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. Acylglycine   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Acylglycine
CPT Code: 82544

Specimen Type: Urine

Tube Type/Collection Container: Urine container

Collection Volume: 5.0 mL

Cause for rejection: -

Storage: Frozen

Availability: Sent to reference lab

Methodology: Gas Chromatography-Mass Spectrometry (GC-MS) Stable Isotope Dilution Analysis

Special Instructions: -

TAT: 7 days


Lab/Phone: 330-543-8418

Additional Info: Reference range: Ethylmalonic Acid: 0.50-20.20 2-Methylsuccinic Acid: 0.40-13.80 Glutaric Acid: 0.60-15.20 Isobutyrylglycine: 0.00-11.00 n-Butyrylglycine: 0.10-2.10 2-Methylbutyrylglycine: 0.30-7.50 Isovalerylglycine: 0.30-14.30 n-Hexanoylglycine: 0.20-1.90 n-Octanoylglycine: 0.10-2.10 3-Phenylpropionylglycine: 0.00-1.10 Suberyglycine: 0.00-11.00 trans-Cinnamoylglycine: 0.20-14.70 Dodecanedioic Acid(12:0): 0.00-1.10 Tetradecanedioic Acid(14:0): 0.00-1.00 Hexadecanedioic Acic(16:0): 0.00-1.00

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: