGOT: 25 Medication Currently used :
SGPT: 29 Nexium 40 mg tablet, OD
Total cholsterol: 203.04 At 9.30 AM dr Gunadhi see the ptn :
HDL cholesterol: 78 - Cancel Lovenox inj
LDL cholesterol:107 - Plavix (clopidogrel 75 mg) 4 tab
Triglyceride:125,05 at once  1 tablet/day
Natrium:132 - ascardia tablet 160 mg, OD
Kalium:3.9 - cedocard 10 mg tablet, TID
- valisanbe 5 mg tablet,TID
- Pls inform dr Gunadhi if
Triple cardiac marker, : cardiac result finish  done
WNL - Repeat check ECG if car
marker result finish done

Called dr. Gunadi on 13/6/11

informed the cardiac marker advised
- Ptn can be discharged
- No need sign refusal form
- Continue therapy
- Take cedocard 5 mg , 1 tab,
lingual, if feel chest pain again
as soon as posible to come hosp
- Review on Friday 17/6/11 at 9
pls remind ptn and dr one
before, ECG first  tried to rem
ptn, ptn cancel to have review w
dr Gunadi.

NOTE :
- Pls give Medical report and tr
cardiac marker result when
review on 17/6/11. All docum
 kept at file

Nobuhiro Kono/ 10/6/2011 at Observasi Dr. Intan BP: 130/90mmHg Patient came with chief complaint
M/ 48 YO/ Japan 9 AM Febris day 7t P : 82 bpm weak and feverish since 1 week.
Acute diarhea Dr. WJ T :36 C acompanied with sore throat, dia
non SpO2: - % RA after meal with watery consistency
dehidration times/day, no blood, no mu
Lab resulted on 10/6/11 : Headache, slight dizzy, no nausea
Typhoid fever CBC vomiting, no epigastric pain, urin
WBC :4.88 regular normal, no cough, no ru
RBC :4.97 nose, no shorthness of breath. Ha
HCT :44,3 alcohol compsumtion 1 small bottle
HGB :14.8 but since 2 days no compsumption
PLT :289 Past Medical History :
Lymph :1.04 Hypertension
Increased Liver function test
Serology : (-)
Ig M Anti Slmonella Thypi: Treatment so far :
(+) scale 5 antiinflamation and anti pi
(medicine from Japan)
Paratyphi A-H :pos 1/80
SGOT :18 Ptn came on 14/6/11 to saw dr
SGPT :22 adviced :
Gamma GT :102.2 - Myonal tab, TID
- Ultracet tab, TID

CC on 17/6/11 will CC by
 sakurafell better,still cont
physiotherapy.

Inuijo Chie / 32 on 7/6/11 Follow up Dr. Supri Vital sign : Patient came to have follow
yo / F / at 6 pm primer infertil BP : 110/70 mmHg consultation with Gynecologist. Sh
P : 74 bpm in menstruation/period now (started
Japanese
SpO2 : 97% RA june 5 2011).
T : 36 °C
RR : 18 x/mnt As per dr Supriatmaja,SpOG
(Gynecologist) :
- profertil tablet (clomiphene sit
BID
- asthin force tablet,OD

Review on june 14, 2011 at 6 pm.

Ptn came on 14/6/11 at 06.00 pm fo
dr. Supriatmaja Sp.OG, advised :
- Continue th/
- USG Transvaginal, RO : 1,7
LO : 1,8 cm
- Sexual intercourse on 16 – 22 Ju
- Review depend on ptn, if
menstruation need to perform
( Histerosalpingografi ) on days
11th after menstruation and
sexual intercouse on day 9th to 1
- Can not perform at SHH.
 NOTE :
HSG can be perform at Prima Me
Hospital, IDR. ± 500.000 or in Japan

Aydan Ali/M/1 On 4/6/11 at Observation of Dr. Siadi - Patient’s mother wants to h

yo/INA 7.30 pm conjuctivitis consultation with pediatrician. His
got red eyes but now it subsided.
Observation of also notices something unusual (m
lymphnode on his right auricle. It is not painful
enlargement on redness on the affected area.
right auricl She wants to know about her s
vaccination schedule
as per dr Siadi,SpA
(pediatrician) :
- Infantrix HIB on august 2011
arrange the time
- lymphnode enlargement monito
- gentamicin eye drop on both ey
drop, TID

Teichi ichiwara/ 1/6/11 Suspect Dr Laksmi KOH  Not Found  Patient came to have review
Japanese At 3 PM Candida Duarsa already informed to dr dermatologist. The lession better m
Interdigiti 3,4 Laksmi dry, still wet on his interdigiti 3
R/L foot 4(right and left foot). Dr. Lak
Kultur and sensitivity : advised :
will finish around 3 month - clanexi 500mg tab, TID (for 10da
(September),pls f/up - decubal cream apply on dry skin
- check Kultur jamur and KOH
 Ptn came on 14/6/11 to saw dr Lak
adviced:
- add med claneksi 500mg tab TID
10 days
- Review if needed
Delfosse Jacques / On 31/5/11 Hipertension Dr. Ana Vital Sign Patient come to check his b
M/ 74 YO/ Dutch at (in control) Dr. BOWO L BP: 130/70mmHg pressure. He has complaint someti
13.00 T : 36 °C feel pain on lower abdomen area
Obs hematuri P :70 x/min pain is on and off but not dis
SpO2: 99% on RA activity. No headache, no dizzy,
R R : 20 x/min nausea nor vomiting, no epigas
pain, no palpitation nor chest pain
PMH : SOB
Hypertension grade II
At 5 PM informed the lab result b
CBC on 31/5/11: Ana suggest to see urologist
WBC :6.85 prefer see Urologist ( dr Bowo L )
RBC : 4.62 On 1/6/11 at 11 AM, saw dr B
HGB :14.3 advised:
HCT : 43.2 - continue meds
PLT : 162 - suggested Urology USG (if
Random Glucose : 91 agree) ptn refuse
(normal) - Review on 1/7/2011 or in case,
Urinalisis : Blood 10(+1) and UL test before see Dr. Bowo
PSA : as chart arrange 1 day before)

Th/ :
 - Norvask 5mg, tab, OD
- harnal Ocas, tab , OD
- Olmetec 20mg , tab,
OD

Primitivo Costa On 30/5/11 Right Colic Dr. GWK Vital Sign Ptn come didn’t bring referal letter
Cava/M/67 YO/ at BP: 150/90mmHg he request to see Dr GWK, he c
Spain 16.30 Right Kidney T : 36 °C with complaint painfull on right fl
stone P :83 x/min already call dr GWK he will c
SpO2: 97% on O2 3 lpm tonigth
Right ureter R R : 20 x/min As per dr GWK Advised:
stone - IVFD Nacl 0,9 % with Pethidin
CBC on 30/5/11: mg + ketrobat 1 amp 30 dpm.
Mild WBC: 6.08 - BOF +USG Urology
hidronephrosis RBC:5.33 - Check lab CBC, BUN, SC, UL
of the right HGB:15.1 - Waiting dr GWK visite
kidney HCT:46.7
PLT:220 Dr. GWK visited at 8.30 pm, advised
BUN :16,6 - ceptik 200mg, PO, OD
SC:1,2 - ultracet tab, PO, TID, after meal
UL: - harnal ocas 1tab, OD
bacteria: positive - Review on 1/7/11. Pls arrange
blood+5) time 1 day before with dr.GWK
leu esterase: (+1) ptn.

BOF on 30/5/11:
No evidence of
 raduopaque shadow along
the urine tract projection

USG Urology on 30/5/11:

Mild hidronephosis of the
rigth kidney
Small stone of the inferior
calyx of the rigth kidney
Mild prostatic enlargement

Th/:
- ceptik 200mg, PO, OD
- ultracet tab, PO, TID,
after meal
- harnal ocas 1tab, OD

