Form LAB448 (MDL60) "Fungus Culture for Identification" - California

What Is Form LAB448 (MDL60)?

This is a legal form that was released by the California Department of Public Health - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2004;
  • The latest edition provided by the California Department of Public Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form LAB448 (MDL60) by clicking the link below or browse more documents and templates provided by the California Department of Public Health.

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Download Form LAB448 (MDL60) "Fungus Culture for Identification" - California

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State of California-Health and Human Services Agency
ces
FUNGUS (;ULTURE FOR IDENTIFICATION
State Laboratory number
Please print or type.
Patient's name (last, first)
Age
'Sex
Date collected
Description of Specimen
Address
Check source:
Physician's name
D
Case
D
Human
D
Animal (species):
D
Diagnostic specimen
0
Other (specify):
Clinical condition or suspected disease
Date of onset
Check box which describes the specimen from which the submitted
Return report to:
culture was obtained:
O
Blood
0
Gastric
0
Sputum
0
CSF
Name
i
·-
7
0
Throat
D
Urine
D
Feces
0
Skin
Tissue (type):
Address
Pus (source):
Exudate (source):
Wound (location):
ZIP code
L
_J
Other (specify):
Submitter's identification of organism:
Brief case history, therapy, outcome
IMPORTANT:
Enter your laboratory findings on reverse side.
Was skin testing done?
OYes
ONo
Results: Coccidioidin
Histoplasmin
Other (specify):
(Continue on reverse if necessary.)
Antifungal or antibacterial agents:
D
None
Date
Date
Tiavel and
Residence Locations
Data
T~,---
Dosage
Begun
Complete
I
y._,.::~
USA
Foreign
Animal contacts (species):
DO NOT WRITE BELOW THIS LINE
Report of State Laboratory Investigation
Growth Rate
Pigment
Colony morphology on
Microscopic Characteristics
Medium
25-30°
37°
Surface
-Reverse
Sabouraud medium
Age:
Medium:
Age:
SC
' '
sec
BBHI
Ferm.
Assim.
CM
Dextrose
Accuprobe result for:
D
Coccidioides immitis
PDA
Galactose
D
Histoplasma capsulatum
CMD
Lactose
D
Blastomyces dermatiditis
Maltose
EMS
Sucrose
0
POSITIVE
D
negative
GMT
Trehalose
Other tests or comments:
Urease
Raffinose
VB Agar
Melibiose
Hair Penetration
Cellobiose
Organism identified as:
Thiamine
Inositol
Xylose
Loeffler
Dulcitol
Gelatin
KN03
SC
= Sabouraud dextrose agar+ chloramphenicol
CM
= Cornmeal agar
Date received
sec
= Sabouraud dextrose agar + chloramphenicol + cycloheximide
CMD = Cornmeal dextrose agar
BBHI = Brain heart infusion agar+ blood
CMT = Cornmeal tween agar
Date reported
PDA
= Potato dextrose agar
VB
= Vegetable juice agar
Microbial Diseases Laboratory • 850 Marina Bay Parkway, E164 • Richmond, CA 94804 • (510) 412-3700
Page 1 of 2
LAB 448 (7/04) (MDL 60)
~
Department of Health Servi
California Department of Public Health
State of California-Health and Human Services Agency
ces
FUNGUS (;ULTURE FOR IDENTIFICATION
State Laboratory number
Please print or type.
Patient's name (last, first)
Age
'Sex
Date collected
Description of Specimen
Address
Check source:
Physician's name
D
Case
D
Human
D
Animal (species):
D
Diagnostic specimen
0
Other (specify):
Clinical condition or suspected disease
Date of onset
Check box which describes the specimen from which the submitted
