Department of Pathology
and Laboratory Medicine

Akron Children's Hospital
One Perkins Square
Akron, OH 44308
Laboratory
Ph: (330) 543-8573
Fax: (330) 543-3659

LABORATORY TEST REQUISITION


PATIENT INFO
Patient Name:
Medical Record #:
BD:        /        /              Sex:    F    M

PHYSICIAN INFO
Physician Name :
Address:
Ph: (        )        -              Fax: (        )        -              
Additional Report to:
Ph: (        )        -              Fax: (        )        -              

TESTS REQUESTED
Test Name: ICD9 Code: (required)
1. Cardiac Ischemia Assessment   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Cardiac Ischemia Assessment
CPT Code: 82550, 82553, 84484

Specimen Type: Blood

Tube Type/Collection Container: Gold top SST (Serum separator tube, no anticoagulant), red top (no anticoagulant) tube, or Green top (lithium heparin) tube

Collection Volume: 2mL (minimum 1mL)

Cause for rejection: Hemolysis

Storage: Refrigerated

Availability: Sent to reference lab

TAT: 2 hours

Panel Includes: CK Total, CKMB, and Troponin I


Lab/Phone: 330-746-9623

Additional Info: Reference ranges: Total CK: Female: 20-180 U/L Male: 20-200 U/L CKMB: Female: 0.0-3.8 ng/mL Male: 0.0-6.7 ng/mL Troponin T: Upper Reference Limit: 0.03 ng/mL Possible myocardial injury: 0.04-0.09 ng/mL Myocardial injury: > or = 0.10 ng/mL

Transport specimens to processing area of the laboratory in an appropriate container. Additional information is available from Cindy Maurer at (330)543-8689.

SHIP TO:
Department of Pathology and Laboratory Medicine
CCL
Akron Children's Hospital
One Perkins Square
Akron, OH 44308


Physician Signature: Date: