Lab Manual 11102016 PDF

Laboratory User Manual
Department of Pathology
Hospital Tuanku Jaafar Seremban
2016
EDITORIAL COMMITEE
ADVISOR
Dr Azizon binti Othman : Head of Department of Pathology
COORDINATOR
Dr. Nazlinda Sulaiman : Anatomic Pathologist
Puan Murniza Ahmad Najimudin : Science Officer Microbiology Unit
MEMBERS:
Dr Suryani binti Mohd Yusoff : Head of Cytopathology Unit
Dr Nik Faizah binti Hik Hussein : Head of Chemical Pathology Unit
Dr Noor Hasni binti Shamsudin : Head of Histopathology Unit
Dr Nik Hafidzah binti Nik Mustapha : Head of Haematology Unit
Dr Idaleswati binti Nor Mohamad : Head of Transfusion Medicine
Dr Marlindawati binti Mohd Ali : Head of Medical Microbiology Unit
Puan Norhazwati Mokhtar : Science Officer Chemical Pathology Unit
Puan Maimiza Zahari : Science Officer Transfusion Medicine
Puan Ierdawateey binti Ibrahim : Science Officer Histopathology Unit
Cik Teh Lay Kuan : Science Officer Cytology Unit
2
VISION STATEMENT
To provide immediate, accurate and efficient Pathology Services based on a well organised
management, towards achieving customer satisfaction.
MISSION STATEMENT
In the spirit of team work we shall provide an efficient, reliable service towards achieving
excellence in patient care and to pursue professional and technological advancement through
training, research and development.
CLIENT CHARTER
1. Every customer will be treated with quality service and care.

2. Every customer will be treated with consideration, dignity and honesty.
3. Every customers test will be treated within the appropriate time frame depending on
the test requested.
3
TABLE OF CONTENTS PAGES
FOREWARD:
5
Hospital Director
Head of Department 6
Department telephone directory 7
Scope of services, specimen collection and transportation 8
Request form and specimen rejection 9
Service hour 10
Cytology Unit 11-15
Histopathology Unit 16-21
Blood Transfusion Service 22-35
Chemical Pathology Unit 36 - 156
Haematology Unit 157 - 183
Microbiology Unit 184 - 209
Appendices 210 - 238
Acknowledgements 239
4
FOREWARD
Pathology laboratory service is an integral part of modern health care. Appropriately used,
laboratory investigations may improve the quality of patient management and prevent or
reduce morbidity and mortality. However, with escalating costs of reagents, consumables
and equipment, cost effectiveness and evidence based practice should be the priority.
I would like to congratulate the Department of Pathology, HTJS for producing the 2015
version 2 of this comprehensive Laboratory User Manual for Clients in HTJS, district
hospitals and other health facilities in Negeri Sembilan.It provides important guides and
information for laboratory users to help them in the diagnosis, prognostication and follow
up of patients.
I take great pleasure in expressing my appreciation to the Head of Department of

Pathology, HTJS, Dr Azizon binti Othman and her staff for successfully completing this
important manual. I am certain that users will find this manual very useful as a quick
reference and guide to utilise effectively pathology laboratory services.
I would also like to express my special thanks to the Pengarah and Timbalan Pengarah
Kesihatan Negeri, Negeri Sembilan for their support.
5
FOREWARD
I would like to congratulate all committee members for completing the 2015 issue of HTJS
Pathology Services User Manual.
Special thanks to all Heads of Units and contributors for contributing, reviewing and
updating the relevant sections.
The issue contains information on pathology services available in HTJS as well as

outsourcing services in other KKM referral laboratories to which our department
subscribes. The sample acceptance and rejection criteria are also outlined as ensuring
quality at the pre-analytical phase is a critical pre-requisite for attaining quality in patients
investigation results. The turn around time of laboratory investigations are also included.
Our department will continue to strive to provide the best possible service for our fellow
colleagues from the other departments in HTJS and our external clients. We are committed
to engage ourselves in continuous self-enhancement alongside the rapidly advancing field
of pathology and medicine.
It is our hope that this manual will effectively enhance mutual cooperation and
understanding between us and our clients. We sincerely hope that our clients find this
manual very useful as guides for better patient management.
We would like to express our appreciation to the Hospital Director, Dr. Ariffin Mohamad
and the Pengarah Kesihatan and Timbalan Pengarah Kesihatan Negeri, NSDK for all the
support and cooperation.
Dr Azizon binti Othman
Senior Consultant Pathologist (Haematologist)
Head of Pathology Department
Hospital Tuanku Jaafar Seremban
6
DEPARTMENT TELEPHONE DIRECTORY
LOCATION EXTENSION LOCATION EXTENSION

NUMBERS NUMBER
Main Receiving Counter 4304 Dr. Azizon Othman 4301

(Head of Department)
Haematology Lab 4251 Dr. Suryani Mohd Yusoff
(Anatomic Pathologist)
Chemical Pathology Lab 4225 Dr. Noor Hasni Shamsudin 4212
Drug lab 4306 Dr. Roslina Suboh
Histopathology Lab 4307 Dr. Nor Akmar Tak
Cytology Lab 4235 Dr. Nik Faizah Nik Hussein 4223
(Chemical Pathologist)
Bacteriology Lab 4317/ 4318 Dr. Nik Hafizah Nik
Mustapha
(Haematologist) 4224
Serology Lab 4256 Dr. Munirah Abd Razak
(Haematologist)
Virology Lab 4218 Dr. Nazlinda Sulaiman
H1N1 lab 4316 Dr. Norfadzilah Mohd Yusof 4293
TB lab 4702 Dr Junalina Jaafar
Blood Transfusion Lab 4308 Dr. Idaleswati Nor
Mohamed
(Transfusion Medicine) 4224
Donor area 4309 Dr. Ong Chiew Ping
(Transfusion Medicine)
Medical Officer/ Science 4221 Dr. Malinda Mohd Ali
Officer (Clinical Microbiologist)
Pejabat 4211 Dr Nor Zanariah Zainol 4318/4317
Abidin
(Clinical Microbiologist)
7
A: SCOPE OF SERVICE
The Department of Pathology Hospital Tuanku Jaafar, Seremban carries out medical testing in
the following fields:
1. Haematology
2. Chemical Pathology
3. Microbiology
4. Histopathology
5. Cytology
6. Blood Transfusion
B: LOCATION
The laboratory occupies an area on the ground floor of the hospital.
C: OPERATION HOURS
The laboratory provides a 24 hour service for routine essential tests while other tests are only
done during office hours.
D: SPECIMEN COLLECTION AND TRANSPORT
Test offered, specimen types and containers are variable.
It is important that specimens are collected and transported properly. The importance of proper
positive patient identification cannot be overemphasized. The requirement of specimen labelling
shall bear at least 2 identifications which includes name and one other unique identification
number.
Deviations from the instructions given in this manual may result in pre-analytical errors.
Specimens should be sent to the laboratory as soon as possible.
8
E: REQUEST FORMS
1. Use the correct request forms and ensure that forms are properly and clearly filled.
2. Forms must be signed by requesting doctor with official stamp.
3. Relevant information and history must be included.
4. Requester is advised to be selective and confine tests that are relevant and useful for the
diagnosis or control of treatment.
5. For any enquiry, please refer to respective unit/ laboratory. Please note that specific
forms, other than PER PAT 301 forms, may need to be used for special investigations.
F: SPECIMEN REJECTION
General criteria
Please refer to respective unit/ laboratory for specific criteria and details.
Specimens Request forms

No specimen received No request form received
Specimen is insufficient for analysis Incomplete patient data/ IC
Specimen not labelled No clinical indication/ history written
Specimen leaked Doctors signature/name absent
Wrong usage of container Ward/clinic not written
Lipaemic sample Required test not written

Hemolysed sample Information on the request form and
Jaundiced sample the specimen do not match
Sample clotted Incorrect request form received
9
G: SERVICE HOURS
LOCATION TEST OPERATING HOUR
Main Receiving Counter Chemical Pathology tests 24 Hours
Haematology tests
24 Hours
Microbiology Lab Microbiology tests
Counter
Serology tests-Hep B, Hep C
and HIV
H1N1, Mers-CoV, Influenza A &

B, Zika Virus
Tibi Lab AFB Office hours only (at Tibi Lab Counter)
Histopathology and HPE Office hours only

cytology
FNAC
Body fluids
Blood Transfusion Lab Group Crossmatch 24 hours
Group Screen and Hold
Request for blood product
10
CYTOPATHOLOGY UNIT
(A) INTRODUCTION
(B) SERVICES
i. Gynaecological Pap smear

ii. Non-gynaecological Smear
iii. Fine Needle Aspiration for Cytology (FNAC)
(C) REQUEST FORM
i. All Non-gynaecological and Fine Needle Aspiration Cytology samples are to be accompanied
by a completed request form (PER-PAT 301) in duplicate.
ii. All Gynaecological PAP smears are to be accompanied by a completed request form (PS1/98-
Pindaan 2007) in duplicate.
iii. All request forms must be filled up completely and legibly.
iv. Patients biodata with relevant clinical information to be written clearly and signed by
requesting doctor with official stamp
v. Previous cytopathology and histology number is required if cytology or other tissue specimen
has been sent for the patient.
vi. Requesting doctors name should be legibly written down together with a contact numbers as
a direct contact by phone can be made if it is urgent.
vii. The name of the doctor / specialist/ consultant who does the procedure/ operation is also
required for easy communication.
viii. For urgent cases, the form should be labelled as urgent. Please indicate on the
request form where the result to be dispatch.
11
(D) SAMPLE COLLECTION
1. Gynaecological Pap smear: Method of cervical screening used to detect

potentially precancerous and cancerous process in the cervix.
(i) Specimen to be collected prior to bimanual examination.

(ii) Use an Unlubricated speculum (if necessary only water or water
based gel may be used)
(iii) No douching or sexual intercourse prior to specimen collecting.
Sample Container Fixative Form TAT Result

(a) Conventional Glass Slide 95% Alcohol Ps1/98- Urgent (14
Pap Smear Pindaan 2007 working days)
(duplicate) Routine (4 weeks
working days)
Note: (i) The end of spatula is inserted into the cervical os and rotated through 360
(ii) The sample adhering to the spatula is spread evenly across a glass slide
which has been previously labelled in pencil or diamond pen with the patients
name.
(iii) The slide must be spray fixed immediately or by immersion in 95% ethyl alcohol
for minimum of 30 minutes after which it may be safely removed and stored dry
at room temperature.
(iv) Pap Smear/glass slide should be sent in a slide mailer to prevent damage.
Specimen Container Fixative Form TAT Result

(b) Liquid Based Vial Preservative Ps1/98- Urgent (14
Cytology Fluid Pindaan 2007 working days)
(duplicate) Routine (4 weeks
working days)
Note :(i) Insert broom-type sampling device (rovers cervix brush) into endocervical canal.
(ii) Rotate broom five times in clock wise direction (360 rotation).
(iii) Drop detachable head of device into vial.
(iv) Place cap on vial and tighten.
(v) Send vial to lab for processing.
12
2. Non-gynaecological smear: Cytological examination of body fluid, body
aspirate, CSF, bronchial washing, gastric aspirate, sputum, discharge and
urine to detect cell abnormalities.
Sample Container Sample Collection Form TAT Result

(a) Body fluid/ i) Sample collected must send to the
CSF / Body lab immediately for urgent Urgent :
Aspirate processing. (5 working days)
ii) If samples are collected after
office hour, it must be kept in the
refrigerator at 2-8 C and send to Routine :
the lab the next working day so (14 working days)
that it can be processed on the
Sterile same day. The LTAT calculate
container based on the date and time
reach cytology counter on the
next working day.
(b) Bronchial Samples are collected must send to
Washing the lab immediately for urgent
and Gastric processing.
Aspirate PER-PAT
(c) Sputum (Samples must be collected on 301
three consecutive days)
i) Instruct the patient to empty the
mouth of all saliva immediately
after he wakes in the morning.
ii) The patient should then cough
deeply and collect the resulting
sputum in a container.
iii) The sample must be sent
immediately to the laboratory.
Sample sent exceeding 10am
from the day of collection will
be reject.
iv) Do not forget to collect a similar
specimen on the next days.
(d Discharge Glass slide i) Sample should be collected by
(Nipple applying the slide directly to the
Secretions) nipple, followed by immediate
fixation/ air dried.
ii) All glass slides should be sent in a
slide mailer to prevent damages.
(e) Urine Sterile i) Sample must be collected on three
container consecutive days.
ii) The patient should void and
discard the first morning sample.
iii) The patient should drink as much
water as possible for the next 1
and hours, discard all urine
passed during the time, empty
the bladder at the end of the two
hours period and discard.
iv) Collect the urine passed during
the next half-hour and send it
13
3. Fine Needle Aspiration (FNAC): Diagnostic procedure where a needle is
inserted into your body and a small amount of tissue is sucked out for
examination under a microscope.
Day Time Location TAT Result