Nana Policlinic on Combustio on Dr Intan Vital sign : Patient came to hospital due to pain
Nagasima/30 27/5/11 Both calves BP :110/70mmhg both calves. Her calf exposured
yo/F/Japaness 09.30 AM P : 88bpm knalpot when she parking motorb
T : 36oC The accident around 1 hour ago.
Acut Diarhea SpO2 : 98% hyperestesia nor anestesia.
non RR : 18 x/min
dehidration Ptn came on 13/6/11 at 12.30 to h
Therapy: wound dressing on both legs with
- Amoxan 500 TID ana, advised :
- Mefinal TID PRN - wound dressing on left calf w
- Wound dressing with NaCl 0.9% then apply the nebac
Burnasin cream powder then cover with leukom
 T plus. Wound condition : little
Wound condition: wet, no sign of infection
Both calves : redness (+), - wound dressing on right calf w
slight wet (+), pain (+) to Nacl 0.9% then apply the nebac
pressure,no pus powder then cover with supras
A then cover with leukomed T p
Lab result on 1/06/11: Wound condition : still wet, no
CBC of infection
WBC:7.88
RBC:4.57 Review on 16/6/11 with GP, for wo
HGB dressing:
HCT:37.3 - Left leg: redness but dry alrea
PLT:3.39 clean with NS and put in nebac
Lymph: 1.18 powder, cover with leukomed
Plus
Electrolite - Right leg: redness and slight wet
Na: 135 the middle, clean with NS and
K:3.8 in nebacetin powder, cover w
Chl:106 leukomed T Plus
- Review on Monday 20/6/11
Stool:
mucus: positive
leu:3-5
ery:5-7 Note: Ptn still have nebacetin pow
carbohidrat: positive suprasorb A, cutisorb LA and burn
cream, kept on cupboard 205

Pls input IDR 70.000 for the wo

 dressing fee

Malcolm Leonald Thursday, Hepatitis C Dr. JWL Vital Sign Patient came to have consultation w
Fraser/ M/57yo / 28/4/11 at 10 BP :130/80 mmHg Internist.
New Zealander AM P :84 bpm As per dr.Jaowenny Lolo, SpPD
T : 36.2 °C - Pegassys 180, SC, once a week
NON KITAS SpO2 :96 % RA - Copegus (ribavirin) tab, 2-0-3
RR : 18 x/mnt - Imreg tab, BID
- Hp pro tab, BID
- Fludane tab, BID, if needed
- Need to have review and perf
PMH: some lab check with Internist
Hepatitis C infection Friday (Internist) (May 6th, 2011)
confirm to dr JWL what kind o
Lab resulted on 6/5/11 : check that ptn need
CBC - On 5/5/11 at 10 AM,Already rem
WBC : 4.89 ptn and dr.JWL
RBC : 4.82 - She available at 10-12 PM.
HGB :16.0 Malcolm will come at 9 AM
HCT:48.4 Check CBC, SGOT/SGPT
PLT :154
Lymph: 2.11 On 6/5/11 ptn’s came to
Dr.JWL,advised :
SGOT : 77 - Check for labs ; GOT, GPT, alkali
SGPT : 88 fosfatase, CBC
Alkaline phosphate :82.3 - Pegassys 180,SC, once a week
- Copegus tab, 2-0-3
Check lab on 6/6/11 - Imreg tab, BID
CBC : - HpPro tab, BID
WBC : 4.09 - Merlopam 2 mg tab, OD (if need
RBC :4.19, - Panadol tab, TID (if needed)
HGB :13.1, - Review 3 june 2011, pls remind b
HCT : 40.1, day before Called ptn to re
PLT : 138 him,but ptn can’t come tomo
AST/ALT : 39/30 because he busy, he wan
reschedule on Monday, 6/6/1
arrange!!!!

Ptn came at 9.10 am on 6/6/11 for sa

JWL adviced :
- Copegus tab decrease 2-0-2
- continue other therapy
- need to recheck lab CBC, AST,
(lab surya), HCV RNA kwanti
(lab dewani) on 22/7/11
- Next review on 22/7/11, pls rem
ptn to come early (check lab 1 st)
JWL available at 09.00-12.00
- Remind both 1day before

Ptn came at 10.50 am on 14/6/11 for

dr. JWL adviced :
- Pegassys 180, once a week
- Continue previous oral
medicines
 - Levocin 500 mg tab, OD (for
5 days)

