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4 IHC RUMAH SAKIT PEIABI'HAN CIREBON

INSTALAS' LABORATORIUM PATOLOGI KLINIX

FARAH OW ANGCRAEN,dI

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cedificate of TB (tuberculosis) screenin
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r. (Medi..l .umin.tion rcsuk,
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1. +1aq { eyra rre'tm.nr hi,toryr:
. 9E No, v/ B ?8(Yer r. + E 6Lund4 n"ril"1r,'
2. E{ elC=g(slqB & srhprohs lugg.stive ofrB): A AANo) E/B gC(Yer:
3. A+x|i e4 Erl(9F of ch.n xr"yt lr \ lt tart.rt+ t.r
a 3&\omalr -/ B rrrl cE sl.lEEBqxCJ+d d' h6du" ,Br
c. Zq ff^A6uspecled active IB) L
1, 4'JZ+ grlD.b orsp uh erahrhrloh)
1) ?lEJ.EEe^l{sputum AFB smear): A 88(Neqatve).3 of,C(Posirive) f
2) z\.JBllota\l,5e!\!n M fube@tosE (uhure) A 8c(Nesative) B. oJc(Posrive) Lt
3) qt=+z\rrB PcR): a adN€eative) L- B oJdPosirve) c. u llr
e(Not done) l
lt. alktnte
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2 lE€ Bq E= EqllC(Ad'verBor!Gp€(t.dTB)E
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The examinanon was perfohed as abde
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E-.jEE(tkens No) / E^lCE(Name oi Physi.

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(summary or^tthe exam nalion) t \l1s
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{Remarks aboul examinee s domest. nay)
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{Additiona (ose examrnatio.) (Atta.h do.tor'r oplnion lmer, il needed)
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