PENGAJUAN KEWENANGAN KLINIS DOKTER UMUM

YTH. KETUA SUB KOMITE KREDENSIAL RSUD BIAK

DI
TEMPAT

Saya yang mengajukan permohonan kewenangan klinis ini :

NAMA : AHMAD PASHA

PENDIDIKAN TERAKHIR : S1

Dengan ini mengajukan kewenangan klinis sesuai dengan kompetensi saya sebagai dokter umum
sebagaimana disebutkan dalam undang undang kedokteran.
Tidak Tidak
Disetujui Disetujui
Disetujui Disetujui
Diagnosis Diagnosis
Dengan Dengan
Mandiri Mandiri
Supervisi Supervisi

CARDIOVASCULAR Lymph vessels

Cardiac disorders: 1. Lymphangitis V

1. Angina pectoris V 2. Lymphadenitis V

3. Lymphedema, primary
2. Unstable angina V and secondary V

3. Myocardial V RESPIRATORY
infarction

1. Uncomplicated
4. Heart Failure V V
pulmonary TBC

5. Cardiorespiratory
V 2. TBC with HIV V
arrest
6. Supraventricular V 3. Acute Bronchitis V
tachycardia

7. Atrial flutter V 4. Bronchiolitis3 V

8. Ventricular V 5. Bronchial asthma V

extrasystole

Aorta-arteries 6. Status asmaticus V

disorder
1. Essential V 7. Lung emphysema V
hypertention

2. Secondary V 8. Atelectasis V
hypertension

3. Septic shock V 9. Bronchiectasis V

4. Hypovolemic V 10. COPD V

shock
Veins 11. SARS V

1. Thrombophlebitis V 12. Pneumonia V

Tidak Tidak
Disetujui Disetujui
Disetujui Disetujui
Diagnosis Diagnosis
Dengan Dengan
Mandiri Mandiri
Supervisi Supervisi
13. Pleurisy TBC V 5. Colitis V

6. Rectal, anal
14. Pneumothorax V V
prolapsed
15. Aspiration V 7. Proctitis V
Pneumonia
GASTROINTESTINAL Pediatrics

1.
Mouth Gastroesophageal V
reflux4

1. Candidiasi V 2. Gastroenteritis4 V

3. Gastroenteritis
2. Mouth ulcer V V
dengan dehidrasi3B

3. Glossitis V 4. Worm V

Esophagus 5. Dehydration V

1. Corrosive lesion of V 6. Malabsorbtion V

esophagus

2. Reflux esophagitis V 7. Food intolerance V

8. Peritonitis
Acute abdomen V
tuberculosi

1.Ileus V 9. Umbilical hernia V

2.Salphingitis V 10. Hepatitis V

11. Cirrhosis of the

3.Acute appendicitis V V
liver

4.Appendicular V 12. Food allergy V

abscess
Stomach and NEFROLOGY
duodenum

1. Acute
1. Gastriti V V
glomerulonephritis

2. Gastric/ duodenal 2. Chronic

V V
ulcer glomerulonephritis

3. Gastrointestinal V 3. Renal colic V

bleeding

4. Urinary stone
4. Gastroenteriti V diseases or urinary V
calculi without colic

5. Urinary tract
Liver V
infection

6. Uncomplicated
1.Fatty live V V
pyelonephritis

2.Hepatitis V 7. Prostatitis V

3.Uncomplicated
V Male genitalia
hepatitis

4.Amoeboic liver V 1. Hypospadia V

abscess

5.Acute cholecystitis V 2. Epispadia V

3. Undescended
Jejunum, ileum, testes/ V
colon cryptorchidism

4. Retractile of
1. Enteriti V V
testes

2. Irritable bowel V 5. Torsion of testes V

syndrome

3. Necrotizing V 6. Paraphimosi V
enterocolitis
4. Diverticulosis/ V 7. Ruptur uretra V
diverticulitis

Tidak Tidak
Disetujui Disetujui
Disetujui Disetujui
Diagnosis Diagnosis
Dengan Dengan
Mandiri Mandiri
Supervisi Supervisi

