Nama : Kala Subheida, Mrs

Name
TRAVELLING DIALYSIS
Diagnosa Utama Umur
: CKD STG V on Reguler Haemodialysis : 48 years
Age
Primary Diagnosis
Jenis Kelamin : Male
Diagnosa Sekunder :
( P H C Hospital S u r a b a y a ) Sex
Secondary Diagnosis
Jl. Prapat kurung Selatan No.1 Surabaya Indonesia. Nomer Register : 385704
Riwayat Penyakit : Hypertension
Phone +62 31 3294801, Fax. +62 31 3294804 Reg. Number
History
Alamat : Sukun 13/2 Kamal
Tanggal Awal HD Tanggal
Address
Terakhir HD
Date of Beginning Dialysis : 30 November 2010
Madura
Date of Last Dialysis : 10 Desember 2012
PRESENT
TREATMENT
Tekanan Darah Sistole : 150 - 180 Frekwensi HD : Five days
Blood Pressure Diastole : 90 - 120 Dialysis Frequency
Optimal Blood Flow : 200 Rpm
Mean/ Optimal blood flow
Tempat dilakukan HD : Hospital Lamanya HD : 4 - 5 hours
Place of Dialysis Duration per Dialysis
Komposisi Dialisat : Bicarbonat Sero Marker Hepatitis : Negative
Composition of Dialysate Hepatitis sero marker
Tipe Dializer : F8 HPS Fresenius Riwayat Transfusi Darah : None
Type of used Dialyzer History of Blood Transfusion
Akses Vaskuler : Cimino Alergi : None
Vascular access Allergies
Berat Badan Kering : 58 kg
Dry weights
Heparinisasi : minimal Kenaikan BB Intradialisis : 2 - 3 kg
Heparinization Weights gain Intradialysis
Komplikasi Selama HD : Headache Keterangan Lain
Intradialysis complications Further Comment :

Diet Low Salt Obat yang dikonsumsi saat ini :

Diet : Present Medication
Obat durante HD
Peridialysis Medication : Recormon 5000 u

HASIL PEMERIKSAAN LABORATORIUM TANGGAL

LABORATORY RESULT DATE :
BUN/ Urea : 92,39 Blood Sugar : 121
Creatinin : 15,63 Fe :
Hb : 8,8 g/dl Ferritin :
Na : 137,1 Transferrin saturation :

K : 4,93 Albumin
HCO3+ : PTH :
Ca : HBs Ag : Negatif
PO4 : Anti HCV : Negatif
Phospor : Anti HIV : Negatif

Surabaya, 10 Desember 2012

Renal Physician

( dr Chandra Irwanadi SpPD-KGH)

NAME : Mr/Mrs
AGE : years old

(PHC General Hospital Surabaya) SEX : Male/ Female

Jl. Prapat kurung Selatan No.1 Surabaya Indonesia.
REG. NUMBER :
Phone +62 31 3294801, Fax. +62 31 3294804
Recent Address :
 TRAVELLING DIALYSIS
Primary Diagnosis :

Secondary Diagnosis :

History :

Date of Beginning Dialysis : Date of Last Dialysis :

PRESENT
TREATMENT
Recent Blood Pressure Sistole : mmHg Dialysis Frequency : x/ week
Diastole : mmHg Mean/ Optimal blood flow : Rpm
Place of Dialysis : Center/Home trained Duration per Dialysis :
Composition of Dialysate : Hepatitis sero marker : Negative/Positive
Type of used Dialyzer : History of Blood Transfusion : Yes/ Never
Vascular access : Allergies :
Left/ Right Dry weights : Kg
Heparin/ LMWH : unit/hour Weights gain Intradialysis : Kg
:
Intradialysis complications :
Peridialysis Medication

Diet :

Present Medication :
Further Comment :

LAST LABORATORY RESULT DATE :

BUN/ Urea : Blood Sugar :

Creatinin : Fe :

Hb level : Fe binding capacity :

Na : Transferrin saturation :

K : Ferritin :

HCO3+ : PTH :

Ca : HBs Ag :

PO4 : Anti HCV :

Anorganic Phospor : Anti HIV :

Albumin : nPCR :

ALT : URR :

AST : Kt/V :

Surabaya, .. 20.
Renal Physician:

Chandra Irwanadi, dr, SpPD-KGH

 Nama : Ny. Umi Ruwaicha
Name
TRAVELLING DIALYSIS
Diagnosa Utama : CKD STG V Umur :47 th
Age
Primary Diagnosis
Diagnosa Sekunder Jenis Kelamin : Female
( P H C Hospital: SHipertensi
urabaya) Sex
Secondary Diagnosis
Jl. Prapat kurung Selatan No.1 Surabaya Indonesia.
Nomer Register : 92108
Riwayat Penyakit
Phone +62 31 3294801, : Fax.
Hipertensi
+62 31 3294804
History Reg. Number
Alamat : Jl. Merpati 173 Sampang
Address
Tanggal Awal HD Tanggal Terakhir HD
Date of Beginning Dialysis : 21-11 2012 Date of Last Dialysis : 30-11-2012
PRESENT
TREATMENT
Tekanan Darah Sistole : 140 - 190 Frekwensi HD : 2x/minggu
Blood Pressure Diastole : 70 - 100 Dialysis Frequency
Optimal Blood Flow : 200 Rpm
Mean/ Optimal blood flow
Tempat dilakukan HD : Rumah sakit Lamanya HD : 4 - 4,5 jam
Place of Dialysis Duration per Dialysis
Komposisi Dialisat : Bicarbonat Sero Marker Hepatitis : Negative
Composition of Dialysate Hepatitis sero marker
Tipe Dializer : F7 HPS Fresenius Riwayat Transfusi Darah : None
Type of used Dialyzer History of Blood Transfusion
Akses Vaskuler : Three Lument Alergi : None
Vascular access Allergies
Berat Badan Kering : Belum bisa timbang
Dry weights
Heparinisasi : Normal Kenaikan BB Intradialisis : -
Heparinization Weights gain Intradialysis
Komplikasi Selama HD : Hipertensi Keterangan Lain
Intradialysis complications Further Comment :

Diet Low Salt Obat yang dikonsumsi saat ini :

Diet : Present Medication
Obat durante HD
Peridialysis Medication : Sohobion 5000 inj

HASIL PEMERIKSAAN LABORATORIUM TANGGAL

LABORATORY RESULT DATE :
BUN/ Urea 59,72 ( pre HD 30/11/2012 ) Blood Sugar :
Creatinin 8,01 ( pre HD 30/11/2012 ) Fe :
Hb 9,8 ( 27/11/2012) Ferritin :
Na 133,2 ( 27/11/2012) Transferrin saturation :
K 4,41 ( 27/11/2012) Albumin :
HCO3+ PTH :
Ca HBs Ag : Negatif
PO4 : Anti HCV : Negatif
Phospor : Anti HIV : Negatif

Surabaya, 1 Desember 2012

Renal Physician

( dr. Chandra Irwanadi SpPD- KGH)