LAKESLA Drs. Med. R. RIJ ADI 5.

, Phys
Jln. Gadung No. 1 Surabaya
Tel" : 62'()31-8439042. 8421197

,
RESULTS OF THE MEDICAL & PHYSICAL FITNES FOR DIVER

I. IDENTIFICATIONS
Name Tn. Dedi Kusuma
Date of birth 18 Juli 1980
Address Cilacap Selatan
File No. 73N1I1/2021

II. PHYSICAL & ANTHROPOMETRICAL EXAMINATION

Height 165 Cm
We i g h t 70 Kg
Blood pressure 120/80 mmHg
Pulse rate 77 Im in
Portion of fat %

III. EARS, NOSE & THROAT

Otoscope Good
V.lsava Good
Tympanic Membranes Good

IV . CARDIOVASCULAR SYSTEM
1. Reaction to heavy exercise : Good
2. Resting E.C.G. Good
3. Exercise E.C.G Good

V. MUSCLE STRENGTH'S TEST

Result ( Dlnamomentry )

VI. AUDIOMETRY Normal I Normal

V II. Oxygen Tolerance Test (OTT) Good

V III. RESPIRATORY FUNCTIONS TEST

Forced Vital Capacity (FVC %) 3.22 ( 80 % Pred)
Forced Expiratory Volume 1 sec 2.76 ( 83 % Pred )
F. E V 1/VC 86 ( 107 % Pred )
FEV1/FVC 87 ( 106 % Pred )
PEF 10.00
Result (Spiremetri ) Normai

VIII. USG: Date

Result
IX. X- RAY EXAMINATIONS

1. Chest X Ray: Date 02 Agustus 2021

Result Normal

X LABORATORY FINDINGS
1. URINE
a. Protein : Negatif
b. Sugar : Negatif
c. Sediment : Erythrocyte (0-1 )/LPB, Leucocyte
(0-1)/LPB, Epithel (0-1)/LPB
,
2. BOOD CHEMISTRY & BLOOD CELL COUNT
a. Hemoglobin 16.4 mg%
b. White Blood Cell (Leukosit) 8.7 Imm 3
c. Hematocrite 45.5 %
d. LED 5 mm/hour
e. Glucosa ( nuchter) 86 mg/dl
2 hrs after meal 90 mg/dl
f. Cholesterol Total 166 mg/dl
g. Cholesterol HDL 32 mg/dl
h. Cholesterol LDL 110 mg/dl
i. Tryglyceride 116 mg/dl
j. SGOT 24 U/L
k. SGPT 40 U/L
I. Bilirubin Diree 0.30 mg/dl
m.Bilirubin Total 0.65 mg/dl
n. Creatinin 0.85 mg/dl
o. BUN 14 mg/dl
p. Uric Acid 5.5 mg/dl
q. HBsAg Negatif
r. HIV Non Reakti!
s. Narkoba Negatif

XI. CONCLUSION

HE IS : FIT FOR DIVING

XII. REMARKS: NEXT EXAMINATION ONE YEAR (02-08-2022)

 Professional Olver's Logbook Professional Diver's Log book
Medical Certificate Medical Certificate

Fu:1Name of Diver :
M(2.. Dm\
..... ...... .....
rv~Pr
. ....... .. ~ .. .
Full Name of Diver :

Date of Medical Examination : ......CT!:: ... f!!...~.:. Date of Medical Examination :

Date of X-Ray Examination : ....... 0?:: .. i't;T..!:':"I...... Date of X-Ray Examination :

Resutt of Medical Examin ation : ~~FIT Result of Medical Examination : FIT/UNFIT

f'o D- PLIJ/N()

Medical Restriction on Diving or Compression (if Aplicable) Medical Restriction on Diving or Compression (if Aplicable)

- No 0\.., l'IlS'II'-\U1Do..l
......... ........ .... ..... ... ..

Duration of Validity of Certificate : ow<- ~€N'- . Duration of Validity of Certificate :

Date of commencement: .......... P6r h>'-'" .......... ............ ......

or .................... Date of commencement:

Date of Expiry : <TJ-- I'1&f

............... :><>'"'-'­
............................... .. ..........
Date of Expiry :

Name of Approved Doctor : ... ).:: II!~~...F;I;!!_II. .. ~<...~ .. . Name of Ap proved Doctor :

Address of Approved Doctor : .. >11~~ .. !1:-.r;f'f>~~ ... 1,..~:i. .. . Address of Approved Doctor :

Telephone No. of Approved Doctor ....UIl'2

~~
l!,4'>'lWD
. ...... .. ......................................
Telephone No. of Approved Doctor
Signature of Approved Doctor
 DINAS KESEHATAN TNI ANGKATAN LAUT

LAKESLA Drs.Med. R. RIJADI S., Phys.

