PELAYANAN 24 JAM
Jl. Mohammad Toha KM.2 No 1, Karawaci, Tangerang
www.metrohospitalsgroup.com
PERMINTAAN PEMERIKSAAN LABORATORIUM
Ringkasan Klinis/ Diagnosis:
Pemeriksaan yang diminta harap diberi tanda (√)
01. HEMATOLOGI
UMUM
[ ] Darah Rutin
(Hb,Ht,Eri,Leuko,Tr)
[ ] Darah Lengkap
(DR,DIFF,MCV,MCH,MCHC,LED)
[ ] Laju Endap Darah (LED)
[ ] Golongan Darah A,B,O & RH
HEMOSTASIS
[ ] Waktu Perdarahan (BT)
[ ] Waktu Pembekuan (CT)
[ ] Waktu Protombin (PT) & INR
[ ] APTT
[ ] Masa Trombin (TT)
[ ] Fibrinogen
[ ] D-Dimer
[ ] Agregasi Trombosit (*)
ANEMIA
[ ] Retikulosit
[ ] Serum Iron (SI)
[ ] TIBC
[ ] Ferritin
[ ] Transferin
[ ] Vitamin B-12
[ ] Asam Folat
[ ] Paket Gambaran Darah Tepi
[ ] LE Sel
[ ] Analisa Hb (Elektroforesa)
[ ] IT Ratio
[ ] Coomb's Test
02. KIMIA
DIABETES
[ ] Glukosa Puasa (*)
[ ] Glukosa 2 Jam PP
[ ] Glukosa Sewaktu
[ ] Glukosa Kurva Harian (*)
[ ] GTT (Tes Toleransi)(*)
[ ] HbA1C
[ ] Insulin (*)
[ ] C-Peptide (*)
LEMAK
[ ] Kolesterol Total
[ ] HDL Kolesterol Direk
[ ] LDL Kolesterol Direk
[ ] Trigliserida (*)
[ ] Apo-A1 (*)
[ ] Apo-B (*)
[ ] Lipid Total (*)
[ ] Small Dense LDL (*)
FUNGSI GINJAL
[ ] Ureum
[ ] Kreatinin
[ ] Asam Urat
[ ] Urea Clearance
[ ] Creatinine Clearance
[ ] Mikroalbumin 24 jam
[ ] Mikroalbumin sewaktu
[ ] Cystatin C
FUNGSI JANTUNG
[ ] CK / CPK
Penanganan Hasil :
006-001-MHMT-00-2021
label identitas pasienl
Diterima Tanggal : ………………….……………………………………………………………………
Pukul : ………………….……………………………………………………………………
Petugas : ………………….……………………………………………………………………
Cito Biasa
[ ] CK-MB [ ] Free PSA (Prostat) [ ] ACA IgG [ ] BTA Pagi
[ ] LDH [ ] Anti EBV VCA IgA [ ] ACA IgM Bahan : ………………………………………..
[ ] hs-CRP [ ] Anti EBV VCA IgG [ ] Antigen Sars-Cov-2 [ ] BTA SPS (Sewaktu 1,Pagi,Sewaktu 2)
[ ] Troponin T [ ] Anti EBV VCA IgM [ ] Anti Sars-Cov-2 Bahan : ………………………………………..
FAKTOR RISIKO PJK/STROKE TORCH 04. HORMON [ ] BTA SP (Sewaktu,Pagi)
[ ] Lp (a) (*) [ ] Anti Toxoplasma IgG TIROID Bahan : ………………………………………..
[ ] Adiponektin (*) [ ] Anti Toxoplasma IgM [ ] T3-Total [ ] Malaria
[ ] Homocystein (*) [ ] Anti Rubella IgG [ ] T4-Tota [ ] Mikrofilaria
FUNGSI HATI [ ] Anti Rubella IgM [ ] TSHs KULTUR + RESISTENSI TES
[ ] SGOT (AST) [ ] Anti CMV IgG [ ] FTI Bahan : ………………………………………..