3. Respiratoty
8. Ruptur V V
stress syndrome

4.
9. Ruptur ginjal V Bronchopulmonary V
dysplasia

5. Aspiration
10. Striktura uretra V V
pneumonia

11. Priapismu V 6. Pneumothorax V

12. Penyakit peironi V 7. Apnea attacks V

13. Ekstrophia 8. Jaundice of the

V V
vesicae newborn

Vulva 9. Severe neonatal V

jaundice3

1. Vulvitis V 10. Hypoglycemia V

2. Cyst of bartholin, 11. Child of diabetic

abscess of bartholin’s V V
mother
gland

3. Abscess of hair 12. Neonatal

follicle or sebaceous V V
convulsion
gland

4. Condiloma 13. cerebral

V V
acuminate hemmorhage

Vagina, cervix, 14. Conjunctivitis V

uterus, adnexae

15. Infection of
1. Vaginiti V V
umbilicus

2. Bacterial vaginosi V 16. SIDS V

 ENDOCRINE,
METABOLIC
3. Foreign body V DISORDER and
NUTRITION

4. Cerviciti V 1. IDDM V
5. Salphingitis V 2. NIDDM V

3. Complication of
6. Ovarian cyst V DM V
(acute&chronic)

HEMATOLOGY 4. Hypoglycemia V

1. Iron deficiency
V 5. Hyperthyroidism V
anemi

6. Adrenal cortex
2. Macrocytic anemia V V
failure

3. Hemolytic anemia V 7. Marasmu V

4. Anemia associated V 8. Kwashiorkor V

with chronic disease

9. Vitamin
IMMUNOLOGY V
deficiencies

10.
1. Uncomplicated V Hyperlipoproteine V
mia

2. Vasculitis Lupus V 11. Gout V

3. Polymyalgia V 12. Obesity V
rheumatic

CENTRAL AND
4. Rheumatoid V PERIPHERAL
arthritis NEURAL SYSTEM

5. Anaphylactic Loss of
V
reaction consciousness

1. Metabolic
6. Rheumatic fever V V
encephalopathy

7. Atopy V 2. Comatous V

8. Immunodeficiency V 3. Brain death V

GENETICS/NEWBOR
N/CHROMOSOMAL Headache
DISORDER
 1. Tension
1. Hypotermia V V
headache
2. Bacteraemia and V 2. Migraine V
septicaemia
Tidak Tidak
Disetujui Disetujui
Disetujui Disetujui
Diagnosis Diagnosis
Dengan Dengan
Mandiri Mandiri
Supervisi Supervisi

3. Cranial arteritis V 3. Neuropathy V

4. Trigeminal V 4. Peroneal palsy V

neuralgia

5. Guillain Bare
5. Cluster headache V V
syndrome

Cardiovascular 6. Myasthenia
disease gravis V

1. TIA V Infectious disease

2. Cerebral infarction V 1. Meningitis V

3. Intracerebral V 2. Encephalitis V
hematoma

4. Subarachnoid V 3. Malaria cerebral V

hemorrhage
5. Hypertensive V 4. Tetanus V
encephalopathy

Cranial nerve and 5. Cerebral V

brainstem lesions toxoplasmosis

1. Bells palsy V 6. HIV-AIDS V

2. Brain stem lesions V

Congenital ,
pediatric
neurologic
disorders

Disorder of 1. Hydrocephalus V
vestibular system

1. Meniere’s disease V 2. Meningitis V

2. BPPV V 3. Encephalitis V

3. Vertigo central V 4. Cerebral abscess V

Movement disorder 5. Epilepsi V

1. Parkinson’s 6. Petit mal
V V
disease epilepsy

2. Secndary 7. Febrile
V V
parkinsonism convulsion

8. Poliomyelitis V

Epilepsy and other 9. Cerebral palsy V

seizures

1. Generalized V 10. kernicterus V

epilepsy

Neurobehaviour
disorders, trauma,
2. Absance seizure V
tumor CNS,
gangguan visual

1. Amnesia pasca
3. Status epilepticus V V
trauma

Diseases of spine 2. Afasia V

and spinal cord

1. Complete spinal 3. Mild Cognitive

V V
transaction impairment

2. Neurogenic 4. Epidural
V V
bladder hematom

5. Subdural
3. Myelopathy V V
hematom
4. Medulla V 6. SAH V
compression acute
5. Radicular 7. Trauma medulla
V V
syndrome spinalis

8. Tumor CNS
6. Spondilitis V V
primer

Neuromuscular
9. Tumor CNS
diseases and V
sekunder
neuropathy

1. Carpal tunnel V 10. Buta mendadak V

syndrome

2. Tarsal tunnel V 11. Diplopia V

syndrome
Tidak Tidak
Disetujui Disetujui
Disetujui Disetujui
Diagnosis Diagnosis
Dengan Dengan
Mandiri Mandiri
Supervisi Supervisi
 1. Medial and
EAR, NOSE AND lateral brachial cyst V
THROAT and fistula

Ears, hearing and 2. Cystic hygroma V

equiblirium
1. Inflammation of V 3. Torticollis V
auricle

2. Herpes zoster Thyroid gland and

V
oticus parathyroid glands

3. Pre-auricular V 1. Cyst V
fistula
4. Foreign body in V 2. Goitre V
ear

5. Wax (serumen) V 3. Hyperthyroidism V

4.
6. Otitis externa V Hyperparathyroidis V
m

5.
7. Acute otitis media V Hypoparathyroidis V
m
8. Otitis media V EYE
serous (glue ear)
9. Chronic otitis V Conjunctiva
media

10. Perforated 1. Conjunctiva,

V V
tympanic membrane foreign body

2. Conjunctivitis,
11. Bullous myringitis V V
allergy

3. Conjunctivitis,
12. Otosclerosis V V
viral

4. Conjunctivitis,
13. Tympanosclerosis V V
bacterial

14. Presbyacusis V 5. Pterygium V

6. Subconjunctival
15. Mastoiditis V haemorrhage V

16. Benign postural V Eyelids

vertigo

17. Motion sickness V 1. Blepharitis V

18. Meniere’s V 2. Hordeolum V
disease

19. Acute acoustic V 3. Chalazion V

trauma

20. Ear, other trauma V 4. Eyelid laceration V

21. Congenital V 5. Eyelid retraction V

deafness

Anterior chamber,
22. Facial palsy or iris and ciliary
V
paralysis body, glaucoma,
lens

Nosesand sinuses 1. Hyphaema V

1.Epitaxis V 2. Hypopyon V

2.Furuncle of nose V 3. Iridocyclitis, iritis V

3.Acute rhinitis 4. Glaucoma

V V
(common cold) congenital

4.Vasomotor rhiniti V 5. Simple glaucoma V

5.Allergic rhiniti V 6. Acute glaucoma V

7. Secondary
6.Chronic rhinitis V V
glaucoma

7.Chronic sinusitis V 8. Cataract V

8.Foreign body in V 9. Lens dislocation V

nose

Refraction and
Larynx and pharynx accommodation

1. Pharyngiti V 1. Hypermetropia V

2. Tonsilitis V 2. Myopia V
Neck
Tidak Tidak
Disetujui Disetujui
Disetujui Disetujui
Diagnosis Diagnosis
Dengan Dengan
Mandiri Mandiri
Supervisi Supervisi

3. Astigmatism V Bacterial infections

4. Presbyopia V 1. Impetigo V
 2. Ulcerative
5. Anisometropia V V
impetigo (ecthyma)

Vision and visual 3. Superficial

V V
fields folliculiti

4. Furuncle,
1.Amblyopia V V
carbuncle

2.Diplopia V 5. Erythrasma V

3.Suppresion V 6. Erysipelas V

Superficial fungal
4.Night-blindness V infection

5.Scotoma V 3. Tinea faciale V

6.Hemianopia V 4. Tinea corporis V

7.Loss of vision and V 5. Tinea manus V

blindness
Optic disc and optic 6. Tinea unguinum V
nerve

1. Papiledema V 7. Tinea cruris V

2. Optic atrophy V 8. Tinea pedis V

SKIN 9. Tinea versicolor V

Eczematous 10. Mucocutaneus

V
dermatitis candidiasis

1. Contact dermatitis Insect bites and

V
irritan infestations

2. Contact dermatitis V 1.Pediculosis capiti V

allergic
3. Atopic dermatitis V 2.Pediculosis pubis V
(kecuali recalcitrant)
4. Nummular V 3.Scabies V
dermatitis
5. Lichen simplex 4.Insect bites
V V
chronicus reaction

Allergic skin,
6. Napkin eczema V autoimmune diseases

Erythrosquamous 1. Urticari V
lesions

1. Psoriasis vulgaris V 2. Angioudema V

2. Palmoplantar 3. Lupus
V V
pustulosi erythematosus

3. Seborrhoic V Disorders of hairs

dermatiti

1. Alopesia
4. Pityriasis rosea V V
areata3A

Disorders of skin 2. Androgenic

eccrine and V
alopecia
sebaceous glands

1. Acne vulgaris V 3. Trichotillomania V

4. Telogen
2. Rosacea V V
effluvium

3. Hidradenitis Disorders of
V
supurativa keratinizations

4. Perioral dermatitis V 1. Ichtyosis vulgaris V

Other
noninfectious
5. Miliaria V
inflammatory skin
disorders

Viral skin infections 1. Lichen planus V

2. Granuloma
1. Verruca vulgari V V
annulare

2. Condyloma V Drug reactions

accuminata

3. Molluscum 1. Exanthematous
V V
contagiosum drug eruption

4. Herpes zoster V
Tidak Tidak
Disetujui Disetujui
Disetujui Disetujui
Diagnosis Diagnosis
Dengan Dengan
Mandiri Mandiri
Supervisi Supervisi
2. Fixed drug 2. Tetanus
V V
eruption (pediatric)

Pigmentary Mycobacterial
disorders diseases

1. Tuberculosis
1. Vitiligo V V
cutis

2. Melasma V 2. Leprosy V
3. Post inflammatory V 3. Lepra reaction V
hyperpigmentation
4. Post inflammatory Spirochetal
V
hypopigmentation diseases
INFECTIOUS ABD 1. Syphilis V
TROPICAL DISEASES
Localized infections 2. Yaws V
and abscess

1. Tinea capiti V 3. Leptospirosis V

2. Tinea barbae V Viral infections

Infections of the 1. Influenz V
hands
1. Paronichia V 2. Avian influenza V

2. Suppurative 3. Viral
V V
tenosynoviti gastroenteriti

3. Human bite V 4. Poliomyelitis V

Infections of the 5. Rabies V

head and neck
1. Suppurative V 6. Morbili V
parotiti
2. Suppurative V 7. Varicella V
cervical adeniti
3. Peritonsilar
V 8. Herpes zoster V
abscess

4. Ludwig’s angina V 9. Herpes simple V

5. Bezold abscess V 10. Mump V

Grampositive and 11. CMV infections V
negative cocci
1.Superficial V 12. DHF V
infections
2.Osteomyelitis V 13. HIV-AIDS V

3.Staphylococcal Protozoal
V
pneumonia infections

4.Rheumatic fever V 1.Amebiasis V

5.Nasopharyngitis V 2.Malaria V

3.Leishmaniasis
Gonococcal and V
infections tripanosomiasis

1. Gonnorhea V 4.Toxoplasmosis V

Gram negative bacilli 5.Giardiasis V

1. Urinary Tract V 6.Trichomoniasis V

Infecton

2. Typhoid fever V Worm infestasions

 1.Hookworm
3. Dysentry bacilli V V
diseases

4. Cholera V 2.Strongyloidiasis V

5. Pertussis V 3.Ascariasis V

6. Canchroid V 4.Filariasis V

Toxin producing 5.Schistosomiasi V

bacteria

6.Cutaneus larva
1. Diphteria (THT) V V
migrant

Tidak Tidak
Disetujui Disetujui
Disetujui Disetujui
Diagnosis Diagnosis
Dengan Dengan
Mandiri Mandiri
Supervisi Supervisi

