RUMAH SAKIT ISLAM

YAYASAN AMAL SHOLEH IPHI JOMBANG

Jl. Brigjen Kretarto 22 A Telp. ( 0321 ) 860074 – 868972
JOMBANG

RADIOLOGI
Nama : L Tgl. Lahir/Umur : / th.
Alamat : P Telp / HP :
Asal Pasien : IGD RAWAT INAP PRAKTEK DOKTER SPESIALIS RUJUKAN / LUAR RS
Diagnose / Keterangan Klinik :

GENERAL X-RAY & USG

CENTRAL NERVOUS SYSTEM RESPIRATORY,TEETH,ORBITA,EAR X-RAY CONTRAST
Skull PA/AP Thorax PA/AP Collon in Loop
Skull LAT/Adenoid Thorax Lateral DEX/SIN IVP (Intra Venus Pyelography)
Skull AP & LAT Thorax RLD ..…………………………………………………
Sella Tursica Thorax LLD
EXTREMITY
Basis Cranii AP/LAT/OBL/ - DEX/SIN Sternum & Costa
Vert. Cervicalis AP & LAT Orbita AP/PA Digiti Dex Sin
Vert. Cervicalis OBL (DEX & SIN) Rheese (Foramen Opticum) Manus Dex Sin
Vert. Thoracalis AP & LAT Nasal Bone / Nasal Lateral Wrist Joint Dex Sin
Vert. Thoracalis OBL (DEX & SIN) Mastoid Schuller DEX & SIN Antebrachii Dex Sin
Vert. Lumbosacral AP & LAT Waters (Maxilla) / Sinus Paranasalis Humerus Dex Sin
Vert. Lumbosacral OBL (DEX & SIN) Temporo Mandibular Joint DEX & SIN Elbow Dex Sin
Vert. Sacrococcygeus Mandibula AP Shoulder Dex Sin
Scoliosis Program AP/LAT (6 Posisi) …………………………………………………….... Clavicula Dex Sin
………………………………………………….. Scapula Dex Sin
Femur Dex Sin
USG BODY & PELVIS Genu Dex Sin
USG Whole Abdomen Plain foto Abdominal (BOF) Genu Skyline Dex Sin
USG Gynaecologis Abdomen 3 Position Cruris Dex Sin
USG Urologi Abdomen RLD Pedis Dex Sin
USG Thyroid Abdomen LLD Ankle Dex Sin
USG Mammae Pelvis AP Mortis view Dex Sin
USG Musculosceletal Os Coxigeus AP & Lat Calcaneus Dex Sin
USG Kandungan Hip Joint AP DEX/SIN ………………………. Dex Sin
…………………………………………………... Hip Joint LAT DEX/SIN
Hip Joint Axial DEX/SIN
…………………………………………………………
CT SCAN
CT SCAN NON CONTRAST CT SCAN CONTRAST
CT Brain CT Pelvis CT Brain Contrast CT Whole Abdomen Contrast
CT Mastoid CT Upper Extremity CT Mastoid Contrast CT Thoraco Abdominal Contrast
CT Thorax CT Lower Extremity CT Thyroid Contrast CT A Brain
CT Vertebra Cervical CT Guiding Biopsi/FNAB CT Nasopharynx Contrast CT A Cardiac
CT Vertebra Thoracal CT Vertebra Lumbosacral CT Larynx Contrast CT A Abdomen
…………………................ CT Thorax Contrast CT A Extremity
………………………………………

Dengan ini saya menyatakan bahwa saat ini saya sedang tidak hamil Dokter yang meminta

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