Jln. Gadung No.1 Surabaya

SUMMARY OF TREADMILL TEST

Date .. iJ1, Jilt 7wi Weighl li?.. Kg

Methode ~. tocol
Height ... ~6L ... Cm
Name : Mr rs/Mt .... ·~tIm'JMIr MaxHR .. J~ ... Minutes
Date of Birth: ..... W~.... ~'I>1? ...... 85 MHR ( Submax): ...i.S).,.,... Minutes

~
1. onary Artery Disease
a. egative

. Positive ( Mild/Moderate/Severe )

2. Fitness Classification ( Cardiopulmonary )

a. Poor ( ..................................... Mets )

b. Far (.......... .. . .. ............. Mets )

c. Average ( ..................................... Mets )

«['Good ( ....... [9,.6.......... Mets )

YExcelient ( .....................................Mets)

3. Heart Rate ( Treadmill Test )

- Beginning : ......... !Jk................ BPM

- Ending .... .. ..,t,8>................

BPM

Blood Preasure (Treadmill Test)

- Beginning .. .......... ..WY'f;!. . ..... mm Hg

- Ending . .. ............~1'. .. ... mm Hg

Treadmill test stopped due to : D\lif .... .c <;:e.:. '? fj\INU1'!;!) ............... ...................... .

Exercives
Other
/

4. Recomendation
a. Exercives - Walking;QRunning ....... .. .... ,z ..........",. ............ .. ... .... v-0.5hrOR

- Heart Rate ..............9.6. ~9.o. ."1............ .......... Minutes

- Frequency ..................3.:'Cy..."'! ................... a Week

Before excercise warming up 5 -10 and after exercise cooling down 5' -10'

Other excercise Golg, Badhminton, Tennis, swiming , basket ball , etc ...................... .... ..

b. Cardiologist Consultation
- Necessary

(Yot necessary

c. Repeat treadmill test after: ......................."4:.C~ ............................................. Months

Surabaya, 2. Ast- 202'1

GLAKE . R~.-:R1J:-A-O-I-S-P'-
:;;:;;;:·S;;;LA7.0:::':::S:-:M-:C-:d- " "---'U EI8
ining Doctor
UNlT • ..."
H B 0 TH ERAPY~
~------':'''':::::'~-::J.Ju , ~U(es ~,<I
................................ /.'.'.... ..

 LAKESLA Drs. Med. R. Rijadi S., Phys

JI. Gadung No.1, Jagir, Wonokromo, Surabaya

Telp: (03 1)·842· 11 97

Patient 10:
02082021B Sex: male Height: 165 em
Name:
DEDI KUSUMA Date of birth: 7/1811980 Weight 70 kg
First Name:
TN Age: 4 1 years BMI : 25.7 kg/m2

FN report

"T'I
0
~
10.5
<7
Q.
c
~
s
.I i
i
I
, ~
.., 100

-<:
0
•
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if!. 75
7.0 5 i
,
i leN
4 ,
I
3.5 __--1 --- - - - . . 50 ~

2
i
"
0.0
25
2 3 4 5
•
Volume [I)
7

·3.5
0 0 LC"

-7.0
0 2 4
Time [5]
• 0 25 50 75
%VCRef (%)
100

FVCEx

FVCma x
Unit
1~ 5 )

,.
Prad o

4.02
4.02
Pm
3.22
3.22
%proo.

80% 2.86
80% 2.86
- - - %Pr(l d.

71%
7 1%
3.22
3.22
%Pred.

80%
80%
3.19
3.19
%Pred.

79%

79"
1')(C )
VC 4.01 3.22 80% 2.86 71 % 3.22 80% 3.1 9 79%
(35)
FEV' 3.31 2.77 84% 2.50 76% 2.76 83% 2.77 84%
FEV1/FVC % '" 82 86 104% 87 106% 86 104% 87 106%
tPEF m, 5. 64 56 56
j1)(1';)
FEV1NC % 80 86 108% 78 97% 86 107% 86 108%
PEF/FVC 1/, 3.1 0 2.9S 3.10 2.79
PEF U, 10.00 8.53 10.00 8,90
MEF75 U, 8.75 8.12 8.75 6.89
MEF50 U, 4 .42 3.92 4 .42 4.10
MEF2 5 U,
"" 1.27 1.26 99% 1.31 103% 1.26 99% 1.75 138%

(C): Converted for ethnic group

(1): ECCS 1993 (35): GU 2012

Tested: 812/2021 . 1. BT PS: 21.0 ' C, 1013 hP~ , 50 %

Gerath6rm RBSpiratrxy GmbH WMY.gsratherm-resp;mtory. com Blu9 Chsrry Vl.3. 7.3
 LEMBAGA KESEHATAN KELAUTAN TNI AL Dr. R.RI1ADI S.S.Phys
lL. GADUNG NO 1 SURABAYA KODEPOS 60244
NO. TELP. 031 8421197
AUDIOMETRY REPORT SIBELMED W50
Name : TN, DEDI KUSUMA Test Date : 02/0 8/ 2021
A.gQ (al : 41 Reference: 02082 021
Sex: Man Technici an : ARU JI
Hlinght (em) : 165 Reason :
W&lght(Kg ) : 70
IlM" 25 . 7 Origin:

