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FOLLOW UP PASIEN KESEHATAN ANAK RUMAH SAKIT UMUM DAERAH LUBUK PAKAM TGL :22/5/2013 rabu TGL :23/5/2013 kamis S :demam (+) 3 hari,sesak nafas (+),kaki pegal2,Bab 2 hari (-), S : Demam (-),sesak nafas (+),sakit perut,pusing lemas 0 : RH :128x/s HR :58x/s Temp :38.6 C BB : 10 kg O : RH :132x/s HR :60x/s Temp :37.3C BB :10 kg A : Anemia ect…. A : Anemia + thypoid fever P : O2 1-2 liter Pct syr 4x 1 cth Ringer laktat 25 gtt/s Transpusi 75cc P : O2 1-2 liter Pct 4x 1cth Ringer laktat 25 gtt/s Ceftriaxone 500mg/H

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Page 1: Soap

FOLLOW UP PASIEN KESEHATAN ANAK RUMAH SAKIT UMUM DAERAH LUBUK PAKAM

TGL :22/5/2013rabu

TGL :23/5/2013kamis

S :demam (+) 3 hari,sesak nafas (+),kaki pegal2,Bab 2 hari (-),

S :Demam (-),sesak nafas (+),sakit perut,pusing lemas

0 :RH :128x/sHR :58x/sTemp :38.6 CBB : 10 kg

O :RH :132x/sHR :60x/sTemp :37.3CBB :10 kg

A :Anemia ect….

A :Anemia + thypoid fever

P :O2 1-2 literPct syr 4x 1 cthRinger laktat 25 gtt/sTranspusi 75cc

P :O2 1-2 literPct 4x 1cthRinger laktat 25 gtt/sCeftriaxone 500mg/HApialys 1 x1

Page 2: Soap

FOLLOW UP PASIEN KESEHATAN ANAK RUMAH SAKIT UMUM DAERAH LUBUK PAKAM

TGL :24/5/2013 jumat

TGL :25/5/13 sabtu

S :: Demam (-),sesak nafas (+),sakit perut,perut kembung.

S :Demam (-),sesak nafas (-),sakit perut,perut kembung.

0 :RH :110x/sHR :48x/sTemp :38.3 CBB : 10 kg

O :RH :74x/sHR :32x/sTemp :36,7 CBB : 10 kg

A :

malaria

A :

malaria

P :O2 1-2 literPct 4x 1cthInf.2:1 25 gtt/sCeftriaxone 500mg/HApialys 1 x1Farmakuin 1 x ½ tabTranspusi 60 cc

P :O2 1-2 literPct 4x 1cthInf.2:1 25 gtt/sCeftriaxone 500mg/HApialys 1 x1Farmakuin 1 x ½ tab

Page 3: Soap

FOLLOW UP PASIEN KESEHATAN ANAK RUMAH SAKIT UMUM DAERAH LUBUK PAKAM

TGL :26/5/2013 minggu

TGL :

S :demam(+) S :

0 :

RH :120x/sHR :60x/sTemp :40 CBB :10 kg

O :

A :

malaria

A :

P :

Rujuk RS. Adam malik medan

P :