(a) Monday 11.00 am 1.00pm
Surgical Patient Urgent
(Cases requested as walk-in (5 working days)
basis)
Surgical Clinic Routine
(b) Tuesday 11.00 am 1.00pm (14 working
Surgical Patient days)
(Cases requested as walk-in
basis)
(c) Wednesday 11.00 am 1.00pm
Surgical Patient
(Cases requested as walk-in
basis)
2.00pm 4.00pm
Ultrasound Guidance Ultrasound Room
(Cases are accepted on an
appointment basis)
(d) Thursday 2.00pm 4.00pm
ENT Patient Surgical Clinic
(Cases are accepted on an
appointment basis)
Note: i) The Pathologist should be contact for any additional urgent cases. (EXT:
4212/4293)
ii) Patient from other clinic or ward, FNAC must communicate and discuss.
iii) FNAC samples are to be accompanied by complete request form (PER-PAT 301)
in duplicate.
iv) Consent for for FNAC is the responsibility of the Surgeon/ Doctor attending to the
case.
14
(E) REJECTION CRITERIAS FOR CYTOLOGY
REJECTIONS CRITERIAS ACTIONS
No request form received. Informed wad/ clinic to send request form urgently.
Continue processing of specimen, if no action taken
within two working days, specimens will totally reject.
Request form incomplete :- Informed wad/ clinic to send/ complete request form
Demography data urgently. Continue processing of specimen, if no action
Clinical history taken within two working days, specimens will totally
Signature and cop requester reject.
Cytology specimen received after office

hour. Continue processing of specimen the next working days
if specimen still valid.
Information on the request form and the Rejections of specimen
specimen do not match.
Incorrect request form received.Please Informed wad/ clinic to send proper request form
use appropriate form. urgently. Continue processing of specimen, if no action
taken within two working days, specimens will totally
reject
Test not available Rejections of specimen
Test requested not specific.Please Informed wad/ clinic to send proper request form
specify the correct test required. urgently. Continue processing of specimen, if no action
taken within two working days, specimens will totally
reject
Empty container received.Please send Rejections of specimen
new sample.
"Sputum for Cytology".Please send Rejections of specimen if sampel received after 10am or
sample immediately to the lab before more than two hours from sample collection.
10am working day.
FNAC not done.No define mass. Pathologist/ Medical Officer reject FNAC cases.
FNAC not done.Suggest ultra sound

guidance FNAC.
Pathologist/ Medical Officer reject FNAC cases.
Specimen not labeled. Rejections of specimen
Wrong specimen Informed wad/ clinic to send correct specimen urgently. If

no action taken within two working days, specimens will
totally reject
15
HISTOPATHOLOGY UNIT
A. INTRODUCTION
The unit is concerned with diagnosis by macroscopic and microscopic examination of
tissues. This includes the histological assessment of specimens removed at surgery, or
at biopsy procedures and the investigation of disease at autopsy. In each case the
diagnostic examination is part of the clinical investigation of the patient and cannot be
performed satisfactorily in isolation. The quality of pathological interpretation and the
diagnosis given may depend upon the information written on the request form.
Relevant clinical history is mandatory whereby if not available the request will be
rejected.
B. SERVICES
a) Histopathological Examination (HPE)
i) Surgically or non surgically removed tissues