R. E.
((((0 L.E. 0 ))1 1
o125 250 500 IK 2K 4K 8K -10 125 250 500 ' IK 2K 4K 8K
(Hz)
0 ~--~--~7-~~+_~+_~

10 f---r---r--:-t---t--'--t--'-1
20 ~--+_---~--~-,-*-+~~~

30 t=t=~~=f:EtIj

40
50 f---f-~~~~-+~-+-,~
60 r---+_--~~-r~-+-+--1-4~

70 f---r-~~~~-+---+-+~
80 r---~--+_+-+_+-+_+-+_~

90 ~--~--+_~+_--+_+--~~

100 r---~--+_+-+_--+_+-+---+-\
IIO ~--+_--~---r---+-+-+--~
120 L -:c:---'-----'---'---'--+--'--+--'---"---'
(dB)
No Masking R.E. l.E. With Masking R.E. L. E.
COUNCIL OF PHYSICAL THERAPY
R.E. L.E. ." 0 X ~,
A 0
Hearing Loss (tl 3.6 .7.0 Bone < > Bon.
" ~

Average dBs 16.2 20.0 F. Fle Id ~

Bilateral Loss (tl 4.0 '"
Right ear Nomal
Left ear Normal

SISI TEST LOSCHER TEST

Hz 500 1000 2000 4000 Hz 500 1000 2000 4000 8000

R.E. % --­ --­ --­ --­ R.E. dB

.--­ --­ --­ --­ --­

l.E. % --­ --­ --­ --­ L.E . dB --­ --­ --­ --­ _.­

Printing Da te : 02/0 8/ 2021 Page 1 of 1

L2ibe/medi
 DEnl KUSUMA, TN Patient Information 8/2/2021 2:40:58 PM
Bruce
02082021A

l m~_-.-?~c~~ second 10: Adm ission ID:

~
Da-te-~f Birth: 7/18/1980 Height: 165 em Address: City: State:

Age: 11 Years Weight: 70 kg Postal Code: Country: Email Address:

I Gender: Male Race: Asian Home Tel.: Work Tel. : Mobile Tel. :

~L-~
,g-in-a: Unknown
I.An- History of MI: Unknown [ Indications
Plior CABG: Unknown Prior cath: Unknown
Diabetic: No Smoking: Yes
~mil y H isto ry~ ~~~k~n~own
Un ~______ _ _ _ __ _ _ -.J

[R;~ni~~ Pilysidan: Location: Procedure Type: ]

I
~
,Attending Phy: TargetHR: 152 bpm (85%) Reasons for end: .
L]"~_h_nici<:l n : . 8r Zubaidi Max HR(%MPHR): 155 bprr, (86%) Symptoms:

I Diagr1o$' s .------- ~ Notes - -------­

l'!trMdll 1re88tn'
,
lll T~
L
I
___ ConcJusions

,i
I
I LAK.ESLA Drs. Med . R. RlJADl S, Poys
UNIT
L_ HB0 TIiERAP Y

Reviewed by: .{r . ~",k w'" ~bOfO qpj> Electronically Signed by: admin
---------
Date: 8/2/2021

9 ·Stress 6,3.0.63634 LAKESI.A Drs. Med. R. Rijadi S., Ph}'$.. Page 1

 DEDI KUSUMA, TN Exam Summary 8/2/2021 2:40:58 PM
Bruce
02082021A
Summary - -- - - - - - - - - - - - - - - - -­ - - ----, Max Values - - - -- - -- - -- - - - - - -- - -- -----,
Exercise Time: 09: 17 Speed : 4 .2 MPH HR: 155 BPM 86% of MPHR (179 bpm)
Leads with 1 OOuV ST: I, II , aVR , V2. V 3, V4 Grade: 16 % S8 P: 130/80 mm Hg
PVCs: 0 METs: 10. 6 DBP: 130/80 mmHg
HR'BP: 20300 BPM ' mmHg
ST/HR Index: 7.24 uV/bpm in aVR at 05:00
----------------~
MaX S T - Max ST Changes - - - - - - - -- - - -- - - - - - ------,

r
,
Sf elevation: 3.1 mm in V3 at 10:10
ST depression: -1.8 mm in aVR at 05:00
ST elevation change: 1.6 mm in II at 05 :00
ST depression change: -1 .4 mm in I at 09:20

I
I

STAGE SUMMARY
S T measurement based on J '60ms

ST L EV EL (mm)
Speod Grade HR BP METs HWBP II III aVR aVL aVF VI V2 V3 V, VS V.
(MPH) (%) (BPM) (mmHg)

