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. CK Isoenzymes   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for CK Isoenzymes
CPT Code: 82550, 82552

Specimen Type: Blood

Tube Type/Collection Container: Gold top SST (serum separator tube, no anticoagulant)

Collection Volume: 5.0 mL (minimum 2.5 mL)

Cause for rejection: -

Storage: Frozen

Availability: Sent to reference lab

Methodology: Spectrophotometry; Electrophoresis

Special Instructions: Total CK should be > 100 U/L to provide meaningful isoenzyme results. Remove serum from cells ASAP CK-MB and CK-BB are temperature labile. Repeated freeze/thaw cycles destroy CK activity.

TAT: 3-4 days

Panel Includes: Creatine Kinase, % CKMB, % CKMM, % CKBB


Lab/Phone: 330-543-8418

Additional Info: Reference range: Creatine Kinase: Sex: Male; Age: 2-18 Years; Range: <175 U/L Sex: Male; Age: >18 Years; Range: <195 U/L Sex: Female; Age: 2-18 Years; Range: <152 U/L Sex: Female; Age: >18 Years; Range: <170 U/L %CKBB: Range: Not detected %CKMB: Range: <4% of Total %CKMM: Range: 97-100% of Total

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: