Laboratory Request Form Department of Microbiology, King Chulalongkorn Memorial Hospital
Barcode
1873 Rama IV Rd., Pathumwan District, Bangkok 10330, Thailand Tel. 0-2256-4132 Fax 0-2252-5952
Name………………………….….……….. Sex M F Age………yrs. Clinic/Ward……..…………… HN………………..… AN…………..…… Requested by / Code……………. Diagnosis…….…...……………
HIS Lab No. MB/MF………..…….…….
SPECIMEN : Must be filled in completely : Collection Date ………………………….… Time ………………….……... By ……………………….…………. Blood Gastrointestinal tract Tissue Clotted 1st serum Hemoculture ระบุ Central
2nd serum Peripheral
Body fluid
Ascitic fluid Bile Bone marrow CSF Gastric content/washing
Pericardial fluid Peritoneal dialysate Peritoneal fluid Pleural fluid Synovial fluid
Stool
Rectal swab
Aspirate Autopsy Biopsy Specify site …………………………………………… (ระบุ)
Vaginal swab
Urinary tract
Genitourinary tract Cervical swab Urethral swab
Urine Suprapubic aspirate
Upper respiratory tract
Miscellaneous
Nasal swab Throat swab Nasopharyngeal swab Sinus washing / discharge
Eye
Lower respiratory tract
Aqueous fluid Corneal scraping
Conjunctival swab Vitreous fluid Others ………………………………………… (ระบุ)
Bronchoalveolar brushing/washing/lavage (BAL) Endotracheal aspirate (ETA) Sputum
MB004 AFB stain MB061 Dark-field examination MB027 Giemsa stain (Chlamydia trachomatis inclusion bodies; only corneal scraping)
MB015 Gram stain MF013 Gomori’s methenamine silver nitrate (GMS) stain MF005 India ink preparation
Hair Isolated bacterium Isolated fungus Milk Nail Skin Water Tip, catheter Wound/Abscess/Discharge Specify site …………………………………………… (ระบุ)
Direct Examination
BACTERIOLOGY
BACTERIOLOGY Culture
BACTERIOLOGY
MB001 MB005 MB059 MB060 MB006 MB007 MB014 MB018
Aerobic culture with AST 1 (except blood) Anaerobic culture Blood culture, aerobe Blood culture, anaerobe Bordetella pertussis culture 2 Campylobacter culture Corynebacterium diphtheriae culture 2 MIC : agent (s) ………………………………………2
MB008 MB010 MB011 MB036 MB037 MB034 MB035 MB012 MB045 MB038
C. trachomatis culture C. pneumoniae IgG (MIF) C. pneumoniae IgM (MIF) C. psittaci IgG (MIF) C. psittaci IgM (MIF) C. trachomatis IgG (MIF) C. trachomatis IgM (MIF) Chlamydia/Chlamydophila IgA for species …………… PCR for C. pneumoniae PCR for C. trachomatis Syphilis
MB041 MB050 MB039 MB040
MB019 MB032 MI053 MI100 MI101
Legionella culture 2 Legionella culture from water Legionella IgG Ab (IFA) Legionella IgM Ab (IFA)
Mycobacterium MB002 Mycobacterium culture (Automated) and susceptibility testing MB029 Blood, sterile fluid for Mycobacterium MB066 Susceptibility test for rapid grower Mycobacterium 2 MB068 Identification for Mycobacterium by INNO-LiPA 3 MB067 Multiplex PCR for Mycobacterium identification 4 MB020 PCR for Mycobacterium tuberculosis complex MB063 PCR for MTB rpoB gene MB064 Base sequencing for MTB rpoB gene MI183 QuantiFERON-TB Gold
Helicobacter MB016 Helicobacter culture MI075 H. pylori Ab