Next review on 22/7/11, pls remind

to come early (check lab 1st). Dr.
available at 09.00-12.00

C/N : ptn’s 081337873958

Yoko Tomiyama/ On 30/3/11 Post DVT Dr. KBN ECG on 30/03/11 : at file Patient came to have consultation w
F/ 72 YO/ at 2 pm Pulmonary Cardiologist. She complained
Japanese embolism Echocardiografi result : shortness of breath after climbing sta
- LV Hipertrophy Past Medical History :
Atrial - LV diastolic Pulmonary embolism, DVT, and a
fibrillation dysfunction fibrillation history since January 201
- LV fs (S) normal Medication Currently used :
- Warfarin 4.5 mg tab, OD
INR: 1.89 - Digoxin 0.125 mg tab, OD
- Verapamil 80 mg tab, BID
INR on 20/4/11 : 2.33 - Bisoprolol 2.5 mg tab, OD
INR on 4/5/11 : 1.85 - Rabeprazole 10 mg tab, OD
ECG on 4/5/11 : on file
Treatment so far :
ECG on 8/6/11 : on file - Warfarin 4.5 mg tab, OD
INR on 8/6/11 : 2.26 - Digoxin 0.125 mg tab, OD
- Verapamil 80 mg tab, BID
- Bisoprolol 2.5 mg tab, OD
- Rabeprazole 10 mg tab, OD
 Ptn came on 8/6/11 at 12 pm for INR
and ECG and see dr.KBN
As per dr.KBN :
- Warfarin 6 mg, tab, OD
- Digoxin 0.125 mg, tab, OD
- Bisoprolol 2.5 mg, tab, OD
- OMZ caps, OD
- Review on Wednesday, 6/7
Check ECG and INR first.

Emilie Victoria on 8/06/10 Dermatitis dr. Laksmi Vaccination list:

Ferrara/ f/ 4 at 9.30am Atopic dr. Andhita Th/ dr. Andhita:
months/ French +
- On 3/7/10: Pediacel 0.5 ml, im
pneumococcus
- Prevenar the left thigh  done
vaccination
Vaccination
IM)
- on 6/8/10 at 10 am for Hep
Prevenar vaccination  done

- on 7/9/10 AM for Pedi

Therapy on 7/9/2110 at vaccination done
10.00 am
Pediacel Vaccination (SC - on 6/10/2010 at 10.00
dalam)left thigh prevenar (pneumunococus)
done
On 6/10/2010 at 10.00
Therapy from dr Anditha
- on 6/11/10 at 11.00 for vacina
Prevenar vacination campak done
(pnemunococus)
 on 6/11/10 at 11.00 for
- on 09/02/11 preve
vacination campak vaccination done

- on May 2011 (MMR)  done

on 09/02/11 prevenar
vaccination - on 16/5/2011 at 09.00 am M
(TRIMOVAX)  done

Ptn came on 16/5/11 at 8.30 am

- for TRIMOVAX vaccination by
andhita
- Next vaccination on august
(when emilia on 18 months old)
mother request to remind her be
10 august 2011 for 4th prevenar

NOTE:
MR on 16/5/11 ptn’s mother said
kept on ptn file
Metani On 15-18 HD Got information from ibu chikako
Yoshiyo/ F/ July 2011 will come to do HD on :
On 15-18 July 2011 at 8am
Japanese
Mr.Taniguchi On August HD Prof.Suwitra Got information from Ibu Sakura
takashi/M/65 29,31 and ptn will come to do HD on
September
yo/Japanesse
2,5 at 8 am 31/8/11 at 8 am
 2/9/11 at 8 am
5/9/11 at 8 am
7/9/11 at 8am
Mr.James Dr. harry On 2/6/11at 5 pm, Mr.James Secre
Russel called us (nina FO) to ask about
vaccine for 2 person, but unfortun
Crow/M/Austr
our pharmacy only have 1
alia pharmacy will order 2 more vacc
and not sure when the vaccine availa
Pls called ptn if flu vaccine ready
Pls f/up to pharmacy also f/u
15/6/11 need prescription!!!

Kathleen Policlinic on Obs enlarge Dr.Kris Vital Sign Patient came with chief complaint lu
Mitchinson/F/53 14/5/11 at 2 thyroid gland Dr.Yeni Sp.PD BP :120/80mmHg on her right neck. She noticed it s
yo/England pm T : 36 0 C around 4 days ago, not noticed whe
P : 80 bpm the lump is getting bigger or equa
SpO2 : 98% RA size. Now she felt a bit discomfort w
she swallow food, no breathing
Lab on 14/5/11: voice problem, no pain on the lu
FT 3  attached on file area, no fever, no palpitation,
sweating a lot, no tremors. She alre
CBC took some medicine but
WBC:5.65 improvement for the symptom.
HGB:12.4
RBC:4.26 Right neck : Lump (+) size +/- 4x5
PLT:296 rubbery consistency, smooth mar
HCT:37.1 mobile, no pain on palpation

AST:19 Dr. Kris advised:

ALT:19 - consult to internist  wa
Lipid profile: internist visit (dr. yenny)
Tot choles: 204,10
HDL : 82 as per dr yenny advised:
LDL : 117 - check lab CBC ,AST,ALT,L
Trigliserode : 92,41 profile,Tot choles,BUN,SC,
BUN:6,5 Acid,UL, RBS, albumin, TsHs, F
SC:0,7 Ft 3
Uric Acid:4,2 - USG gland thyroid
RBS : 78, 5 - No treatment for a moment
Albumin : 4,5 - Review After Lab Finished
TsHs :1,44 yenny request review on 18/5/11
FT4 : 0,978 yenny at 2.30 PM) pls inform
UL:WNL remind again to dr yenny 1
before.
Thyroid USG on 14/5/11 :
Result : Single cyst with
On 18/05/11 at 2 pm saw dr.Yenn
solid component inside on
per dr.Yenny :
the right thyroid suggest
- Co.to dr.Sudarsa Sp B,Onk
uninodular goiter. Istmus
- Already called dr.Sudars
and left thyroid are normaladvised :
Check FNAB Thyroid before see
FNAB on 19/5/2011: specialist refferal letter (to
Nodule Thyroid Dextra, Susraini) kept by ptn and ptn
FNAB: Colloid nodule go by her self to sentra diagno
 on 19/5/11 at 2 pm

Got called from Dr.Yeny on 19/5/11

am, informed that the patient alre
check FNAB and see Dr.Suda
directly see Prof.Suastika, without
Dr.yeny again, because she will g
jakarta

Call dr Sudarsa on 19/5/11 inf

FNAB result adviced :
- need to have review on Monda
may in his practice at Sanur.
Ptn can’t wait until Monday
Call again dr yeni, advised : need to
internist only(prof swastika).
arrange (pt request tomorrow
20/5/2011)Already confirmed
Dr.Tuti on 19/5/11 at 9 pm,ask
Dr.tuti pls call Prof.suastika in
morning

On 20/5/11 at 9 am ca
prof.Suastika,asking what time
available tonight,as per prof.
available at 6.30 pm already infrom
ptn
Try tto call dr.Sudarsa the ph
was’t active. Dr go to Malaysia u
Sunday, 22/5/11.

Ptn came on 20/5/11 to saw

Swastika adviced :
- no need medication
- suggest to consultation with n
surgeon
- no need review with internist

Pls arrange the time with dr Widiana

Onk called dr widiana many ti
MP active but no body pick up
phone, so send SMS to him not r
yet.
Already inform also to Mrs kathl
but pls pls call her if possible on Sun
(22/5/11) she still waiting fur
information from us
(actually Mrs kathleen just want
know how long she need hospital
for the treatment if tomorrow can
done the treatment ,she said
available stay longer in bali)

On 23/5/11 at 4 pm callled ptn 

already at flores ,will call us when
 in bali.

On 15/6/11 at 5 PM DOD received e

from ptn ask about consultation w
oncologi surgeon and operation in
same day , and how long for sta
hospital?  already confirmed to
Widiana, the dr need to see the ptn fi
Already reply the email by Dr Iin

Hand over by : AM, TW, MW at: 7.30 Am Acknowledged by : Dr.ANA

Received by : RK, ST, HN at : 7.30 Am

INPATIENT IV LINE
DATE OUTPATIENT DISCHARGED OK
OLD NEW NEW RESITE

18/6/11 M

18/6/11 A

18/6/11 N

Total
TO ALL NURSES :

If any patient with diet fasting , not allow to order food for ptn’s
witness/ family
but if ptn age 6 months or less without fasting , allow to order food for
their witness/ family

New form for ptn hemodialysis “ PERESAPAN HEMODIALISIS “ PLS

GIVE THIS FORM EVERY PTN GET HD

PLS READ “NURSE COMMUNICATION”, there is new Protap “

Penanganan Petugas Terkena Pajanan”
- Pls always input price for outpatient according to the hard copy of FO
price list kept at Jadwal Praktek Dokter Specialist dan Price List Harga
Executive
- Inform to nurses : start from Wednesday, 8/6/11 if any patient from
others unit bisnis SH or others hospital that will be in patient or out patient
in executive floor, so one of nurse and ambulance driver will pick the patient
up to the ptn place. If the executive nurses busy, pls ask doctor MOD to pick
the ptn up. The service is free of charge

- We have new form for “Pemantauan Pasien Tirah Baring” changed with
“Form Pemantauan Pasien yang Beresiko Terjadi Dekubitus “ Pls use the
new one

- Cara Pengoperasian safety box :

1. tekan tombol merah sampai terdengar suara beep
2. untuk menutup pintu saftey box: tekan nomor sesuai digit
yang
diinginkan, kemudian tekan huruf B (ex : 123B)
3. untuk membuka pintu safety box : tekan nomor sesuai digit
sebelumnya, kemudian tekan huruf A (ex : 123A)
- TOLONG SELALU INPUT FEE PEMERIKSAAAN
DOKTER UMUM UNTUK SETIAP PASIEN RAWAT
INAP DAN DOKTER SPESIALIS, PLS BE AWARE!!
- Setiap ada pasien operasi,mohon check list persiapan operasi
difotocopy.
- Di ruang spool hok ,ada 3 macam tempat sampah,1 untuk sharp container,1
untuk sampah medis ,1 untuk flacon
- new ext. For FO: 262, OPS. Yudi +Lala: 272, Bli Wy. Sudi: 579
- if any out patient pls input BHP handscone 4 pcs, and if GA (CS)
use mask pls input also into BHP for PINOK
- Stock for medical stuff in # 201 already match with the STOCK
OPNAME and STOCK in system.
- IBU arjaya’S FAMILY ALLOWED FOR
HOSPITALIZED AT EXC
- every change the IVFD pls write down on the
bottle : start time and finish time of IV fluid and
also write down how many drops/min
- If input Sterile Gauze Pack, pls input “Kasa : 10” also on BHP!!!
- We have Formulir Pemeriksaan Patologi Anatomi kept on blue File
(only at sentra medica)
- As per Ibu chika ,if any ptn japanese order menu japanese can order
from dapur umum available for now Bubur Jepang and Chiken
soup Jepang, waiting others menu

- As per dr Donny start on 13/4/11 pls stand by humidier, sterile water

and nasal canul in every room if any new inpatient

- NEW IKU : “Pemeriksaan pre op untuk operasi elektif di ruangan

oleh tim” , jadi setiap ada operasi elektif, cek list pra operasi
dilengkapi kemudian di copy

- New IKU: start form April, 6th 2011: “ waktu tunggu out patient ≠>
10 menit” then make documentation on “Out Patient Registration
 Book”, but if.....time patient is longer than it pls make a
documantation on “Buku Pantau Out patient” (small yellow
book) to give the reason.

- Setiap ada tindakan baik rawat jalan atau rawat inap tolong
masukkan paket BHP
- Tlg input accucheck lancet (1 ) and accucheck stick (1 ) di BHP
tidak d tagihkan di poli executive untuk setiap in patient, dan di
input setiap shift. Untuk outpatient di input per pasien. BHP juga
masuk ke poli executive tidak ditagihkan.
Tetapi kalau :
Accu check stick di stock sistem komputer sudah mencapai 51
DONE
Accu check lancet sudah mencapai 66
Tlg jangan di input lagi !!!

- Tlg order Leukomed T plus yg kecil 7,2 x 5 cm ( 1), kl ada out patient atau
 in patient yg rawat luka dan di cover INS
- Kl ada pemakaian disposible atau obat di 201, dan stock di farmasi tidak
ada boleh di keluarkan melalui BHP boleh dari poli atau rawat inap, tapi
kl mengurangi BHP baik di poli executive atau rawat inap jika di stock
sudah minus jangan di masukkan pindah ke section poli atau rawat
inap.cari yang masih ada stock.Untuk paket BHP ( misal :paket pasang
infus, paket memandikan , paket lavement, bisa di lihat di paket BHP),
tidak bisa pindah section

- if any executive B patient (Tourist) with payment cover by insurance (not

local insurance), pls input all the bill in executive A  for in patient and
out patient  as Bpk. Raja information  FO will arrival patient into Exc.
A/B, so it’s still outomatic system.

- Mulai sekarang , bila akan menyeteril alat harap membawa buku

ekspedisi sterilisasi. Buku di simpan oleh setiap ruangan masing-masing.
Tidak di tinggal di ruang steril lagi. BTK
- IF any colonoscopy/Endoscopy procedure : Pls, pls, pls, always
confirm one day before to doctor who handle the colonoscopy, to make
sure the doctor available on that time  start from today, 28/3/11

- Disampaikan kepada seluruh perawat, point jaga P1/2S atau MD/S adalah 2,
point P/S : 3

- kalo ada pemakaian produk Rocer (Otto omeprazole), u/ vial atau box nya
dikumpulkan, 1 vial atau 1 box Rp 3000

- pls always check the vital sign every time you handle the in or out ptn,
especially ptn with insurance

- Pls input BHP when using our medical stuff

- Pls input at our PINOK system on “tirah baring” column, ptn have high risk
with decubitus and age > 75 yo otherwise ptn don’t have mobilization disorder.

- Japanese staff in charge on Saturday is Chikako San, and on Sunday is Sakura

San
- Pls input to the system dr name for exc ptn if there are MCU ptn especialy
when echo...so admin can’t prepare doctor fee. Pls always input doctor name
for MCU ptn, message from admin!

- The remain of meds (injection) keep at room 201 (lower cupboard)

- We have vegetarian menu, so if any ptn need to order, pls offering the menu
from “TASTY VEGAN”

- To night shift nurse on duty: Pls also clean & keep tidy the room 201 & nurse
station, and if it done, pls tick on daily check list. Thanks for your cooperation.
And pls do not only tick on the list, pls check according to the list.

- To NOD : if any patient need to have consult with the specialist, pls inform the
specialist doctor , don’t miss it

- dr. netty juga menginformasikan, kalau ada dr. specialist yang minta harga procedur sendiri
sedangkan rumah sakit sdh punya tarif, tolong disampaikan ke specialistnya bahwa tarif RS yg
dipakai. : kalo specialist ngotot, silahkan langsung ke manajemen
- If any patient used panso inj,Socef,Soclaf ,Sopime ,Sodime ,Sopirom ,Pls don’t
throw the box,pls collect it and pls report to kadek rus

- Bu Mang Suryani pinjam buku laporan jaga 2 buah

- Pls pls pls!!!!!!! Write down in the Laundry lyst if you put on the dirty linen on
black plastic bag..................., put the white & yellow one, pls put it orderly and
tie it well!!!

- IF ANY PTN WITH IKS STATUS THEN THEY COME TO EXC FOR
TREATMENT WITH SPECIALIST, PLS INFORM TO THE DR ABOUT
THE STATUS. IF POSSIBLE , PLS ASSIST THEM TO POLI UMUM, NOT
TREAT AT EXC

- IF ANY INDONESIAN PTN, PLS ASK THEM TO FILL “KUISONER

PELAYANAN KEPERAWATAN” BEFORE THEY DISCHARGE KEEP AT
DRAWER NURSE STATION IN BLUE MAP.

- Pls always remember!!!For, ptn with insurance case, Do not input food and
beverage into ptn’s bill !!
- We have some paper for vaccine:

- Screening questionair Immunization for adult  this is must be fill by adult

ptn and kept at file after vaccine

- Acceptor Vaccine data  fill by dr and kept at file after vaccineCertificate of

vaccination  fill by dr and bring by ptn after vaccine

- Recommended adult Immunization Schedule guidance for dr before give

vaccine

- Pls prepare it all if any ptn want to vaccine.All of paper kept at blue book on
nurse drawer.

- untuk semua perawat kalau input Fee dr umum (for In Patient and OUT
Patient) tolong disesuaikan dan dipastikan dengan dokter yang memeriksa
pasien tersebut.

- Pls. Remember to give “ kwitansi pemakaian obat” to all Indonesian ptn

- Setiap pasien rawat inap tolong di masukkan alkohol glyserin ke paket BHP
(ditagihkan) di taruh di setiap ruangan pasien

- Setiap mengisi neraca cairan selalu tulis tanggal dan inisial perawat yg
mengganti infus

- Untuk semua perawat, tolong dihafalkan Visi, Misi RS dan corporate value SH,
akan diaudit oleh Bli Nyabuh

- We have new form “Tukar Jadwal/tugas and permohonan cuti besar/bersalin“

Pls use it.

