GOVERNMENT OF MALUKU PROVINCE

REGIONAL PUBLIC HOSPITAL OF TULEHU

Jl. Pahlawan No. 36 Tulehu. Phone (0911) 3869260

RESUME PATIENTS
No : /RSUDT/ /2017

I am who sign below :

Name : dr. Mercy Soplanit
Posisiton : General Practitioner
Unit of Work : RSUD Tulehu

Explain that examination from dr. Kevin J. F. Noya on the patient :

Name : Tn. Muhittin Sark
Age : 44 years old
Occupation : Mechanical Tech
Address : PT. Kar Powership Indonesia site Waai Village, District of Maluku Tengah

On November 24, 2017 at 12:20 the patient was admitted to the emergency room at Tulehu Hospital
due to an accident while working in the workplace, Patient in :
- Full awareness
- Looks torn wound on the left upper lip area
- Swollen on the right wrist

Finding in the patient :

a. History
Patients present with a wounded complaint on the left upper lip from a fall in the workplace
approximately 30 minutes ago. Complaints accompanied by swelling on the right wrist. Fever (-),
decreased consciousness (-), vomiting (-).
b. Physical examination
BP : 120/70 mmhg
HR : 92x / m
RR : 17x / m
Temp : 36.5C
Head : Torn wound on the left upper lip
Chest : Normal
Abdomen : Normal
Extremities : Swollen on right wrist, crepitation
 c. Result of Laboratory, Rontgent and Important Consultations :
Head Rontgen : Normal
Right hand rontgen : Normal

Therapy was given:

Treat injuries
Home medicine:
a. Cefadroxil tab 500 mg 2x1
b. As mefenamat tab 500 mg 3x1
c. Dexamethasone tab 0.5 mg 2x1
d. Proza tab 1x1

Diagnosis of the patient:

Vulnus laceratum Regio labium oris superior
Multiple vulnus excoriatum
Wrist pain ec traumatic

Thus this letter was made to be used properly.

Tulehu, November 27, 2017

The doctor

dr. Mercy Soplanit

Nip : 198808152014032004