ua patho gb - sk.laboklin.infosk.laboklin.info/wp-content/uploads/2015/01/patologia_bez-cen.pdf ·...

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Previous lab-No.: _________________________________ Characteristics of the suspected tumor solitary multiple recurrence metastasising invasive expansive Medical history / requests __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ List of differential diagnoses __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ Business Hours: Mo - Fr: 8:00 - 19:00 h, Sa: 9:00 - 13:00 h Courier Further details about the dermatological patient - See back page D000120030132D 000120030132 Aspirate (cytology and clin. chem. ex.) Lymphocyte clonality Thorax, abdomen (Total protein, specific gravity, cell count) (Total protein, specific gravity, cell count, glucose) Bacteriology incl. differentiation Antibiogram flat rate Mycology Anaerobes Additional tests: (Total protein, specific gravity, pH, cell count, Rivalta's test, cholesterol, triglycerides, LDH, glucose) Synovia, others Cerebrospinal fluid (CSF) Owner's address: Sex: F F.N. M.N. M Breed: _________________________ Pathology Submission form Patient-ID: ___________________________ Date of sampling: _________________ Animal data: Cat Dog _____________________ Other: Horse Name: __________________________ Customer-No. / Barcode Tel.No.: __________________________________________ Zipcode/city: Street: __________________________________________ __________________________________________ __________________________________________ First name: __________________________________________ Name: Date of birth: __________________ Immunohistology (Aspirate, impression smears, vaginal cytology, bone marrow) (Tumor diagnostics, dermatopathology, pathology of organs, endoscopic biopsies) Cytology Histopathology Following histopathology e.g.: - CD3/CD79a (lymphoma), - COX-2, Ki-67 (mast cell tumor), - Epithelial / mesenchymal markers - Infections: FeLV, FHV, FCoV ("FIP"), parvovirus Localisation: _________________________________ _____________________________________ Date and signature: ______________________ _________________________________ Fax/e-mail: VAT-ID : (stamp or block letters) Submitting veterinary surgery: Sample: Organ Tumor Biopsy Cytol. slide Aspirate 8418 205 150 151 165 207 206 209 204 201 Post box 1810 · 97668 Bad Kissingen /Germany Phone 0049 (0)971/72020 fax 0049 (0)971/68546 E-Mail: info@laboklin com

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Page 1: ua patho gb - sk.laboklin.infosk.laboklin.info/wp-content/uploads/2015/01/patologia_bez-cen.pdf · Previous lab-No.: _____ Characteristics of the suspected tumor solitary multiple

Previous lab-No.: __________________________________________________________

Characteristics of the suspected tumor

solitary

multiplerecurrencemetastasising

invasiveexpansive

Medical history / requests

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

List of differential diagnoses

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

Business Hours: Mo - Fr: 8:00 - 19:00 h, Sa: 9:00 - 13:00 h

Courier

Further details about the dermatological patient - See back pageD000120030132D000120030132

Aspirate (cytology and clin. chem. ex.)

Lymphocyte clonality

Thorax, abdomen

(Total protein, specific gravity, cell count)

(Total protein, specific gravity, cell count, glucose)

Bacteriology

incl. differentiation

Antibiogram flat rate

MycologyAnaerobes

Additional tests:

(Total protein, specific gravity, pH, cell count, Rivalta's test, cholesterol, triglycerides, LDH, glucose)

Synovia, others

Cerebrospinal fluid (CSF)

Owner's address:

Sex: F F.N. M.N.M Breed: ___________________________

Pathology

Submission form

Patient-ID: ___________________________

Date of sampling: ___________________________

Animal data: CatDog _________________________________Other:Horse Name: ____________________________

Customer-No. / Barcode

Tel.No.: __________________________________________

Zipcode/city:

Street:

__________________________________________

__________________________________________

__________________________________________First name:

__________________________________________Name:

Date of birth:____________________________

Immunohistology

(Aspirate, impression smears, vaginal cytology, bone marrow)