BP PRE·X 0.0 0.0 9. 110170 10560 0.5 0.2 -0.4 -0.4 0.4 -0.1 0.6 1.4 2.2 1.2 0.5 ' .3
Treadmill Started PRE.X 1.0 0.0 96 0.5 0.2 -0.4 -OA 0.' -0.1 0.6 1.4 2.2 1.2 0.5 0.3
START EXE EXE 00:00 1.0 0.0. 107 1.3 0.7 01 -0.6 -05 0.6 -0.3 0.5 1.1 2.2 1.3 0.5 u.3
BP EXE 02:08 1.7 10.0 11 9 120180 4.6 14280 0.1 -0.1 -02 -0 1 0.1 -0.1 0.5 2.1 0.9 0.2 0
STAGE 1 EXE 03:00 1.7 10,0 11"4 4.7 0.1 0 -0.1 ·0.1 0.1 -0.1 0.6 1 2.1 1.1 0.' 0.1
BP EXE 05:10 2.5 12.0 125 130180 7.1 16250 1.4 1.1 -0.2 -1.3 0.7 0.4 0.' 1 1.8 0.' 0.3 0.1
STAGE 2 EXE 06:00 2.5 12.0 12. 7.1 0.2 0.2
-0.1 -0.3 0.1 0.1 0.5 0.' 1.8 0.8 0.2 0
·STAGE 3 EXE 09:00 3.' 14 .0 I SO 10.3 0.2 0.2
-0.1 -0.3 0.1 , 0 0.5 1.1 2.1 0 .• 0 -0.2
Peak EXE 09:17 4.2 16.0 153 10.6 0.1 0
-0.2 -0. 1 0.1 -0.1 0.4 1 2 0.7 0 -0.2
BP REC 01 :26 1.5 0.0 121 130180 7.' 15730 1 0.2
-0 .8 -0.7 0.9 -0.3 0.3 1.2 2.' 1.• 0.7 0.3
BP REC 02:09 1.5 0.0 116 120f80 .7 13920 0.5 0.1
-0.5 -0.4 0.4 -0. 2 0' 09 22 1 0.3 0
ENOREe REC 03:04 1.5 0.0 113 ' .9 0.3 0
-0, -0.3 0.3 -0.2 0.3 0.8 1. 0.7 0.2 0

Q-Stress 6. 3. 0.63634 LAKESLA Drs. Med. R. RiJacli S., Phy:>,. Page "
 DEDI KUSUMA, TN Rate/BPlWorkload Trends 8/212021 2:40:58 PM
Bruce
02082021A
= HE art Ra e B M) "'T ~p~edl (N\PH I p'~d. ('!o) '"

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~-Slress 6.3.0.63634 LAKESLA Drs. Med. R Rijadi S.. Phys_ Page 3
 TN DEDI KUSUMA Exam Start: 8(2(2021 2:40:58 PM
02082021A Event Time: 8(2(2021 2:42:00 PM
1 MPH HR 109
Bruce Date of Birth: 711811980 01 :01 PRE-EXE 0 % BP110/70
Gender: Male
PRE-EXE 00:32

I ~.
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12 Lead Report
Q-Stress 6.3.0.63634 LAKESLA Drs. Med. R. Rijadi S., Phys. Page 4
 TN DEDI KUSUMA Exam Start: 81212021 2:40:58 PM
02082021A Event Time: 812/2021 2:45:59 PM
02:59 EXER 1.7 MPH HR 114
Bruce Date of Birth: 7/18/1980 02:59 STAGE 1 10 % BP 120/80
Gender: Male
EXER 02:08

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a-Stress 6.3.0.63634 LAKESLA Drs . Moo. R. Rljad i S .. Phys. Page 5
 TN DEDI KUSUMA Exam Start: 8/2/2021 2:40:58 PM
02082021A Event Time: 81212021 2:48:59 PM
HR 128
Bruce Date of Bi rth : 7/1811980 BP 130/80
Gender: Male
EXER 05:10

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Q-Stress 6.3.0.63634 LAKE SLA Drs. Med. R Rijadi S., Phys. Page 6
 TN DEDI KUSUMA Exam Start: 8121202 1 2:40 :58 PM
02082021A Event Time: 8121202 1 2:5t :59 PM
08:59 EXER 3.4 MPH HR 149

Bruce Date of Birth: 7/18/1980 02:59 STAGE 3 14 % BP 140/90

Gender: Male

EXER 08:15
~
1

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Q-Stress 6.3.0.63634 LAKESLA Drs. Mee!. R. Rijadi S., Phys. Page 7

 TN DEDI KUSU MA Exam Start: 8/2/2021 2:40:58 PM

0208202 1A Event Time: 8/2120212 :52: 18 PM
09:17 EXER 4.2 MPH HR 153
Bruce Date of Birth: 7/18/1980 00:17 STAGE 4 16 % BP 140/90
Gender: Male
EXER 08: 15

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II RAHASIA ICONFIDENTIAL I

HASIL PEMERIKSAAN KESEHATAN

No. Reg : 00520210800003

l~"
No. Lab : 2108020003
Nama : Tn. Ded i Kusuma
I
I ", , \~ Umur I Gender
Perusahaan
Departemen
:
:'
:
41 Tah un 0 Bulan
LAKES LA
Penyelam
Laki -Iaki

