PEMERIKSAAN YANG DIMINTA HARAP DIBERI TANDA X

Nama Pasien : Dokter :

Umur : Diagnosa :
JenisKelamin : Tanggal :

HEMATOLOGI ⃝Tes Toleransi Glukosa ⃝ Protein Bence Jones ⃝Komplomen C4 ⃝ LH

⃝Rutin 1 ⃝Kurva Harian Glukosa ⃝Ureum Urine ⃝ ANA ⃝ FSH
(Hb, Leu,Ht, Trombo) ⃝Hb A1-C ⃝Kreatinin Urine ⃝ SMA ⃝ Estradiol
⃝…………………………
⃝ Rutin 2 ⃝ C – peptide * ⃝ Anti Ds-DNA ⃝Prolaktin
………
(Hb, Leu, LED, Diff) ⃝ ACA lg G ⃝Proqesteron
⃝ DarahTepi Enzim Lain Lain ⃝ ACA lg M ⃝Testosteron
(Hb, Leu, Hl, Trombo, diff) ⃝ CPK ⃝TesKe hamilan ⃝ ACA lg A ⃝Aldosteron
⃝ Darah Lengkap ⃝ CK-MB ⃝ Beta hCG Titter ⃝ Ig E (Spesifik) ⃝ …………………
(Rutin 2, Ht, Eri, Trombo Nilai Eri) ⃝ LDH ⃝……………………… ⃝Sel T – Sel B
⃝ Retikulosit ⃝ HBDH ⃝ CD 4 – CD 8
⃝ Hitung Eosinofil Narkoba ⃝Analisa Kromosom PETANDA TUMOR
⃝ Gambaran Darah Tepi Lemak Darah ⃝Barbiturat ………………………… ⃝ AFP
⃝ Coomb’s Test ⃝Trigliserida* ⃝Benzodiazepin ⃝ CEA
⃝ G-6 PD ⃝ Cholesterol Total* ⃝Coccain TORCH & CHLAMYDIA ⃝ CA 15.3 (Payudara)
⃝ SI TIBC ⃝ Cholesterol HDL* ⃝Opiat ⃝ Anti Toxoplasma lgG ⃝ CA 125 (Ovarium)
⃝Femitin ⃝ Cholesterol LDL* ⃝Canabis ⃝ Anti Toxoplasma lgM ⃝ CA 19.9 (Pankreas)
⃝Transferin ⃝Lp (a)* ⃝Amfetamin ⃝ Anti Rubella IgG ⃝ PSA (Prostat)
⃝Transferin Saturasi ⃝ Anti Rubella lgM ⃝Freo PSA (Prostat)
⃝ ANC (Absolute Netrofil Count) Fungsi Ginjal FAECES ⃝ Anti CMV IgG ⃝ SCC (Serviks)
⃝ Vit B12 ⃝Ureum Darah ⃝Lengkap ⃝ Anti CMV IgM ⃝ Beta hCG Kuantitatif
⃝ Asam Folat ⃝Kreatinin Darah ⃝Analisa Faeces ⃝ Anti HSV I lgG ⃝ …………………
⃝ Elektroforesa Hb ⃝Asam Urat Darah ⃝Darah Samar ⃝ Anti HSV l lgM
⃝ Sel LE ⃝Creatinin Clearence ⃝ APT Test ⃝ Anti HSV II lgG MIKROBIOLOGI
⃝ LF Test ⃝………………….... ⃝ Anti HSV II lgM ⃝ Malaria
⃝ Gol Darah ABO-Rh Elektrolit & Gas Darah ⃝ Anti Chlamydia Total ⃝Filaria
HEMOSTASIS ⃝ Na CAIRAN TUBUH ⃝ Anti Chlamydia lgG ⃝Sekret Vagina
⃝ Rumpel Leede ⃝K ⃝Analisa Sperma ⃝ Anti Chlamydia lgM ⃝Sekret Uretra
⃝ Masa Pendarahan ⃝ CI ⃝ PCT ⃝ Toxoplasma IgG Aviditas ⃝Sekret Mata
⃝ Masa Pembekuan ⃝Kalsium ⃝Analisa Cairan Otak ⃝ CMV lgG Aviditas ⃝ Sputum BTA
⃝ Masa Protrombin (PT) ⃝Kalsium Ion ⃝Analisa Trans-Eksudat ⃝ ……………………… ⃝………………
⃝ INR ⃝Fosfor Anorganik ⃝Analisa Batu Ginjal
⃝ APTT ⃝ Magnesium HEPATITIS Kultur
⃝ Masa Trombin (TT) ⃝Analisa Gas Darah SEROLOGI ⃝HBsAG (EIA) ⃝ MO + Resistensi
⃝ Fibrinogen Lain Lain ⃝ VDRL ⃝ Anti HBs (Titer) Bahan……………
⃝ D-Dimer ⃝Fosfatase Asam ⃝ TPHA ⃝ Anti HBc Total ⃝ BTA
⃝ Trombolest ⃝Fostatase Asam Prostat ⃝ RF ⃝ Anti HBc IgM Bahan……………
⃝ Agregasi Trombosit* ⃝Amilase Darah ⃝ ASTO ⃝HBeAg ⃝ GO
⃝KIMIA KLINIK ⃝ Lipase Darah ⃝ CRP ⃝ HCV – RNA Bahan……………
⃝Aseton Darah ⃝Widal ⃝ Anti HBC ⃝Jamur
KIMIA KLINIK ⃝Amonia Darah ⃝ PCR Salmonella ⃝ HBV DNA Bahan……………
FungsiHati ⃝Laktat Darah ⃝ Anti TB lgG ⃝ Anti HCV Total ⃝Gali
⃝Elektroforesa Protein ⃝ PCR TB ⃝ Anti HCV IgM Bahan……………
⃝ Protein Total-Albumin URINALISA ⃝Seramoeba / IDT ⃝ HCV RNA
⃝ Bilirubin Bayi ⃝Lengkap ⃝ Dengue Blot lgG + lgM ⃝ Anti HAV Total TDM
⃝ Bilirubin Total-Direk ⃝BeratJenis ⃝ Dengue NS 1 ⃝ Anti HAV IgM ⃝ Theophylin
⃝ SGOT ⃝ PH ⃝ Salmonella IgM ⃝ ……………………… ⃝ Digoxin
⃝ SGPT ⃝ Protein ⃝ Helicobacter Pylori IgH ⃝ Phanibarbital
⃝Gamma_GT ⃝Glukosa ⃝ Helicobacter Pylori IgM HORMON
⃝Fosgatase Alkali ⃝Keton ⃝ Anti HIV ⃝ T3 Total Lain Lain
⃝ Cholinesterase ⃝ Bilirubin IMUNOLOGI ⃝ T4 Total ⃝ …………………
⃝ Urobilinogen ⃝ Ig G ⃝ T3 Uptake ⃝ …………………
Karbohidrat ⃝Sedimen ⃝ Ig A ⃝ FTI ⃝ …………………
⃝Glukosa Sewaktu ⃝ Ig M ⃝ Free T4
⃝Glukosa Puasa Urine 24 Jam ⃝ Ig E (total) ⃝ Free T3
⃝Glukosa 2 jam PP ⃝ Protein Kuantitatif ⃝Komplemen C3 ⃝ TSH Sensitif
*Puasa 12 Jam
PEMERIKSAAN PAKET :
PRENATAL BARU TANPA TORCH OPERASI SEDANG (SC/CITO)
PRENATAL BARU + TORCH OPERASI BESAR
PRENATAL RUTIN GTT
PRENATAL TRIMASTER III
TROCH TandaTanganDokter

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