TRAVELLING DIALYSIS QUESTIONARE

Patient’s Name : ny wirna

MR Number : 10.03.73+
Date of birth : 10th oktober 1953
Address : Jakarta
Diagnose and history :CKD stage 5 on dialysis,Hypertension,
Renal Anemia,DM
Is the patient home trained or center dialysis : center dialysis
How long has the patient been on dialysis : dialysis starts in MMA Hospital since
13th Mei 2022
Laboratory Value over the past month : the patient have all the copy of lab
result
Recent blood pressure status during dialysis : Systole 150- 190 mmHg
Dyastole 90-110 mmHg
Composition of dialysis : Bicarbonate
Dialyzer used : Polypure Diacap Pro13H (B Braun)
Heparinization used : Continue ;Loading Dose 2500-3000 IU,
Maintenance 1000 IU, last 1 hour free
heparin
Dialysis time per run : 5 (Five) Hours
Number of runs per week : three times a week
QB / QD : 100-300 / 500 ml/minutes
TMP : 65 – 70 ml/ Hour
Arterial pressure / Venous Pressure : - 104 mmHg / -212 mmHg
HbSAg Antigen Test : Non reactive (Januari 2022)
Anti HCV ; Negativ (MEI2022)
Anti HIV : Non reactive (MEI2022)
History of Blood transfusion : -
Diet : water restriction 600ml/day
Allergies : No

1
Patient’s Dry Weight : 54 Kg
Further Comment : none

Jakarta, 25th MEI 2022

dr. Marihot Tambunan Sp.PD-KGH

Nefrology and hipertension Specialist