Travelling Hd Versi Phc Indonesia Inggris

: Kala Sub(eida2 @rs

Nama  +ame

TRAVELLING DIALYSIS

: '$ years

Umur : CKD STG V on Reguler Haemodialysis Haemodia lysis

Diagnosa Utama

 %ge

 Primary Diagnosis

: @ale

/enis 'elamin

:

Diagnosa Sekunder

, P  - os%ital S u r a * a y a . Secondary Diagnosis -ndonesia= Riwayat Penyakit : Hypertension +(one 9 3! 3%'$0!2 &a?= 9 3! 3%'$0'  History

Tanggal Awal D  Date of Beginning Dialysis Dialysis : 30 November 0!0

Se,

: 3$"40'

Nomer Register  -eg. +umber 

Alamat : Su,un !31 Kamal Tanggal Terak!i Terak!irr D  %ddress   @adura

 Date of Last Dialysis Dialysis :  : !0 Desember 0!

PRESENT TREAT"ENT Tekanan Dara!  Blood Pressure Pressure

Sistole : !"0 # !$0 Diastole : %0 # !0

: &ive days

#rekwensi D  Dialysis Frequency Frequency

: 00 Rpm

$%timal &lood #low  Mean/ Optimal blood flow flow

: Hospital

Tem%at Tem%at dilakukan dil akukan D  Place of Dialysis Dialysis

: ' # " (ours

Lamanya D  Duration per Dialysis

: )i*arbonat

'om%osisi Dialisat omposition of Dialysate

: Negative

Sero "arker e%atitis  Hepatitis sero sero mar!er 

: &$ H+S &resenius

Ti%e Diali(er "ype of used Dialy#er 

Riwayat Trans)usi Dara!

: None

 History of Blood "ransfusion "ransfusion

: Cimino

Akses Vaskuler $ascular access

: None

Alergi  %llergies  %llergies

: "$ ,g

&erat &adan 'ering  Dry weig&ts

: minimal

e%arinisasi  Heparini#ation

:  # 3 ,g

'enaikan && Intradialisis 'eig&ts 'eig&ts gain (ntradialysis

'om%likasi Selama D -ntradialysis complications

: Heada*(e

Diet

.o/ Salt

'eterangan Lain  Furt&er omment

:

$*at yang dikonsumsi saat ini +  Present Medication

 Diet :

$*at durante D

: Re*ormon "000 u

 Peridialysis Medication

ASIL PE"ERI'SAAN LA&$RAT$RIU" LA&$RAT$RIU"

TANGGAL  D%") *

 LABORATORY  LABORATORY RESULT 

)N1 rea Creatinin

: %23% : !"23

)lood Sugar &e

: !! :

Hb

: $2$ g1dl

&erritin

:

 Na

: !342!

Trans5errin Trans5errin saturation

:

K

: '2%3

6lbumin

7

HC839

:

+TH

:

Ca

:

H)s 6g

: Negati5

+8'

:

6nti HCV

: Negati5

 +(  +(ospor

:

6nti H-V

: Negati5

     

Surabaya2 !0 Desember 0! Renal +(ysi*ian

 dr C(andra -r/anadi Sp+D#KGH;

+HC General Hospital Surabaya; -ndonesia= +(one 9 3! 3%'$0!2 &a?= 9 3! 3%'$0'

 N6@A

:

@r1@rs

6GA

:

years old

SAB

: @ale1 &emale

RAG= N@)AR

:

Re*ent 6ddress

:

TRAVELLING DIALYSIS +rimary Diagnosis

:

Se*ondary Diagnosis

:

History

:

Date o5 )eginning Dialysis :

Date o5 .ast Dialysis :

PRESENT TREAT"ENT

Re*ent )lood +ressure

Sistole : Diastole :

mmHg mmHg

Dialysis &reuen*y

:

?1 /ee,

@ean1 8ptimal blood 5lo/

:

Rpm

+la*e o5 Dialysis

: Center1Home trained

Duration per Dialysis

:

Composition o5 Dialysate

:

