Laboratory Request Form
Department of Microbiology, King Chulalongkorn Memorial Hospital
1873 Rama IV Rd., Pathumwan District, Bangkok 10330, Thailand Tel. 0-2256-4132 Fax 0-2252-5952
Name………………………….….………... Sex r M r F Age………yrs. Clinic/Ward……..……………… HN………………..… AN…………..…… Requested by / Code………………….. Diagnosis…….…...…………..
Bacteriology HIS Lab No. MB….………..…….…
SPECIMEN : Must be filled in completely : Collection Date ……………………….. Time …………………………... By ……………………………………. Blood Gastrointestinal tract Tissue r serum ….. rStool rRectal swab rGastric content rAspirate rAutopsy rBiopsy r Clotted Genitourinary tract Specify site ……………………………..…… (ระบุ) r Heparin r EDTA Urinary tract r Hemoculture ระบุ r Central r Peripheral rCervical swab rVaginal swab Body fluid rUrethral swab rMid-stream Urine rSuprapubic aspirate Upper respiratory tract Miscellaneous rPericardial fluid rAscitic fluid rPeritoneal dialysate rNasal swab rSinus washing/discharge rWater rIsolated bacteria rBile rNasopharyngeal swab rThroat swab rSkin rTip, catheter rBone marrow rPleural fluid Lower respiratory tract rSynovial fluid rMilk rCSF rBronchoalveolar brushing/washing/lavage (BAL) rWound/Abscess/Discharge Eye Specify site ………………………………….. (ระบุ) rAqueous fluid rConjunctival swab rEndotracheal aspirate (ETA) rCorneal scraping rVitreous fluid rSputum rOthers ...…………………………………… (ระบุ) Direct Examination Mycobacterium 1 rMB015 Gram stain rMB002 Mycobacterium culture and AST (Automate: I,R,S,E) rMB004 AFB stain rMB026 Modified AFB stain rMB029 Mycobacterium culture: Blood, body fluid 6 rMB061 Dark-field examination rMB072 MTBC : AST (Automate: I,R,S,E) rMB027 Giemsa stain (Chlamydia trachomatis rMB074 MTBC : AST (Automate: Z) nd inclusion bodies; only corneal scraping) rMB073 MTBC : AST 2 line (MIC Plate, 12 drugs) 5 Culture rMB066 Rapid growing NTM : AST (MIC Plate) 1 rMB001 Aerobic culture with AST (except blood) rMB075 Slow growing NTM : AST (MIC Plate) 3 rMB005 Anaerobic culture rMB068 Identification of Mycobacterium species (Line probe assay) rMB059 Blood culture, aerobe rMB071 Mycobacterium identification by base sequencing 4 rMB060 Blood culture, anaerobe rMB067 Multiplex PCR for Mycobacterium identification 2 rMB006 Bordetella pertussis culture rMB076 MTBC : Identification and genotypic AST for I and R (Line probe assay) nd rMB007 Campylobacter culture rMB077 MTBC : Genotypic AST 2 line (Line probe assay) 2 rMB014 Corynebacterium diphtheriae culture rMB020 PCR for MTBC 2 rMB018 MIC : agent (s) …………………………………………………... rMI183 QuantiFERON-TB Gold** Mycoplasma Legionella 2 rMB019 Mycoplasma pneumoniae culture rMB041 Legionella culture 2 rMB032 PCR for Mycoplasma pneumoniae rMB050 Legionella culture from water rMI053 M. pneumoniae Ab titer rMB039 Legionella IgG Ab (IFA) rMI100 M. pneumoniae Ab : IgG (Qualitative) rMB040 Legionella IgM Ab (IFA) Leptospira rMI101 M. pneumoniae Ab : IgM (Qualitative) 2 Helicobacter rMB017 Leptospira culture rMB069 PCR for Leptospira spp. rMB016 Helicobacter culture rMI075 H. pylori Ab rMI099 Leptospira Ab : IgM Chlamydia/Chlamydophila Typhus rMB008 C. trachomatis culture rMI133 Murine typhus Ab : IgG rMI134 Murine typhus Ab : IgM rMB010 C. pneumoniae IgG (MIF) rMI076 Scrub typhus Ab : IgG rMI077 Scrub typhus Ab : IgM rMB011 C. pneumoniae IgM (MIF) rMI058 Weil-Felix test rMB036 C. psittaci IgG (MIF) rMB070 PCR for Orientia tsutsugamushi (scrub typhus) Others rMB037 C. psittaci IgM (MIF) rMB034 C. trachomatis IgG (MIF) rMB065 Bacterial identification by base sequencing rMB035 C. trachomatis IgM (MIF) rMB013 Clostridium difficile toxin A&B rMB012 Chlamydia/Chlamydophila IgA rMB052 Colony count (Membrane filter method) for species ……………………………………………………….. rMB051 Colony count (Spread plate method) rMB045 PCR for C. pneumoniae rMB062 Quantitative culture (BAL/ETA) rMB038 PCR for C. trachomatis rMB022 Special identification of bacteria 1 - AST = Antimicrobial Susceptibility Test 4 - ตัวอย่าง : AFB-positive specimen
2 - กรุณาติดต่อห้องปฏิบัติการทุกครั้งก่อนส่งตรวจ 5 - NTM = Non-tuberculous mycobacteria
คาแนะนาในการเก็บตัวอย่างส่งตรวจ -- กรุณาดูรายละเอียดในคู่มือสิ่งส่งตรวจ --
3 - ตัวอย่าง : isolated organism 6 MTBC = Mycobacterium tuberculosis complex
** QuantiFERON-TB Gold ใช้เลือด Heparinized Blood 3-5 ml 2 หลอด รายการตรวจ อื่นๆ โปรด พลิก
Laboratory Request Form
Mycology
Department of Microbiology, King Chulalongkorn Memorial Hospital 1873 Rama IV Rd., Pathumwan District, Bangkok 10330, Thailand Tel. 0-2256-4132 Fax 0-2252-5952
HIS Lab No. MF………..…….….
Name………………………….….………... Sex r M r F Age………yrs. Clinic/Ward……..……………… HN………………..… AN…………..…… Requested by / Code………………….. Diagnosis…….…...……………
SPECIMEN : Must be filled in completely : Collection Date ……………………….. Time …………………………... By ……………………………………. Blood Gastrointestinal tract Tissue rSerum …. rStool rRectal swab rGastric content rAspirate rAutopsy rBiopsy rClotted r Plasma Genitourinary tract Specify site ……………………………..…… (ระบุ) rEDTA rHemoculture ระบุ r Central r Peripheral rCervical swab rVaginal swab Urinary tract Body fluid Upper respiratory tract rMid-stream Urine rSuprapubic aspirate rAscitic fluid rPericardial fluid rNasal swab Miscellaneous rBile rPeritoneal dialysate rNasopharyngeal swab rHair rIsolated bacteria rBone marrow rPleural fluid rSinus washing/discharge rIsolated fungus rSkin rCSF rSynovial fluid rThroat swab rNail rTip, catheter Eye Lower respiratory tract rWater rBronchoalveolar brushing/washing/lavage (BAL) rWound/Abscess/Discharge rAqueous fluid rVitreous fluid rCorneal scraping rEndotracheal aspirate (ETA) Specify site ………………………………….. (ระบุ) rConjunctival swab rSputum rOthers …………………………………… (ระบุ) Direct Examination Susceptibility Test 2 2 rMF013 Gomori’s methenamine silver nitrate (GMS) stain rMF016 Etest : Amphotericin B rMF019 Etest : Ketoconazole 2 2 rMF005 India ink preparation rMF017 Etest : Caspofungin rMF030 Etest : Posaconazole 2 2 rMF006 KOH preparation rMF018 Etest : Fluconazole rMF021 Etest : Voriconazole 2 rMF010 Wright stain for fungus rMF020 Etest : Itraconazole Culture Others 2 rMF022 Blood culture for fungus (Automated) rMF014 Mold identification (Conventional) 2 rMF003 Fungus culture rMF015 Yeast identification 2 Serology rMF027 PCR for fungus detection 2 rMF026 Aspergillus galactomannan antigen (EIA) rMF028 PCR for fungus identification 2 rMF001 Cryptococcus antigen (LA) rMF029 (13)-β-D-Glucan assay 2 rMF031 Pythium insidiosum Ab
Laboratory Request Form
Department of Microbiology, King Chulalongkorn Memorial Hospital
1873 Rama IV Rd., Pathumwan District, Bangkok 10330, Thailand Tel. 0-2256-4132 Fax 0-2252-5952 rMI098 rMI054 rMI061 rMI052 rMI060 rMI057 rMI199
IMMUNOLOGY
Others Infectious Ag/Ab Anti-DNase B ASO Bacterial antigens [Streptococcus group B, E.coli K1, H.influenzae type B, S.pneumoniae, N.meningitidis] Cold agglutinin Melioid Ab Widal test Anti-tetanus
2 - กรุณาติดต่อห้องปฏิบัติการทุกครั้งก่อนส่งตรวจ
คาแนะนาในการเก็บตัวอย่างส่งตรวจ -- กรุณาดูรายละเอียดในคู่มือสิ่งส่งตรวจ --
รายการตรวจ อื่นๆ โปรด พลิก
Laboratory Request Form
Department of Microbiology, King Chulalongkorn Memorial Hospital
1873 Rama IV Rd., Pathumwan District, Bangkok 10330, Thailand Tel. 0-2256-4132 Fax 0-2252-5952
Name………………………….….……………. Sex r M r F Age………yrs. Clinic/Ward……..………... HN………………..… AN…………..………. Requested by / Code………………….. Diagnosis…….…...…….