Job Title : Penyelam

 LA80RATORIUM KLINIK .. POPl'LER .. P1NANGGUHG JAWAB ,
PUSAT : Dr. T1U PUTRI YUNIAIIll, Sp. PI(
JI. Bendul Mer., No 12 Surabaya Telp.(0311 8437902 Fax. 8414840
CabangSUrabaya JI. Manukan Tama No. ill Telp. (0311 7413485 CABANG SURABAYA: Dr. RAHJO£ P. YOGIARTONO
Cabang Tuban JI. AKBP Suroko No. 32 TelplFax (03561 324234 CABANG TUBAN : Or. SANDUNG KURNIAWAN
Cabang Lamongan JLJaksa Agung Supraplo No IITeip (0322) 311048 CA8ANG lAMONCiAN: OI:H. ABOUR R/VA:l Mks, MBA
Cabang BoIOilegOfO JI. Pemuda No. 5P Telp (0353)880617 CABANG fKIJCH<lm: Dr. RIKA TRICHA lNIOIARTT

INFORMASI PRIBADI

Tn. Dedi Kusuma

41 Tahun 0 Bulan
Jeni s Kelamin Laki - laki
Pangirim I Perusahaan LAKESLA
Tanggal Periksa 02-08-2021

PEMERIKSAAN FISIK
TANDAVITAL STATUS GIZI

• Tekanan Darah (TD) 110/70 mmHg • Tin99i Badan 165 em

• Frekuensi Nadi (FN) 78 x I menit • Berat Badan 70 kg
• Fre kuensi Napas (RR) 18 x I menit • Ungkar Pin99ang 89 em
• Suhu Badan (T) 36.2 • C . 8MI 25.71 kglm2

REFRAKSI MATA
• Visus 00 6/6
• Visus OS 6/6

'-' • Gigi
KANANATAS KIRIATAS • KANAN ATAS KIRI ATAS
87654321 12345678

!!I'Y'
, ,, 4
4
J
J ,
2 1 1 1
r 1
, , iNal
,, 5 ;
6
I NI NI NI NI NI NI NI NI HNINjNj NjNjNI NI

I KANANBAWAH KIRIBAWAH IN I NI NI N I NIN I N I N I I NIN l e l N I NIN I N I NI

87654321 1 2 3 4567 8
c.: ~a.ries (karies) M : Missing (hilang) KANAN BAWAH KIRIBAWAH
F . Flllmg (tumpata~) .. . P: Prosthesis (gigi palsu)
I : 1fl1)~ tooth (~paksr g«Jr)R : Ra<lix (akar)
l : Luxation (luksaSr) cr :Crown fracture
K : Kalkulus (karang gigi)

Tn. Dedi Kusumsl41 Tllhun 0 Buillt! 2

 LABORATORIUM KLiNIK .. POPl'LER "
.~
I? I'ENANGGUNG JAWA8 :

~~~~
PUSAT
-
: Dr. TPJ PUTRJ YUNJAAn Sp. PI(
JI. Bendul Meris, No. 12 Surabaya Telp .~03118437902 Fax. 8414840 . ...
"
Cabang SUiabaya :JI. Manukan Tama o. 171 Telp. (031 ) 7413485 CASIING SURABAYA: Dr. RAHJO£P. YOGIARTONO
' ,
CASANGTU BAN : Or. SANDUNG KURNIAWAN

'"
Cabang Tuban JI. AKBPSUioko No. 32 TelplFax (0356) 324234

-~
Cabang Lamongan .Jl.Jaksa Agung Supra~lo No 17 Telp (032 ) 311048 CABliNG lAMONGAN: Dl:H.ABOUR R1VA'~ M.Xes, MBA
Cabang Bolonegoro JI Pemuda No. 5P Te p. (0353) 880617 ( ABANG ~ Ot RICA TRlCHA 'MOIARTl

PEMERIKSAAN FISIK

• Kepala Normal

• Muka Normal ,

• Mata Normal

• Persepsi Warna Normal

• THT Normal

• Mulut Norma l

• Laher Normal

• Dada Normal

• Jantung Normal

• Paru Normal

• Hati
Perut Normal

• I limpa Normal

• Ginjal Normal

• Kulit Normal

• Kelenjar : Normal

• Urogenital Normal

• Ekstremitas Normal

• Lengan Normal

• Tungkai Normal

• Refleks Normal

• Cairan Bebas Negatif

• Sistem Saraf Pusat Normal

• Lain -lain Normal

Tn. Dedi Kusuma 141 TahLm 0 Bulan 3

 EI LABOR ATORIUM KLiNIK .. POl'lLt::R ..
I!!IS&­
P£NANGGUNG JAWAB;

t'~~~
PUSAT : Or. TRI PIffiIJ YUNIARll, 5p. PK
JI Bendul Mensl No. 12 Surabaya TeIP.~03V 8437902 Fax. 8414840
CABANG SURABAYA : Or. AAHJOE P. YOGIARTONO ,
CabangSurabaya JI. Manukan Tama o. 71 Telp.(031) 7413485 ,

•
Cabang Tuban . JI. AKBP Suroko No. 32 TelplFax (0356) 324234 CA8ANG TUBAN : Dr. SANDUNG KURNIAWAN
'U~ Cabang lamongan Jl.Jaksa Agung SUpra~IO No l/Telp (0322) 311048 CABANG LAMONGAN; Dr.H.ABOORRlVA'~ M.Kes, MBA
Cabang 8010n09oro . JI. Pemuda No. 5P Te p.(0353) 880617 CABANG ~ Dr. RIKA TRICHA lMDIARTl
,"_.. _. I

RIWAYAT PAJANAN PEKERJAAN

Pajanan I Hazard Pekerja an Sebelumnya Tahun 2019 - 2020

,
Fisi ka
Suhu Ekstrim Tidak Tidak

Bising ;:. 82 dB Tidak Ya

Radiasi mengion Tidak Tidak
Radiasi oplik (Infrared, sinar tampak, UV, laser
(proses pembakaranfpengelasan, Ya Ya
mengoperasikan kompuler»

Frekuoosi radio Ya Ya
Penerangan Ya Ya
Tekanan udara ekstrim Tidak Tidak
Kimla
Gas ( Sianida/ H2S/CO/CS2/ dU ) Tidak Tidak
Uap ( Metil eti! ketonJdU ) Tidak Tidak
Cairan (Asam kuaVbasa kuaVdll ) Tidak Tidak
Pelarul ( Benzene/toluene/xylene) Tidak Tidak
Debu ( BatubaraJsilika/mineral/dll ) Tidak Ya
Fume ( Mengelaslmematrlfmenyolder) Ya Ya
Kabu t ( Oil mist saat menggerinda ) , Ya Ya
Seral ( Asb e ~kayu/k<lpa sJdll ) Ya Ya
Biologi
Cairanlbagian l ubuh manusia Tidak Tidak

Serangga ( Lebahllaba-labaflomcaVdU ) Ya Ya
Hewan ( Ular/tikusfdll ) Tidak Ya
Jamur Tidak Tidak

Tn. Dedi Kusuma f 41 Tahun 0 Bulan 4

 LABORA T OR IUM KLINIK .. POPl LER " PlNANGGUNG l AWA.8 :
PUSAT : Dr. TRl PUTRI VVMARTl, Sp. PIC.
JI. Bendul MeriSI No. 12 Surabaya Telp (03 1) 8437902 Fax, 8414840
CABANG SURABAVA : 01. RAHJOE P. YOGIARTONO
CabafIQ Surabaya Jt Manukan Tama No 171 Telp (031 ) 7413485
CABANG TUBAN : Or. SAN DUNG KURNIAWAN
Cabang Tuban JI. AKBP Suroka No 32 TelpJFax (03S6) 324234
Gabarlg lamongan : Jt . Jaksa Agung Suprapto No 11 Telp (0322) 311048 CABANG lAMONGAN: Or;H.A8OURRlVA:tMhs, M8A
Caballg BOjonegoro . Jl Pemuda No 5P Telp (0353) 880617 (ABANG ~ Dr. RlKA TRKHA WIOIAAT1

HASIL PEMERIKSAAN
Tanggal 02 Agustus 2021

Pcrusaha.an LAKESLA
Alamat LAKESLA Dr Med Rljadi s. Phys Surabaya

Nama Pasien Tn. Dl3di Kusuma No.ld 00520210800003

Alamat JLKol Sugklno RT31RW4 Cilacap Selatan C ilacap No. Lab 21C)8020003

Jenls Kelamin Laki - laki 1111111111111111111111 1111111111 mil 11111 11111 111