Typhus
MI133 MI134 MI076 MI077 MI058 MB070
Murine typhus Ab : IgG Murine typhus Ab : IgM Scrub typhus Ab : IgG Scrub typhus Ab : IgM Weil-Felix test PCR for Orientia tsutsugamushi (scrub typhus)
MB065 MB013 MB052 MB051 MB062 MB022
Bacterial identification by base sequencing Clostridium difficile toxin A&B Colony count (Membrane filter method) Colony count (Spread plate method) Quantitative culture (BAL/ETA) Special identification of bacteria
Others MI098 Anti-DNase B MI054 ASO MI061 Bacterial antigens (Streptococcus group B, E.coli K1, H.influenzae type B, S.pneumoniae, N.meningitidis)
MI052 Cold agglutinin MI060 Melioid Ab
MI057 Widal test
MYCOLOGY
MYCOLOGY
MYCOLOGY
Culture MF022 Blood culture for fungus (Automated) MF003 Fungus culture
1 3
Etest Etest Etest Etest Etest Etest
แลกขวดคืน
: Amphotericin B : Caspofungin 2 : Fluconazole 2 : Itraconazole 2 : Ketoconazole 2 : Voriconazole 2
2
AST = Antimicrobial Susceptibility Test ต ัวอย่ำง : isolated organism
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Note :-
MYCOLOGY
Serology MF026 Aspergillus galactomannan antigen (EIA) MF001 Cryptococcus antigen (LA)
Susceptibility Test MF016 MF017 MF018 MF020 MF019 MF021
ส่งทันที ห้ำมแช่เย็น Urine :ระบุเวลาเก็บ ส่งทันที ภายใน 2 ชัว่ โมง หรือ เก็บตู ้เย็นไม่เกิน 24 ชัว่ โมง Sputum :เสมหะเช ้า ระบุเวลาเก็บ ส่งทันที หรือเก็บตู ้เย็น ไม่เกิน 24 ชัว่ โมง Swab :aerobe: Amies transport medium (วุ ้นสีดา) fungus: ใส่ขวด sterile ทีม ่ ี NSS ประมาณ 0.5 มล. Tissue :ขนาด < 1 ซม3 ใส่ขวด sterile ห้ำมใส่ formalin ถ ้าสงสัย Pythiosis & Mucormycoses ส่งทันที หรือเก็บทีอ ่ ณ ุ หภูมห ิ ้อง Stool :เก็บใน Cary Blair transport medium (วุ ้นสีขาว) สาหรับ Campylobacter culture เก็บใส่ขวด sterile
.................................
MYCOLOGY
คำแนะนำในกำรเก็บ ต ัวอย่ำง Blood culture :ผู ้ใหญ่ 5 – 10 มล. เด็ก 1 – 3 มล. CSF, Body fluid :้ เก็บใส่ขวดปราศจากเชือ
2
Leptospira
MI047 TPHA (TP-PA) MI160 Treponemal Ab (CMIA) MI046 VDRL (RPR)
Mycoplasma pneumoniae culture PCR for Mycoplasma pneumoniae M. pneumoniae Ab titer M. pneumoniae Ab : IgG (Qualitative) M. pneumoniae Ab : IgM (Qualitative)
BACTERIOLOGY
MB017 Leptospira culture 2 MI099 Leptospira Ab : IgM MB069 PCR for Leptospira spp.
Chlamydia/Chlamydophila
Mycoplasma
BACTERIOLOGY
Legionella
MI049 FTA-ABS : IgG MI050 FTA-ABS : IgM MI048 FTA (CSF)
MF006 KOH preparation MB026 Modified AFB stain MF010 Wright stain
2
Others
MF014 MF015 MF024 MF027
2 4
Mould identification (Conventional) Yeast identification Western blot for pythiosis 2 PCR for fungus detection
กรุณำติดต่อห้องปฏิบ ัติกำรทุกครงก่ ั้ อนส่งตรวจ ต ัวอย่ำง : AFB-positive specimen
รำยกำรตรวจ IMMUNOLOGY and VIROLOGY โปรด พลิก
Laboratory Request Form Department of Microbiology, King Chulalongkorn Memorial Hospital
Barcode
1873 Rama IV Rd., Pathumwan District, Bangkok 10330, Thailand Tel. 0-2256-4132 Fax 0-2252-5952
