Request form Bacteriology P

Laboratory Request Form Department of Microbiology, King Chulalongkorn Memorial Hospital 1873 Rama IV Rd., Pathumwan D...

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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 