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
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