- We have dietary recommendation, pls read it before you advised

ptn about their diet

- Pls, pls,pls remember to return the disposible handschoen to # 201 after

you use it, because now we lost it 350pcs of it (3,5 boxes), so we suffer a
financial lost because of it . RUGI
- Pls remind if any Neurosurgeon will do Operate for fr. On Lumbal, need
to consulted to Orthopedic or not????

- If any injection by nurse (for out patient) without see the doctor, pls input “nurse
injection” not “Biaya lain-lain” again. Nurse injection ext A Rp 150.000, nurse
injection ext B Rp 100.000

- As dr. Laksmi Duarsa request ;

For executive ptn pls make the appointment’s schedule as follow :
Tuesday and Friday morning (practice time) at 10 am -10.30 am
Afternoon time as dr. Practice time at 7 pm – 7.30 pm
Out of practice schedule pls make confirmation first with the doctor re the
time

- if any ‘In-Patient’ moved to lower class pls don’t close the bill just write
the date when pt move on check lyst.
- Dr. Yeny menyarankan bahwa untuk cek SI, TIBC ke Sanglah  hasil 1 hr
selesai

- If any ptn want to do mantoux test,it can be do it by dr.Siadi sp,A and the
fee :
 For the mantoux test for EXC B Rp.68.000 (harga umum) x 2 = Rp.
136.000
 For EXC A , Rp.68.000 (harga umum) x 4 = Rp. 242.000
 Fee dr.Sp sesuai dgn consul (exc A and exc B)
 Paket BHP will input by nurse at poly like syringe,swab,and med.Rp
40.000 for ptn ecx A and exc B
 Admin RSU Rp 50.000

- PLS closed the tap in portable Oxygen& manometer flow after we use it.

- If any foreign ptn who need baby sitter, can be hired at “yayasan Kasih keluarga” (c/n:
264190), this is the list price:
o 1st administration 100.000—(for foreign), 50.000 (for local)
o Charge Fee @ day: 150.000/24 hr (for foreign), 80.000 (for local): 100.000/12 hr
o Transport: 40.000/day (for foreign), 20.000/ day (local)
- Info from Nina FO: if any out ptn with insurance case, pls put all the receipt (i.e medication, lab
and radiology) on the back pocket of the file.

- Pls do not input echocardiography by us, it will be input by Echo staff.

- Ada “DAFTAR HARGA MAKANAN PASIEN” yang terbaru..Bisa buat pasien atau
penunggu pasien. Jika pasien order sekali makan lebih dari Rp 75.000, akan
dicharge oleh pramusaji lebihnya sesuai dengan harga makanan yang diorder

- F = C x 1,8 + 32
- Dear nurses : pls remember to give the ptn “ Kuisioner Pelayanan Keperawatan”
when the ptn will be discharged (khusus ptn Indonesia)

- If you do blood sugar test with accucheck pls make sure that the skin already dry
after swabbed with alcohol⟶ influence the result

- If you checked the room every night shift, pls check according to the list and make
it tidy, pls…
 - *If any patients get “medicine powder or mixed capsule”, pls ask
pharmacy staff to make estimation 1st before packing to prevent medicine RETUR
(IT CAN’T BE RETURNED)

- If any pt referred for ESWL pls prepare med. action agreement, confidential
MR, doctor’s instruction form...

- As ibu Chikako if we have new Japanese old “out patient” with susp. Muscle sprain
pls tell GP to suggest them to see Physiotherapist.
- Pls always notify to lab PA (sentra diagnostic and PA Mulyadi) to write down the
result in English version if the ptn is foreigner ⟶ just write down “ASING” to the
referral letter.
- Informed by dr Dewi (Clinical pathology lab Surya) if any ptn with susp. Rubella
free for check Rubella in SHH from Din Kes with the symptoms (rash and itchy on
skin) after 4th days.
- To convert mmol/l of glucose to mg/dl, multiply by 18.
- To convert mg/dl of glucose to mmol/l, divide by 18 or mmol