7.Taeniasis V 4. Poisoning V

5. Suffocation V

NEOPLASMA 6. Bleeding V

7. Hypovolemic
1. Leukoplakia V V
shock

2. Benign Prostate 8. Dislocation of

V V
Hyperplasia jaw

3. Condyloma 9. Dislocation of
V V
accuminata knee

10. Dislocation of
4. Epithelial cyst V V
patella

5. Mycosis 11. Prapatellar

V V
fungoides3 bursitis

12. Fractures of
6. Mastocytosis V V
tibia

7. Langerhans cell 13. Rib fractures /

V V
histiocytosis contusion

14. Injury caused by

8. Ganglion cyst V V
rib fractures

15. Sternal
9. Liposarcoma V V
fractures

MUSCULOSCELETAL 16. Fractures of V

SYSTEM toes
 17. Crush injury to
1. Arthritis V the heel (in V
children)

18. Fractures of
2. Osteoporosis V V
fibula

3. Physical overload V 19. Whiplash V

20. Fractures,
4. Osteomyelitis, capsule, tendon
V V
acute and ligament lesion
of ankle

5. Arthriti V 21. Pneumothorax V

6. Fractures of femur V 22. Hemothorax V

23. Injury specific

7. Fractures, capsule, to internal organs
tendon and ligament V V
(liver, kidney, lung,
lesions of knee etc)

24. Injury of
8. Achilles tendonitis V V
peripheral nerves

Neck,shoulder
9. Rupture of Achilles V gridle and upper
tendon extremities

10. Instability of 1.Fractures of

V V
ankle shoulder

2.Dislocation of V
shoulder

3.Ligamentous
lesions of shoulder
TRAUMATOLOGY V

4.Instability of
Birth trauma V
shoulder

1. Caput 5.Fracture of
V V
succedaneum clavicle

Trauma 6.Frozen soulder V

 7. Fracture of
humerus, radius,
1. Drowning V V
ulna, elbow, wrist,
fingers, thumb

8. Lateral
2. Head injury V epicondylitis V
(tennis elbow)

9. Dislocation of
3. Burning V V
distal radius, wrist

Tidak Tidak
Disetujui Disetujui
Disetujui Disetujui
Diagnosis Diagnosis
Dengan Dengan
Mandiri Mandiri
Supervisi Supervisi

10. Progressive
inflammation of 6. Secondary mild
V V
finger following contraction
injury

11. Olecranon V 7. Hypoxia of fetus V

bursitis

12. Carpal tunnel 8. Rupture of

V V
syndrome perineum

13. Injury of finger 9. Retained

V V
tendon placenta

14. Nail loss V Postpartum

15. Subungual 1. Retained

V V
hematoma placental tissue

16. Traumatic vessel 2. Postpartum

V V
injury haemorrhage

Accident and
emergency Puerpurium
neurology
1. Head injuries V 1. Mastitis V
2. Diffuse brain V 2. Cracked nipple V
damage
3. Cerebral
contusions and V 3. Inverted nipple V
concussion

4. Brain death V 4. Endometritis V

 5. Inflamation of
5. EDH V V
pelvis

6. Incontinence of
6. SDH V V
urine

7. Basilar fracture 7. Incontinence of

V V
scalp faeces

8. Acute traumatic 8. Post-natal

V V
spinal transaction psychoses

9. Injury of plexus 9. Post-natal

and peripheral V V
depression
nerves

REPRODUCTION 10. Subinvolution V

SYSTEM of uterus

Infections during
pregnancy/delivery
1. Syphilis V
2. AIDS V
Pregnancy disorder Demikian pengajuan RINCIAN KEWENANGAN
1. Incompleted KLINIS ini saya buat sebagai persyaratan
spontaneous V diterbitkannya surat penugasan klinis. Atas
abortion perhatiannya saya ucapkan terima kasih
2. Completed
spontaneous V
abortion
3. Hyperemesis V
gravidarum
4. Dysmaturity V
5. Polyhydramnion V
6. Iron deficiency
anemia
V Pemohon
Delivery
1. Premature V
contractions
2. Premature V
delivery
3. Postmature infant V
4. Prolonged delivery V
5. Primary mild
contraction V dr. ……………………………………………...