Return report to:
culture was obtained:
O
Blood
0
Gastric
0
Sputum
0
CSF
Name
i
·-
7
0
Throat
D
Urine
D
Feces
0
Skin
Tissue (type):
Address
Pus (source):
Exudate (source):
Wound (location):
ZIP code
L
_J
Other (specify):
Submitter's identification of organism:
Brief case history, therapy, outcome
IMPORTANT:
Enter your laboratory findings on reverse side.
Was skin testing done?
OYes
ONo
Results: Coccidioidin
Histoplasmin
Other (specify):
(Continue on reverse if necessary.)
Antifungal or antibacterial agents:
D
None
Date
Date
Tiavel and
Residence Locations
Data
T~,---
Dosage
Begun
Complete
I
y._,.::~
USA
Foreign
Animal contacts (species):
DO NOT WRITE BELOW THIS LINE
Report of State Laboratory Investigation
Growth Rate
Pigment
Colony morphology on
Microscopic Characteristics
Medium
25-30°
37°
Surface
-Reverse
Sabouraud medium
Age:
Medium:
Age:
SC
' '
sec
BBHI
Ferm.
Assim.
CM
Dextrose
Accuprobe result for:
D
Coccidioides immitis
PDA
Galactose
D
Histoplasma capsulatum
CMD
Lactose
D
Blastomyces dermatiditis
Maltose
EMS
Sucrose
0
POSITIVE
D
negative
GMT
Trehalose
Other tests or comments:
Urease
Raffinose
VB Agar
Melibiose
Hair Penetration
Cellobiose
Organism identified as:
Thiamine
Inositol
Xylose
Loeffler
Dulcitol
Gelatin
KN03
SC
= Sabouraud dextrose agar+ chloramphenicol
CM
= Cornmeal agar
Date received
sec
= Sabouraud dextrose agar + chloramphenicol + cycloheximide
CMD = Cornmeal dextrose agar
BBHI = Brain heart infusion agar+ blood
CMT = Cornmeal tween agar
Date reported
PDA
= Potato dextrose agar
VB
= Vegetable juice agar
Microbial Diseases Laboratory • 850 Marina Bay Parkway, E164 • Richmond, CA 94804 • (510) 412-3700
Page 1 of 2
LAB 448 (7/04) (MDL 60)
~
Department of Health Servi
California Department of Public Health
Submitter's Laboratory Findings
Cultures made from original specimen were:
D
Pure
D
Mixed
If mixed, list other organisms present: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
How many colonies of this organism on primary isolation?
D
1-10
· D
10-25
D
2s-50
D
Over
50
How frequently has this organism been recovered?
D
Once only
D
2-5
times
D
Over 5 times
Was the submitted organism seen in stained smears made directly from clinical material?
OYes
ONo
Medium on which organism is being submitted: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Date inoculated: _ _ _ _ _ _ _ _ _ __
Conditions of incubation prior to mailing:
, Temperature: __________
Atmosphere: _ _ _ _ _ _ _ _ _ _ __
Indicate the results of your laboratory examinations of the pure culture being submitted:
Growth Rate
Pigment
Colony morphology on
Microscopic Characteristics
Medium
25-30°
37°
Surface
Reverse
Sabouraud medium
Age:_ _
Medium:
Age:
SC
sec
BBHI
Ferm.
Assim.
CM
Dextrose
Other tests or comments:
PDA
Galactose
CMD
Lactose
Maltose
EMB
Sucrose
CMT
Trehalose
Urease
Raffinose
va
Agar
Melibiose
Hair Penetration
Cellobiose
Thiamine
Inositol
Xylose
.
Loeffler
Dulcitol
Gelatin
KN03
SC
=
Sabouraud dextrose agar
+
chloramphenicol
CM
=
Cornmeal agar
Date received
sec
=
Sabouraud dextrose agar
+
chloramphenicol
+
cycloheximide
CMD
=
Cornmeal dextrose agar
BBHI
=
Brain heart infusion agar
+
blood
CMT
=
Cornmeal tween agar
Date reported
PDA
=
Potato dextrose agar
VB
=
Vegetable juice agar
Page 2 of 2
LAB 448 (7/04) (MDL 60)
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