VIROLOGY HIS Lab No. MV..………..…….…….
SPECIMEN : Must be filled in completely : Collection Date …………… Time ………. By …………. Antiviral treatment rYes (ระบุ)..................rNo st nd Genitourinary tract Blood rClotted r1 serum r2 serum Respiratory tract rEDTA rHeparin rNasopharyngeal aspirate rNasopharyngeal swab rCervical swab rVaginal swab rBone marrow rEndotracheal aspirate rNasal swab rUrine rCSF rBronchoalveolar lavage (BAL) rThroat swab Gastrointestinal tract rStool rRectal swab rGastric content Eye rConjunctival swab rVitreous fluid Skin lesions rSkin scraping/swab rVesicle fluid rOther…………………………………………..(ระบุ) rCorneal scraping rTear
Adenovirus rMV059 Adenovirus Ag (Rapid) rMV063 Adenovirus isolation* rMV100 Adenovirus viral load BK polyomavirus rMV084 BK polyomavirus viral load Cytomegalovirus (CMV) rMV001 CMV-IgG rMV002 CMV-IgM rMV018 CMV-infected cell Ag* rMV041 CMV-viral load rMV042 CMV-DNA (qualitative) rMV094 QuantiFERON-CMV Dengue virus rMV079 Dengue IgG/IgM/NS1 (Rapid) rMV004 Dengue IgG/IgM (Rapid) rMV068 Dengue IgG (ELISA) rMV092 Dengue IgM (ELISA) rMV080 Dengue-RNA (qualitative) Epstein-Barr virus (EBV) rMV005 EBV-IgG rMV006 EBV-IgM rMV029 EBV-IgA rMV051 EBV(EBNA)-IgG rMV066 EBV-viral load Hepatitis B virus rMV037 HBV-viral load
VIROLOGY
Hepatitis C virus MERS - Coronavirus rMV038 HCV-RNA (qualitative) rMV085 MERS-CoV (RT-PCR)* rMV039 HCV-viral load rMV086 MERS-CoV & Respiratory virus 19 subtypes* rMV065 HCV genotype (Linear array) rMV087 MERS-CoV & Influenza A/B/RSV(RT-PCR)* Hepatitis E virus Mumps virus rMV101 Hepatitis E virus (RT-PCR) rMV070 Mumps-IgG rMV071 Mumps-IgM Herpes simplex virus (HSV) Norovirus rMV007 HSV-IgG rMV008 HSV-IgM rMV096 Norovirus Ag (Rapid) rMV017 HSV-infected cell Ag rMV103 Norovirus (RT-PCR) rMV020 HSV isolation* Parainfluenza virus rMV052 HSV-DNA (qualitative) rMV058 Parainfluenza 1, 2, 3 Ag rMV102 Tzanck smear rMV062 Parainfluenza 1,2,3 isolation* Human papilloma virus (HPV) Parvovirus rMV055 HPV-16/18 & high risk types rMV025 Parvo B19 IgG rMV026 Parvo B19 IgM Human immunodeficiency virus (HIV) Respiratory syncytial virus (RSV) rMV034 HIV-DNA (qualitative) rMV093 Influenza A,B,RSV Ag (Rapid) rMV035 HIV-viral load rMV053 RSV isolation* rMV098 Antiretroviral resistance analysis Rotavirus (RT & Protease) rMV016 Rotavirus Ag (Rapid) Influenza virus Rubella virus rMV093 Influenza A,B,RSV Ag (Rapid) rMV010 Rubella-IgG rMV011 Rubella-IgM rMV081 Influenza A/B/RSV (RT-PCR) Varicella-zoster virus (VZV) rMV061 Influenza (A,B) isolation* rMV030 VZV-IgG rMV031 VZV-IgM rMV064 Influenza A (H5N1)* rMV069 VZV-DNA (qualitative) rMV088 Influenza A (H7N9)* rMV072 VZV-infected cell Ag JC polyomavirus rMV102 Tzanck smear rMV099 JC polyomavirus viral load Zika virus Measles virus rMV089 Zika virus (RT-PCR) rMV032 Measles-IgG rMV033 Measles-IgM rMV090 Zika