This document contains the medical records of a child patient over several days at Lubuk Pakam Public Hospital. On the first day, the child presented with fever for 3 days, shortness of breath, leg pain, and no bowel movements for 2 days. Over subsequent days, the child's symptoms improved but fevers and abdominal pain persisted. The child was diagnosed with anemia initially and later with thyphoid fever and malaria. Treatment included oxygen, intravenous fluids and antibiotics. On the last day of records, the child was referred to Adam Malik Hospital in Medan due to continued high fever.

1. 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,sesaknafas
(+),kaki pegal2,Bab 2 hari (-),
S :
Demam (-),sesaknafas
(+),sakitperut,pusinglemas
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
Pctsyr 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
Apialys 1 x1

2. FOLLOW UP PASIEN KESEHATAN ANAK RUMAH
SAKIT UMUM DAERAH LUBUK PAKAM
TGL :
24/5/2013 jumat
TGL :
25/5/13 sabtu
S :
:Demam (-),sesaknafas
(+),sakitperut,perutkembung.
S :
Demam (-),sesaknafas (-
),sakitperut,perutkembung.
0 :
RH :110x/s
HR :48x/s
Temp :38.3 C
BB : 10 kg
O :
RH :74x/s
HR :32x/s
Temp :36,7 C
BB : 10 kg
A :
malaria
A :
malaria
P :
O2 1-2 liter
Pct 4x 1cth
Inf.2:1 25 gtt/s
Ceftriaxone 500mg/H
Apialys 1 x1
Farmakuin 1 x ½ tab
Transpusi 60 cc
P :
O2 1-2 liter
Pct 4x 1cth
Inf.2:1 25 gtt/s
Ceftriaxone 500mg/H
Apialys 1 x1
Farmakuin 1 x ½ tab

3. FOLLOW UP PASIEN KESEHATAN ANAK RUMAH
SAKIT UMUM DAERAH LUBUK PAKAM
TGL :
26/5/2013 minggu
TGL :
S :demam(+) S :
0 :
RH :120x/s
HR :60x/s
Temp :40 C
BB :10 kg
O :
A :
malaria
A :
P :
Rujuk RS. Adam malikmedan
P :