Progress note

Hari/Tanggal Subjektif Objektif Assessment Plan Dx Rx Mx Ex

Minggu 20/2/2011

Muntah -

TD: 140/90 mmHg N: 84x/menit RR: 24x/menit t: 37oC PF (06.30) Konj. palpebra pucat (+/+) edema palpebra (+/+) RBH basal paru (-/-) Edema extremitas inferior (-/-) GDP 187 mg/dL GD2JPP 291mg/dL PU : 1500cc

CKD stage V

Hipertensi stage II DM tipe II

Diet bubur kasar VS TKRPRG 1900kcal + BC 52 g protein IVFD Martos : PZ = 1 : 1 14tpm Humulin R 4Unit 4Unit 4Unit s.c 15' sebelum makan Ondancetron 1 amp/ 12 jam i.v Lisinopril 10mg 0-1-0 p.o Valsartan 8mg 1-0-0 p.o Asam folat 3 x 400 mg tab VS BC

Tampung urin Batasi minum Diet rendah garam Motivasi HD

Senin 21/2/2011

Rujuk pro HD

TV (06.30) TD: 170/100 mmHg N: 92x/menit RR: 24x/menit t: 36,5oC GDS 316 mg/dL

CKD stage V Hipertensi stage II DM tipe II

Batasi minum Diet Kepatuhan obat