Tgl. Lah ir/Umur: 18-07-1 980/41 T<! hun 0 Bulan
Telepon/HP 08121 5488283

'-rs"EMERIKSAAN HASll NILAI RUJUKAN SATU AN KeTeRANGAN

LABORATORIUM
HEMATOLOGI
Golongan Oarah + Rhesus B (+) Kartu Terlampir

Hemalologi lengkap

Hemoglobin 16.5 13.2 ·1 7 ,3 gfdL

l eukoslt 6 3.8 · 10.6 10"3/uL

Erilrosit 5.59 4.4 · 5.9 10"6fuL

Trombosil 285 150 · 440 10"3/uL

Hematokrit 46.4 40·52 %

LED 5 0- 15 mmfjam

. Eosinofil o· 2- ' %

'-- ' Basofil 0 . 0· 1 %

- Netrofil Segmen 65 50- 70 %
- Limfosil 25 2S - 40 %
- Monosit W 2 -8 %
MCV
83.0 80 - 100
Ii

MCH
29.5 26 - 34
pg
MCHC
35.6 32 - 36
g/dl

ROW
12.5 11.5 . 14.5 %

LABORATORIUM

IMUNOLOGI

Anti - HIV
Non Reaktif Non reaktif

LABORATORIUM

KIMIA KLiNIK

FU NGSI HATI

SOOT
19 <00 UIL

SGPT 28 < 50 UIL

,
HasH berupa tlngka m&nggun8kan $ I$tttm de$imel chm gan separaiOl flrik. _ '",",Ii@!J2~' r2:'lN/)P«r

Tands • menunj uMan nifai ciI 8'8$ atlW ciI bawah nils; rujukan.
 LABORATORIUM KLINIK .. POPI LER"
JI. Bendul Mensi No. 12 Surabaya Telp (031) 8437902 Fax. 8414840
Cabang Surabaya JL Manukan Tama No . 171 Telp. (031) 7413485
PENANGGUNCi JAWA1!:
PUSAT : Dr. TRI PUTRIYUNIARTl, 5p. PI(
CABANG SURA8AYA: Of. RAKJOE P. YOGIARTONO
• .4
,~-.... ,
CABANG TUBAN ; Or. SANDUN G KURNIAWAN '--'-' "
Cabang luball . JI. AKBP Suroka No. 32 TelplFax (0356)324234
~
CaOOng Lamongall JI Jaksa Agung Supraplo No. 17 Telp (0322) 311048 CABANG lAMONGAN: OtH.ABOUR R!VA~ M.KI5, MBA
Cabang Bojonegoro . JI Pemuda No. 5P Telp. (0353) 880617 CA8ANG ~ Dr. R1KA TRICHA WIDIARTJ
"".,
~

j:\ASIL PEMERIKSAAN
Tang9al 02 Agustus 2021

Per usahaan LAKESLA

Alamat LAKESLA Dr Med Rijadi s. Phys Surabaya

Nama Pasien Tn. Dedi Kusuma NO.ld 00520210800003

Alamat JI.Kol Sugiono RT3IRW4 Cilacap Selalan Cilacap No. Lab 2108020003

JQn ls Kelamln Loki - laki 1111111 11111 11111 1111111111 11111 11111 11111 11111 III

Tg1. Lahir/Umur: 16-07- 1980 141 Tahun 0 Bulan

Telepon/HP 0812154B8283

~ EMERIKSAAN HASIL NILA[ RUJUKAN SATUAN KETERANOAN

Blilirubin
8illirubin Direk 0.25 0 · 0.5 mgfd L

Bilirubin Jndirek 0.60 O· 1.0 mgl dL

Bilirubin Total 0.85 0.3 · 1.2 mgldL

METABOLISME KARBGHIDRAT
Glukosa PUBSB 9. 74 · 106 mgldL
Glukosa 2 Jam Postprandial 11 3 < 126 mgldL

FUNGSI GINJAL
Urea N (BUN)
10 8· HI mgfdl
Ktealinin
0.94 0.62-1 .1 0 mg/dL

Asam Ural
4.1 2· 7 mg/dL

'-0 ~BORATORIUM
RIN~LlSA
PENYALAH GUNAAN GBAT
Narkob~ 6 Paraml:!tor

LABORATORIUM
NARKOBA
PENYALAHGUNAAN OBAT
··Amphetamin Negatif
- THC ( Canabinoid ) Negatif

- Morfin Negatif
• Cocain
Negatif
- Methampelamin
Negatif Negati f

- Ben:zodiaz.epam
Negatif Negatil

LABORATORIUM

KIMIA KLiNIK

Profil Lomak

Koleslerol Total
221~ < 200 mg/dL
Has!r berupa angke menggunekan sistem desimal dengan separator litik H. _ 2 0..1 ~0l<)I.=1· 12..";4.;> p.w
Tanda • menunju~kan nilai di a/as a/au di bawah nilai rujukan .
[ F2' _. ., i_ S;S ::nz>Q
= '"
. . LABORATORIUM KLINIK .. POPl LER " ( PENANGGVNG JAWA8:

[~~~
PUSAT ; Or. TRI PUTRIVUNIART1. Sp. PI(
JI. 8endul Merisi No 12 Surabaya Telp_ (031) 8437902 Fax. 8414840
CA8ANG SURA8AYA; Dr. RAHJOE P. YOGIARTONO
Cabang Surabaya JI. Manukan Tama No 171 Telp. (031) 7413485
CABANG T\J8AN ; Or. SANDUNG f(U RNIAWAN
Cabal19 Tuban JI. AKBP Suroko No. 32 Te!pJFs K(0356) 324234
Cabang Lamongan JI. Jaksa Agung Suprapto No, 17 Telp (0322) 311048 CA8ANG lAMONGAN: OtH.A8OURRNA'lM.lCf!oI. MBA
CaballQ Bojonegoro : JI. Pemuda No. 5P Telp. (0353) 880617 CABANG IIOJOt.l.GClRO; Or. R1KA TRICHA WlOIAIm

HASIL PEMERIKSAAN

Tanggal 02 Agustus 2021