[ ] SGPT (ALT) [ ] Anti CMV IgM [ ] T3-Uptake 08. PENYALAHGUNAAN OBAT
[ ] Gamma - GT [ ] Anti HSV I IgG [ ] Free T3 [ ] Methametamin
[ ] Protein Elektroforesa [ ] Anti HSV I IgM [ ] Free T4 [ ] Benzodiazepine
[ ] Total Protein (Alb/Glob) [ ] Anti HSV II IgG [ ] Calcitonin [ ] Marjuana (THC)
[ ] Albumin [ ] Anti HSV II IgM [ ] Thyroglobulin [ ] Amphetamine
[ ] Bilirubin Total PENYAKIT HUB. SEKSUAL [ ] Thyroglobulin Antibody [ ] Cocain
[ ] Bilirubin Direk/Indirek [ ] VDRL (RPR) [ ] Anti TPO IgG [ ] Morphine (Opiat)
[ ] Alkali Fosfatase [ ] TPHA [ ] Thyroid Receptar Ab [ ] Paket Narkoba (Met,COC,Marijuana
[ ] Bile Acid (*) [ ] Anti HIV Penyaring REPRODUKSI Morphine,AMP,BENZO)
[ ] Cholinesterase [ ] Anti HIV [ ] LH 09. KADAR OBAT DALAM DARAH
ELEKTROLIT [ ] Anti Chlamydia IgG [ ] FSH [ ] Carbamazepine (Tegretol)
[ ] Elektrolit (Na,K,Cl) [ ] Anti Chlamydia IgM [ ] Prolactin [ ] Cyclosporins
[ ] Kalsium Total OSTEOPOROSIS [ ] Testosteron [ ] Digoxin
[ ] Kalsium Ion [ ] Osteocalsin [ ] Progesteron [ ] Lithium
[ ] Fosfor Anorganik [ ] β-Crosslaps [ ] Estradiol [ ] Phenobarbital (Luminal)
[ ] Magnesium ALERGI [ ] Beta HCG [ ] Phenytoin (Dilantin)
[ ] Analisa Gas Darah (AGD) [ ] Eosinofil [ ] 17-OH Progesteron [ ] Theophylin (Aminophiline)
PANKREAS [ ] Ig-E Total [ ] Estrone (E1) [ ] Tacrolimus
[ ] Amilase [ ] Ig-E Atopy (20 Alergen) [ ] Estriol (E3) [ ] Valproic Acid (Epilim)
[ ] Lipase [ ] Ig-E Atopy Indonesia 1 [ ] Anti Mullerian Hormon 10. BIOMOLEKULAR
LAIN - LAIN [ ] IgG4 Food Sensitivity 160 Profile LAIN - LAIN [ ] PCR-TB
[ ] Vitamin D25-OH Total [ ] Ig-E Makanan Asia Tenggara [ ] 17-Ketosteroid [ ] PCR-Salmonella
[ ] Asam Laktat [ ] Ig-E Pediatric [ ] ACTH (*) [ ] PCR-HSV
[ ] Glukosa Darah (POCT) [ ] Ig-E Hirup [ ] Aldosteron [ ] PCR-CMV
[ ] UBT (Urea Breath Test) LAIN - LAIN [ ] Cortisol Pagi [ ] PCR-Chlamydia
03. IMMUNOSEROLOGI [ ] CRP [ ] Cortisol Sore [ ] ADA
HEPATITIS [ ] ASTO [ ] Human Growth Hormone [ ] PCR-Dengue
[ ] Anti HAV IgM [ ] RF [ ] PTH Intact (*) [ ] PCR-Malaria
[ ] HBsAg Kualitatif [ ] NS1 Ag Dengue [ ] DHEA-s [ ] PCR-HPV
[ ] HBsAg Kuantitatif [ ] Anti Dengue IgG & IgM [ ] DHT [ ] HBV DNA Kuantitatif
[ ] Anti HBs (Titer) [ ] Widal [ ] Free Testoterone [ ] HCV RNA Kuantitatif
[ ] Anti HBc [ ] Tubex [ ] IGF-1 (Somatomedin) [ ] HCV Genotype
[ ] Anti HBc IgM [ ] Anti salmonella Typhi IgG & IgM [ ] SHBG [ ] RT-PCR Covid 19 (Sameday)
[ ] HBeAg [ ] Malaria Rapid 05. URINE [ ] RT-PCR Covid 19 (1-2 Hari)
[ ] Anti Hbe [ ] Anti Mycoplasma IgG [ ] Urine Lengkap 11. PATOLOGI ANATOMI
[ ] Anti HCV [ ] Anti Mycoplasma IgM [ ] Protein Urine [ ] Histopatologi Jar. Kecil
[ ] Anti HAV Total [ ] E. Histolytica IgG [ ] Keton Urine [ ] Histopatologi Jar. Sedang
PETANDA TUMOR [ ] Anti H. Pylori IgG [ ] Tes Kehamilan (HCG) [ ] Histopatologi Jar. Besar
[ ] CEA (Colon) [ ] Anti H. Pylori IgM [ ] Elektrolit Urine (Na,K,Cl) [ ] Pap smear
[ ] AFP (Liver) [ ] Anti Leptospira IgM (Elisa) [ ] Esbach (#) 12. LAIN - LAIN
[ ] CA 125 (Ovarium) [ ] Anti Measles IgG 06. FESES [ ] Analisa Cairan Otak
[ ] CA 19-9 (Pankreas) [ ] Anti Measles IgM [ ] Feses Rutin [ ] Analisa Cairan Pleura
[ ] CA 15-3 (Breast) [ ] IgA [ ] Feses Lengkap [ ] Analisa Cairan Sendi
[ ] CA 72-4 (Gaster) [ ] IgG [ ] Darah Samar [ ] Analisa Cairan Asites
[ ] SCC (Lung, Serviks) [ ] IgM 07. MIKROBIOLOGI [ ] Analisa Batu Ginjal
[ ] NSE (Neuroblastoma, Lung) [ ] C3 Komplemen [ ] Pengecatan Gram [ ] Analisa Batu Empedu
[ ] Cyfra 21-1 (Lung) [ ] C4 Komplemen Bahan : ……………………… [ ] Analisa Batu Buli - Buli
[ ] Acid Phosphatase [ ] ANA : ……………………… [ ] LDH Cairan
[ ] PAP [ ] Anti-ds DNA [ ] BTA Sewaktu [ ] APT Tes
[ ] PSA Total (Prostat) [ ] IGRA Bahan : ……………………… [ ] Analisa Kromosom
Diambil Pasien Dikirim ke Dokter Dikirim ke Pasien Via Internet (*) Puasa 12 jam (#) Urine 24 jam
Tangerang, ………………./ Pukul: ………..
(TTD DOKTER PENGIRIM)
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