virus-IgG rMV091 Zika virus-IgM Multiple viruses rMV078 Rotavirus and Enteric adenovirus (Rapid) rMV081 Influenza A/B/RSV (RT-PCR) rMV095 Multiplex mosquito borne viruses [Dengue virus type 1-4, Zika virus, and Chikungunya virus] rMV012 TORCH-IgG [Rubella, CMV, HSV] rMV013 TORCH-IgM [Rubella, CMV, HSV] rMV083 Herpesvirus 1-8 and Enterovirus (Microarray) [HSV-1,2, VZV, EBV, CMV, HHV-6,7,8, and Enterovirus] rMV056 Respiratory virus Ag (Panel 7 types) [Influenza A,B; Parainfluenza 1,2,3; Adenovirus; RSV] rMV060 Respiratory virus isolation (Panel 7 types)* [Influenza A, B; Parainfluenza 1,2,3; Adenovirus; RSV] rMV082 Respiratory virus 19 subtypes (Microarray) [Adenovirus; Bocavirus; Coronavirus 229E, HKU1, NL63, OC43; hMPV; Influenza A (H1, H3, H1N12009); Influenza B; Parainfluenza 1, 2, 3, 4; RSV A, B; Enterovirus/Rhinovirus] rMV097 Gastroenteritis panel (Microarray) คาแนะนาในการเก็บตัวอย่างส่งตรวจ -- กรุณาดูรายละเอียดในคู่มือสิ่งส่งตรวจ --
*กรุณาติดต่อห้องปฏิบัติการทุกครั้งก่อนส่งตรวจ รายการตรวจ อื่นๆ โปรด พลิก
Laboratory Request Form
Department of Microbiology, King Chulalongkorn Memorial Hospital
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…….…...……
IMMUNOLOGY HIS Lab No. MI………..…….…………....
SPECIMEN : Must be filled in completely : Collection Date …………… Time ………. By …………. Antiviral treatment Yes (ระบุ)..................No
Body fluid (ระบุ) ………………………………………………. Urine Urine 24 Hrs HIV Serology Immunoglobulin รายการด่วน MI106 Anti HBc (ด่วน) MI034 Anti HIV MI001 IgG MI006 IgG 1 MI105 Anti HBs (ด่วน) MI036 HIV p24 antigen MI002 IgM MI007 IgG 2 Hepatitis B virus Serology MI109 Anti HCV (ด่วน) MI003 IgA MI008 IgG 3 MI035 Anti HIV (ด่วน) MI037 HBe Ag MI040 Anti HBs MI004 Total IgE MI009 IgG 4 MI104 HBs Ag (ด่วน) MI038 HBs Ag MI041 Anti HBe MI135 Serum free light chain : κ MI161 Treponemal Ab (ด่วน) MI039 Anti HBc MI042 Anti HBc IgM MI136 Serum free light chain : λ Syphilis Serology MI151 HBs Ag quantitative MI011 Serum Protein Electrophoresis MI049 FTA-ABS:IgG MI047 TPHA(TP-PA) Hepatitis C virus Serology MI131 Serum Immunofixation MI050 FTA-ABS:IgM MI046 VDRL/RPR MI045 Anti HCV MI158 Serum Immunotyping Electrophoresis MI048 FTA (CSF) Hepatitis A virus Serology MI204 Urine Protein Electrophoresis MI160 Treponemal Ab MI043 Anti HAV IgM MI205 Urine Immunofixation Tumor Marker MI044 Anti HAV (Total Ig) MI206 Urine Immunotyping Electrophoresis Hepatitis E virus Serology Lymphocyte subpopulation MI016 Alpha-fetoprotein MI017 β2-microglobulin MI163 Anti HEV IgG MI164 Anti HEV IgM MI088 CD3, CD4 counts Acute phase protein MI015 CA19-9 MI208 PIVKA-II MI067 CD3, CD4, CD8 counts MI178 Amniotic AFP MI051 CRP MI062 Cryoglobulin* MI068 CD3,CD4,CD8,CD19,CD56 counts Complement MI110 CRP (High sensitivity) MI111 NK cell count (CD56) Specific HLA MI013 C3 *** MI012 CH50 *** MI112 B cell count (CD19) MI014 C4 *** MI149 HLA-B*1502 MI091 HLA-B27 รายการทดสอบที่ตอ้ งติดต่อล่วงหน้า Autoantibody MI144 HLA-B*5701 MI162 HLA-B51 MI080 HLA class II (DR,DQ) DNA typing MI018 Antinuclear Ab (IF) MI145 HLA-B*5801 MI089 HLA class I (A,B) DNA typing Alzheimer MI019 Anti-ds DNA (EIA) MI107 HLA-A DNA typing MI209 Anti-ds DNA (IF) MI188 hTAU Ag MI189 β-Amyloid(1-42) MI108 HLA-B DNA typing MI021 Anti RNP MI190 Phospho-TAU(181P) MI066 PHA stimulation MI137 DHR assay Allergy MI022 Anti Sm MI200 B cell subpopulation test [Transitional B-cell, Plasmablast, Naïve Mature B cells, MI023 Anti SS-A MI130 Tryptase Natural effector cells, CD27+ Memory B cells] MI024 Anti SS-B Specific IgE to (FEIA) MI026 Rheumatoid factor MI154 Amoxilloyl (c6) MI201 T cell subpopulation test [Naïve T cells, Memory T cells, Effector T cells] MI027 Antithyroglobulin MI155 Penicilloyl G (c1) MI028 Antithyroid peroxidase MI120 House dust mite (d1-Dp) MI126 Mixed food [Egg white (f1), Milk (f2) , Fish (f3), Wheat (f4), Peanut (f13), Soya bean (f14)] MI202 Thyroglobulin MI121 House dust mite (d2-Df) MI203 TG Wash MI122 Cat epithelium and dander (e1) MI117 Shrimp (f24) MI029 Anticardiolipin : IgG MI123 Dog dander (e5) MI114 Soya bean (f14) MI030 Anticardiolipin : IgM MI152 Crab (f23) MI153 Squid (f258) MI031 Anticardiolipin : IgA MI118 Egg white (f1) MI115 Wheat (f4) MI032 Antimitochondria Ab MI179 Egg white panel [Egg white (f1), MI181 Wheat panel [Wheat (f4), Ovalbumin (f232), Ovomucoid (f233)] Omega-5-gliadin (f416)] MI033 Antismooth muscle Ab MI146 Anti CCP MI187 Egg yolk (f75) MI127 Mixed grass [Bermuda (g2), Rye (g5), Timothy (g6), Kentucky blue (g8), MI156 Anti β2 glycoprotein I-IgG MI116 Fish (f3) Johnson (g10), Bahia grass (g17)] MI157 Anti β2 glycoprotein I-IgM MI119 Milk (f2) MI186 Anti-PLA2R MI180 Milk panel [Milk (f2), MI150 Fire ant (i70) Beta-lactoglobulin (f77), Casein (f78)] MI124 Cockroach (Ri206) MI184 Anti IFN-gamma MI196 Anti-IL-17A MI113 Peanut (f13) MI125 Latex (k82) MI198 Anti-GM-CSF MI210 Specific IgE to Allergen panel (IB) [House dust mite (d1-Dp), House dust mite (d2-Df), Cat epithelium and dander (e1), Crab (f23), Egg white (f1), Ovalbumin (f232), Ovomucoid (f233), Egg yolk (f75), MI182 ANCA (IFA : cANCA, pANCA, Milk (f2), Peanut (f13), rAra h 2 Peanut (f423), rAra h 9 LTP Peanut (f427), Shrimp (f24), Wheat (f4), Gluten (f79)] MPO, PR3, GBM) MI176 Myositis profile 4 (IB) [Ro-52, OJ, EJ, PL-12, PL-7, SRP, Jo-1, PM-Scl75, PM-Scl100, Ku, SAE1, NXP2, MDA5, TIF1γ, Mi-2β, Mi-2α] MI132 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] MI177 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] Blood
Clotted EDTA Heparin Serum
* Cryoglobulin เจาะเลือด 10 ml ห้ามแช่เย็น ใช้มือกาหลอดเลือดมาแล้วนาส่งทันที
*** ส่งตรวจ complement ส่งทันทีหรือเก็บตูเ้ ย็นไม่เกิน 2 ชัว่ โมง
รายการตรวจ อื่นๆ โปรด พลิก