Hepatitis sero mar,er

: Negative1+ositive

Type o5 used Dialyer

:

History o5 )lood Trans5usion

: Ees1 Never  

Vas*ular a**ess

:

6llergies

:

Dry /eig(ts

:

Kg

Feig(ts gain -ntradialysis

:

Kg

.e5t1 Rig(t Heparin1 .@FH

:

unit1(our

: :

-ntradialysis *ompli*ations +eridialysis @edi*ation Diet :

+

Further Comment

LAST LA&$RAT$RY RESULT

+resent @edi*ation

:

DATE +

 

:

&UN0 Urea

:

)lood Sugar

Creatinin

:

&e

:

* le1el

:

&e binding *apa*ity

:

 Na

:

Trans5errin saturation

:

K

:

&erritin

:

HC839

:

+TH

:

Ca

:

H)s 6g

:

+8'

:

6nti HCV

:

6norgani* +(ospor

:

6nti H-V

:

6lbumin

:

n+CR

6.T

:

RR

6ST

:

Kt1V

:

   

: :

Surabaya2 == 0= Renal +(ysi*ian:

C(andra -r/anadi2 dr2 Sp+D#KGH

Nama

: Ny= mi Ru/ai*(a

 +ame

TRAVELLING DIALYSIS Diagnosa Utama

: CKD STG V

 Primary Diagnosis

Hipertensi Diagnosa Sekunder , P  - os%ital: S u ra * ay a . Secondary Diagnosis -ndonesia= +(one 9 3! 3%'$0!2 &a?= 9 3! 3%'$0' : Hipertensi Riwayat Penyakit  History

Umur

:'4 t(

 %ge

/enis 'elamin

: &emale

Se,

Nomer Register

: %!0$

 -eg. +umber 

Alamat  %ddress

:
Tanggal Awal D

Tanggal Terak!ir D

 Date of Beginning Dialysis :

!#!! 0!

 Date of Last Dialysis : 30#!!#0!

PRESENT TREAT"ENT

Sistole : !'0 # !%0 Diastole : 40 # !00

Tekanan Dara!  Blood Pressure

: ?1minggu

#rekwensi D  Dialysis Frequency

: 00 Rpm

$%timal &lood #low  Mean/ Optimal blood flow

: Ruma( sa,it

Tem%at dilakukan D  Place of Dialysis

: ' # '2" am

Lamanya D  Duration per Dialysis

: )i*arbonat

'om%osisi Dialisat omposition of Dialysate

: Negative

Sero "arker e%atitis  Hepatitis sero mar!er 

: &4 H+S &resenius

Ti%e Diali(er "ype of used Dialy#er 

Riwayat Trans)usi Dara!

: None

 History of Blood "ransfusion

: T(ree .ument

Akses Vaskuler $ascular access

: None

Alergi  %llergies

: )elum bisa timbang

&erat &adan 'ering  Dry weig&ts

: Normal

e%arinisasi  Heparini#ation

: #

'enaikan && Intradialisis 'eig&ts gain (ntradialysis

'om%likasi Selama D -ntradialysis complications

: Hipertensi

Diet

.o/ Salt

'eterangan Lain  Furt&er omment

:

$*at yang dikonsumsi saat ini +  Present Medication

 Diet :

$*at durante D

: So(obion "000 in

 Peridialysis Medication

ASIL PE"ERI'SAAN LA&$RAT$RIU"

TANGGAL  D%") *

 LABORATORY RESULT 

)N1 rea Creatinin

"%24  pre HD 301!!10! ; $20!  pre HD 301!!10! ;

)lood Sugar &e

: :

Hb

%2$

&erritin

:

 Na

!332  41!!10!;

Trans5errin saturation

:

K

'2'!

6lbumin

:

HC839

+TH

:

Ca

H)s 6g

: Negati5

 41!!10!;

 41!!10!;

+8'

:

6nti HCV

: Negati5

 +(ospor

:

6nti H-V

: Negati5

     

Surabaya2 ! Desember 0! Renal +(ysi*ian

 dr= C(andra -r/anadi Sp+D# KGH;