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
multiplerecurrencemetastasising
invasiveexpansive
Medical history / requests
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List of differential diagnoses
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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:
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______________________________________________Date and signature:
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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
General information on skin lesions
yes
yes
yes
yes
yes
noyes _____________________________________________________________
Pruritus:
Symmetry:
or people affected:Other animals
Previous skin or ear problems:
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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:
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no
no
no
no
Previous diagnostics
Fungal culture:
Bacterial culture:
Skin scrapings:
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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
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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
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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:
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Type ______________ Duration ____________ Response _____ %
yes no _____________________________________________________________Futher:
Further comments:
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Feel free to call us
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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