Name………………………….….……….. Sex M F Age………yrs. Clinic/Ward……..…………… HN………………..… AN…………..…… Requested by / Code……………. Diagnosis…….…...……………
HIS Lab No. MV/MI………..…….…
SPECIMEN : Must be filled in completely : Collection Date …….....… Time …..…….. By …….…… Antiviral treatment Yes (ระบุ)…………………… No
Blood Clotted 1st serum 2nd serum Respiratory tract Genitourinary tract EDTA Heparin Nasopharyngeal aspirate Nasopharyngeal swab Cervical swab Vaginal swab Bone marrow Endotracheal aspirate Nasal swab Urine CSF Bronchoalveolar lavage (BAL) Throat swab Gastrointestinal tract Eye Conjunctival swab Vitreous fluid Skin lesions Stool Rectal swab Gastric content Corneal scraping Tear Skin scraping/swab Vesicle fluid Other…………………………………………………(ระบุ) IMMUNOLOGY and VIROLOGY IMMUNOLOGY and VIROLOGY IMMUNOLOGY and VIROLOGY
Infection รำยกำรด่วนส่งทีห ่ อ ้ งปฏิบ ัติกำร ภปร. 4
MI106 MI105 MI109 MI035 MI104 MI161
Anti HBc (ด่วน) Anti HBs (ด่วน) Anti HCV (ด่วน) Anti HIV (ด่วน) HBs Ag (ด่วน) Treponemal Ab (CMIA) (ด่วน)
Adenovirus
MV059 Adenovirus Ag MV063 Adenovirus isolation *
Hepatitis A virus
MI043 Anti HAV IgM MI044 Anti HAV (Total Ig)
Hepatitis B virus
MI040 MI037 MI038 MI151 MV037
MI039 Anti HBc Anti HBs HBe Ag MI042 Anti HBc IgM MI041 Anti HBe HBs Ag HBs Ag quantitative HBV-viral load
MI045 MV038 MV039 MV065
Anti HCV HCV-RNA (qualitative) HCV-viral load HCV genotype (Linear array)
MV084 BK-viral load
Cytomegalovirus (CMV)
MV001 MV018 MV041 MV042
CMV-IgG MV002 CMV-IgM CMV-infected cell Ag * CMV-viral load CMV-DNA (qualitative)
MV079 MV004 MV068 MV080
Dengue IgG/IgM/NS1 (Rapid) Dengue IgG/IgM (Rapid) Dengue IgG/IgM (ELISA) Dengue-RNA (qualitative)
Hepatitis E virus
Herpes simplex virus (HSV)
Epstein-Barr virus (EBV)
MV081 MV078 MV083 MV056 MV060 MV082
EBV-IgG MV006 EBV-IgM EBV-IgA EBV (EBNA)-IgG EBV-viral load
MV007 MV017 MV020 MV052
HSV-IgG MV008 HSV-IgM HSV-infected cell Ag HSV isolation * HSV-DNA (qualitative)
Human papilloma virus (HPV) MV054 HPV-DNA (screening and typing) MV055 HPV-16/18 & high risk types
Human immunodeficiency virus (HIV)
Multiple viruses Influenza A/B/RSV (RT-PCR) Rotavirus and Enteric adenovirus(Rapid) Herpesvirus 1-8 and Enterovirus(Microarray) Respiratory virus Ag (Panel 7 types) Respiratory virus isolation (Panel 7 types) * Respiratory virus 19 subtypes (Microarray)
MI034 MI036 MV034 MV035
Influenza virus
Influenza Influenza Influenza Influenza Influenza
A,B Ag (Rapid) A/B/RSV (RT-PCR) (A,B) isolation * (H5N1) A (H1N1) 2009
Measles virus MV032 Measles-IgG MV033 Measles-IgM
Mumps virus MV070 Mumps-IgG MV071 Mumps-IgM
Parainfluenza virus MV058 Parainfluenza 1, 2, 3 Ag MV062 Parainfluenza 1,2,3 isolation *
Parvovirus
MI163 Anti HEV IgG MI164 Anti HEV IgM
Dengue virus
MV005 MV029 MV051 MV066
MV073 MV081 MV061 MV064 MV074
Hepatitis C virus
BK virus
MV025 Parvo B19 IgG MV026 Parvo B19 IgM
Respiratory syncytial virus (RSV) MV015 RSV-Ag (Rapid) MV053 RSV isolation *
Rotavirus MV016 Rotavirus Ag (Rapid)
