Theophylline
| 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. Theophylline | |
| 2. | |
| 3. | |
| 4. | |
| 5. | |
| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
THEO
Test Workstation :
ACHM5
Specimen Type:
Blood
Tube Type:
Green top (lithium heparin) tube
Minimum Volume:
500 uL
Preferred Volume:
1.5 mL
Storage:
Shipping- Send Refrigerated; Storage-Refrigerated: 1 week; Frozen: 60 days
Availability:
24 hours/day, 7 days/week
Methodology:
Roche-KIMS
Special Instructions:
For therapeutic monitoring, draw peak levels 1 hour postIV infusion, 2 hours postoral ingestion of rapid release theophylline, or 4 hours postoral ingestion of sustained release theophylline, and trough levels immediately prior to next dose.
Lab/Phone:
330-543-8418
TAT:
1 hour
Additional Info:
Therapeutic range: 10-20 ug/mL
CPT Code:
80198
Synonyms:
Aminophylline; Theospan; Somophylline; TheoDur
