RSCM NRM
Nama
:
:
Jenis Kelamin :
RSUPN Dr. Cipto Mangunkusumo Tanggal lahir:
Jl. Diponegoro No. 71 Jakarta 10430 (Mohondiisiatau tempelkan stiker jika ada)
Telp: (021) 3918301 Fax: (021) 3148991
TRAVELING DIALYSIS PATIENT
Patient’s name : Tn. Luhut Matondang
Birth of Date : 09 May 1962 Age : 56 Years
Recent Address : Jl. Bunga Mawar XVII No.4, Royal Sumatra, Medan
Diagnosis and history : CKD Stage V On HD Pro Kidney Transplantation, Hypertension Grade II
Is the patient home trained or center dialyzer? Center Dialyzer
How long has the patient been on dialysis? 3 months
What medication is the patient presently taking? attached
Laboratory values over the past month : attached
Recent blood pressure status : 178/67 mmHg
Composition of dialysate : Sodium Bicarbonate
What dialyzer and delivery system is the patient currently using? Fresenius Fx 10 Low Flux
Known complication with dialysis runs : None
Does the patient have a shunt or fistula? CDL Tunneling Jugular Interna Vein Dextra
Type of Heparinization used : Regular
Number of runs per week : 2 times per week
How long per run : 5 hours
TMP used : 80 mmHg Venous Pressure : 80 mmHg
Australian Antigen test : HBsAG (non reactive), Anti HCV (non reactive), Anti HIV (non reactive)
Blood transfusion : none
Diet : renal diet
Allergies : none
Patient’s dry weight : 59 kg
Further comment : none
Attending Physician,
Dr.
0526/rev00/HD/2012
RSCM NRM
Nama
:
:
Jenis Kelamin :
RSUPN Dr. Cipto Mangunkusumo Tanggal lahir:
Jl. Diponegoro No. 71 Jakarta 10430 (Mohondiisiatau tempelkan stiker jika ada)
Telp: (021) 3918301 Fax: (021) 3148991
0526/rev00/HD/2012