(Tumor diagnostics, dermatopathology, pathology of organs, endoscopic biopsies)

Cytology

Histopathology

Following histopathology e.g.:- CD3/CD79a (lymphoma),- COX-2, Ki-67 (mast cell tumor),- Epithelial / mesenchymal markers- Infections: FeLV, FHV, FCoV ("FIP"), parvovirus

Localisation:

_________________________________

______________________________________________Date and signature:

______________________

_________________________________

Fax/e-mail:

VAT-ID :

(stamp or block letters)Submitting veterinary surgery: Sample:

OrganTumorBiopsy

Cytol. slideAspirate

8418

205

150

151

165

207

206

209

204

201

Post box 1810 · 97668 Bad Kissingen /GermanyPhone 0049 (0)971/72020 fax 0049 (0)971/68546E-Mail: info@laboklin com

Page 2: ua patho gb - sk.laboklin.infosk.laboklin.info/wp-content/uploads/2015/01/patologia_bez-cen.pdf · Previous lab-No.: _____ Characteristics of the suspected tumor solitary multiple

General information on skin lesions

yes

yes

yes

yes

yes

noyes _____________________________________________________________

Pruritus:

Symmetry:

or people affected:Other animals

Previous skin or ear problems:

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

noSystemic illness:

Appearance of early lesions:

Problem since:

_____________________________________________________________Current main skin problem:

mild 1 2 3 4 5 6 7 8 9 10 severeDegree of pruritus:

Seasonality:

_____________________________________________________________

no

no

no

no

Previous diagnostics

Fungal culture:

Bacterial culture:

Skin scrapings:

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

no

no

no

no

no

no

no

no

no

yes

yes

yes

yes

yes

yes

yes

_____________________________________________________________Others:

Biopsy:

Immunology (ANA):

Hormone assays:

CBC, chemistry:

Allergy testing:

Wood's light/hair:

no

yes

yes

yes

Elimination diet:

Lesions

CrustClaw lesionsComedoNoduleCallusHyperpigmentationExcoriationErythemaErosionsEpidermal collaretteDepigmentationAlopecia

Antibiotics:

Lesions resolved

Lesions recur when therapy discontinued yes no

yes no

_________________________

VesicleUlcerScalePustulePlaqueFoot pad lesionsPapuleScarMaculeLichenification

Previous Treatment

Antibiotics: yes no

Glucocorticoids:

Shampoo therapies:

Flea controls:

Anti-scabies:

yes

yes

yes

yes

yes

yes

no

no

no

no

no

no

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

Type ______________ Duration ____________ Response _____ %

Type ______________ Duration ____________ Response _____ %

Type ______________ Duration ____________ Response _____ %

Type ______________ Duration ____________ Response _____ %

Type ______________ Duration ____________ Response _____ %

Type ______________ Duration ____________ Response _____ %

Type ______________ Duration ____________ Response _____ %

Antihistamines:

Anti-yeast/fungals:

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

Type ______________ Duration ____________ Response _____ %

yes no _____________________________________________________________Futher:

Further comments:

__________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________

Feel free to call us

D000000000001D000000000001

General Business Conditions:All prices in Euro ex. VAT / All statements according to our conditions, See www.laboklin.com / All terms and prices are subject to changes.

GB - 012.003 14/07

Supply Order:

Heparin tubes Faeces containers

Submission forms-General

Submission forms-Hygiene

Chlamydophila-Ag medium

Submission forms-Farm Animal

Submission forms-Genetics EquineSubmission forms-Reptiles

Envelopes Submission forms-Allergy

Barcodes

Serum tubes

Submission forms-Equine

Citrate tubes

NaF tubes

Swabs (with medium)

Containers for tubes

Slide containers

Histology containers (formalin)

Submission forms-Pathology

Submission forms-Genetics Dog/CatSwabs (without medium)

Containers for swabs

Urine containers

EDTA tubes

3a 5

56

40

13

94

97

74

10 57

80

1

16

2

4

6

11

12

14

58

64

6a

6b

7

3