Perusahaan LAKESlA
Alamat LAKESlA Dr Mod Rijadi s. Phys Surabaya

Nama Puleo Tn. Dedi Kusuma No. ld 00520210800003

Alamat JI. KoI Sugiono RT3JR W4 Cilacap Selatan Cilacap No. Lab 2168020003

Jenls Kelamin ~akj ·Iaki 111111111111111111111111111 11111 1111111111 11111 I!

Tgl. Lahir/Umur: 18-07-1960 f 41 Tahun 0 8 ulan
TeleponfHP 061215486283

"---.>EMER1KSAAN HASll NILAI RUJ UKAN SATUAN KETERANOAN

- Epithel
0- 1 5 - 15/ LP8 LPK

- Silinder
Negatif Negatif
- Bakleri
Negatif Negatif
- Kristal
Negatlf Negatif
- l.ain-Iain Negatif Negatif

LABORATORIUM

IMUNOLOGI

HbsAg Rapid
Negatif Negatif

LABORATORIUM
LAIN - LAIN
EKG Nannal

Thorax PA ( CR ) Normal
' - Jasa Bacaan T(eadmill TerlampJr

P emeriksa~ln Fisik Lengkap Terlampir

Hasil befUp~ angka mMggl.lnakan sist~ des/mol dengan separator Mit

r anda • menunJu.kkan mlsi dl stas smu dl bsweil nilili rujukan.
 LABORATORIUM KLiNIK .. PO PI LE R " PENANGGUNG JAWAB :
PUSAT : Or. TRI PlJTRI YUNtAR1l, Sp.pt(
JI. Bendul Merisi No 12 Surabaya Telp (031) 8437902 Fax. 8414840
Cabang Surabaya .JI. Manukan Tama No 171 Telp. (031) 7413485 CABANG SURABAVA; Or. RAHJOE P. YOGIARTONO
CABANG TUBAN : Or. SANOUtJG KURNIAWAN
Cabang Tuban _J1. AKBP Suroko No. 32 TelplFax (0356) 324234
Cabang lamongan : JI. Jaksa Agung Supraplo No. 17 Telp (0322) 311048 (AIIANG L.AMa«iAN: OttlABOURRlVA"l M.Ke,. MBA
Cabang Bojonegoro JI Pemuda No. SP Telp (0353) 880617 (ABANG ~ Dr. RlKA TRIOiA W1DlAR11

HASIL PEMERIKSAAN
Tangoai 02 Agustus 2021

Peru sahaan LAKESLA

Alamat LAKESLA Dr Med Rijadi s. Phys Svrabaya

Nama Pasien Tn . Dedi Kusuma No.ld 00520210800003

Alamat JI.Kol Sugiono RT3/RW4 Cilacap Salata" Cilacap No. Lab 2106020003

Jenls KGllamln La ki • laki 111111111111 1111111111 111111111111111 11111 11111 II

Tgl. Lahir/Umur: 18-07-1980/41 TClhun 0 Bulan
Telepon/HP 0812 15488283

' -PEMERIKSAAN HASIL NltAl RUJUKAN SATUAN KETERANGAN

Wakru PengambilWl s p"irnen

- Urine Napz, . 02-08-2021 10:.5:07 AM
- Tread:n"I 02-08-2021 12:24:30 PM
- Rontgen . 02-00-2021 10.21 :34 AM
- EKG . 02-08-2021 12·23.23 PM
- Serum 2 jam PP . 02-08-2021 11:475:1 AM
- Urina : 02-08-2021 10: 45:07 AM
_ S6Il.lm 0 2-QB-2021 10:45:07 AM
. FisiK: 02-08-2021 10.45 07 AM
- Darah EDTA 02-CS-2021 10:4S: 07 AM

Divalidasi oleh : slsmlatl ~,.;

Divalida$i tang9al : 02-08-2021 12:26:22 PM ---;.".Cm
:~."ri'!kLs"C~-
a

H~rI berupD angka menggun~kon 8i8fem desims/ deng¥! separs/or fifik.

Tanda • menunjulc!<an nilai di alas atau di b8W8h nllai rujukan.
 PENANGGUNG JAWAB :
LABORATOR IUM KLiN IK "POPULER" PUSAT : Or. TRl PUTRI YUNlAAn, Sp.PK
P\.ISAl : JL. SENOIA. MERISI NO. 12 SURABAYA TEl? (031 ) 8437902 fAA. 13414340 CABANG $URABAYA : Dr. RAtIJOE P. YOGIARTOHO
CAS. SBY ' Jl, ~UKANTAMANO. 171 lANDES· SUIWlAYA TEl?, (031) 7413485 CABANG TUBAN : Dr. SANDUNG KURNIAWAN
CAS. TUSAN . JL IIKBP SUROKO NO. 32 TUBAN TEl? (0356) 324234
CAS. LAMO NGAN . JL. JAJ($AAGUNG SUPRAPTO~, 17 LA. OGAN TEl? (0322)31'048 CABANG I..AMONGAN : Or. H.AaDUR RIVAl M.Kes, MBA
CAS, BOJONEGORQ . JL. PEMUDANQ, 5 P, BQJONEGOROTELP,(0353)1l80617 CABANG BOJONEGORO: Dr. RIKA TRlCtlA W1D1ARTI

NAMA Tn. Dedi Kusuma Pellgirim

UMUR 41 Tahun
Lakesla
ALAMAT n. KoL Sugiono RT.3/4 Cilacap
NO.REG 2108020003 2021

Sejawat Ter/rormat,

HASIL FOTO THORAX PA

Cor Besar dan benruknya baik.

Pulmo Tak ada Ke lainan

D iagfragma Baik.
I
,

Sinus Prenicocostalis Tajam

I
Tulang Ii Baik.

KESIMPULAN : Tak Tampak Kelainan (NORMAL)

Pemeriksa

a oratorium Klinik "POPULER PU8at Sura aa

IJJ=
I.