Rubella virus MV010 Rubella-IgG MV011 Rubella-IgM
Varicella-zoster virus (VZV)
Anti HIV HIV p24 antigen HIV-DNA (qualitative) HIV-viral load
MV030 VZV-IgG MV031 VZV-IgM MV069 VZV-DNA (qualitative) MV072 VZV-infected cell Ag [HSV-1, HSV-2, VZV, EBV, CMV, HHV-6, HHV-7, HHV-8, Enterovirus]
[Influenza A, B; Parainfluenza 1, 2, 3; Adenovirus; RSV] [Influenza A, B; Parainfluenza 1, 2, 3; Adenovirus; RSV] [Influenza A (H1N1, H3N2, 2009), B, C; Parainfluenza 1 ,2, 3, 4A, 4B; Adenovirus; RSV A, B; hMPV A, B; Enterovirus; Rhinovirus; Coronavirus 229E; Bocavirus]
MV012 TORCH-IgG (Rubella, CMV, HSV) MV013 TORCH-IgM (Rubella, CMV, HSV)
Non-Infection Allergy
Complement
MI130 Tryptase Other Allergy tests use form บ. 6342
Autoantibody MI018 Antinuclear Ab (IF) MI019 Anti-ds DNA
MI021 MI022 MI023 MI024
MI026 MI027 MI028 MI029 MI030 MI031 MI032 MI033 MI146 MI156 MI157 MI175 MI182 MI184 MI186 MI176 MI132 MI177
Anti Anti Anti Anti
RNP Sm SS-A SS-B
MI013 C3 *** MI014 C4 *** MI012 CH50 ***
Immunoglobulin
MI001 MI002 MI003 MI004
IgG IgM IgA Total IgE
Tumor Marker
MI016 MI017 MI015 MI178
Alpha-fetoprotein β2-microglobulin CA19-9 Amniotic AFP
Acute phase protein MI051 CRP MI110 CRP (High sensitivity) MI062 Cryoglobulin **
Specific HLA MI006 IgG 1 Rheumatoid factor MI091 HLA-B27 MI007 IgG 2 Antithyroglobulin MI144 HLA-B*5701 MI008 IgG 3 Antithyroid peroxidase MI009 IgG 4 MI145 HLA–B*5801 Anticardiolipin : IgG MI135 Serum free light chain : MI149 HLA–B*1502 Anticardiolipin : IgM MI136 Serum free light chain : MI162 HLA-B51 Anticardiolipin : IgA MI011 Protein Electrophoresis MI090 HLA-DR4 Antimitochondria Ab MI131 Immunofixation รำยกำรทดสอบทีต ่ อ ้ งติดต่อล่วงหน้ำ Antismooth muscle Ab MI158 Capillary Immunotyping Electrophoresis MI069 HLA class I serotyping Anti CCP Lymphocyte subpopulation MI080 HLA class II (DR,DQ) DNA typing Anti 2 glycoprotein I-IgG MI088 CD3, CD4 counts MI089 HLA class I (A,B) DNA typing Anti 2 glycoprotein I-IgM MI067 CD3, CD4, CD8 counts MI107 HLA-A DNA typing ANCA profile(MPO, PR3, GBM) MI068 CD3,CD4,CD8,CD19,CD56 counts MI108 HLA-B DNA typing ANCA (IFA) MI111 NK cell count MI066 PHA stimulation Anti IFN-gamma MI112 B cell count MI137 DHR assay Anti-PLA2R Myositis profile 3 (IB) [Mi-2, Ku, PM-Scl100, PM-Scl75,Jo-1, SRP, PL-7, PL-12, EJ, OJ, Ro-52] ANA profile 1 (IB) [nRNP/Sm, Sm, SS-A, Ro-52, SS-B, Scl-70, Jo-1, CENP B, dsDNA, nucleosomes, histones, ribosomal P-protein] ANA profile 5 (IB) [nRNP/Sm, Sm, RNP 70, RNPA, RNPC, SS-A, Ro-52, SS-B, Scl-70, PM-Scl, Jo-1, CENP B, PCNA, dsDNA, nucleosomes, histones, ribosomal P protein, AMA-M2]
คำแนะนำในกำรเก็ บต ัวอย่ำงส่งตรวจ -- กรุณำดูรำยละเอียดในคูม ่ อ ื สิง่ ส่งตรวจ -* กรุณำติดต่อห้องปฏิบ ัติกำรทุกครงก่ ั้ อนส่งตรวจ
แก้ไขครงที ั้ ่ 1/2557
** Cryoglobulin เจำะเลือด 10 มล.ห้ำมแช่เย็ น ใช้มอ ื กำหลอดเลือดมำแล้วนำส่งท ันที *** ส่งตรวจ complement ส่งท ันทีหรือเก็บตูเ้ ย็ นไม่เกิน 2 ชว่ ั โมง