ii) Frozen sections
iii) Immunofluorescence for renal and skin tissue
b) Clinical Autopsy
i) Request for Clinical Autopsy shall be discussed with Medical Officer or
Pathologist On Call
ii) Consent for Clinical Autopsy must be obtained by the requestor prior to
autopsy
iii) The Requestor must be among the Medical Officer or Clinician in-charge of
the deceased.
C. CONTACT NUMBERS
Extension number of Histopathology Unit as below :
NO LOCATION EXTENSION NUMBER
1 Pathologists Room 4212 / 4293
2 Histopathology Medical Officer 4221
3 Histopathology Lab 4307
4 Enquiry of HPE number / completed report 4221 / 4307
16
D. REQUEST FORM
a) All specimens sent for HPE must be accompanied with a LAB REQUEST FORM (PER.
PAT 301)
i) All request forms must be filled up completely and send together with specimen/s in
duplicate copy
ii) Patients identification with appropriate and relevant clinical information must be clearly
written in the lab request form including:
Relevant examination findings
Intra-operative findings
Diagnosis
Site and type of specimen (must be concordant with label on the
specimen containers)
iii) All specimens send for examination must be itemized in the request form
iv) Requesting doctors name should be legibly written down.
v) If the case deems urgent, kindly indicate urgency of specimen in request form. Please
mark the request form URGENT (in the right hand corner) and indicate clearly
location/source where the report should be dispatched to.
vi) If more than one container is sent for each patient at one encounter, ensure that the
containers are labelled properly and listed in the same lab request form. Site and type of
specimen must be concordant with label on the specimen containers.
b) Request for Frozen Section Frozen Section Request Form and PER PAT 301
i) Appointment for the service is to be made at least 24 hours before the operation. At
least a Medical Officer must speak to Pathologist on call for the week.
ii) Two request forms need to be filled in for Frozen Section Request
Frozen Section Request Form
The form is available at Histopathology Lab
The form must be filled up completely to indicate the need for frozen
section examination and submitted to the Histopathology Laboratory
staff 24 hours before the operation
Lab Request Form PER.PAT 301
The lab request form must be filled up completely in duplicate copy and
send together with frozen section specimen/s on the day of operation.
Please indicate the extension number of the operation theatre and
the name of surgeon concerned for communication purpose.
iii) Please inform the laboratory when:

The patient is wheeled into the operating room or
The frozen section examination is postponed or cancelled.
17
E. SPECIMEN COLLECTION
TYPE OF
SAMPLE CONTAINER /
NO TEST SPECIMEN COLLECTION
FOR PRESERVATIVE
ANALYSIS
1 Routine Tissue 10% Buffered 1. Place specimen in proper sized tightly closed
HPE Formalin in suitable containers
(Formalin tissue container
fixed tissue) 2. DO NOT put large specimen in small
Volume of formalin container as this would prevent proper
used is at least 10 fixation of the tissue and also distort the
times of specimen size specimen
(to ensure proper
fixation) 3. For adequacy of surgical excision in
malignant neoplasm, the margins must be
marked accordingly by sutures or by
diagrammatic representation of the excised
specimen.
2 Frozen Fresh Sterile tissue container Specimen for frozen must be sent fresh and
section tissue without fixative immediately to the laboratory.
3 Immuno- Fresh Petri dish/tissue Tissue must be submitted fresh without fixative
fluoresence Tissue container containing in petry dish / tissue container containing
moistened gauze with moistened gauze with Phosphate buffer saline
Phosphate buffer to prevent drying.
saline
4 Clinical Tissue 10% Buffered Place specimen in proper sized tightly closed
Autopsy Formalin in suitable containers.
tissue container
F. DISPATCH OF SPECIMENS
a) Specimens for routine histological examination are only can be dispatched to the
Histopathology Laboratory during office hour by the medical personnel from particular
ward/clinic/operation room in HTJS or from District Hospital.
b) Specimens for frozen sections are dispatched immediately to the Histopathology

Laboratory by the (at least) House Officer that involved in the operation procedure.
18
G. TURN AROUND TIME (TAT) OF RESULTS
a) Results of urgent biopsy for HPE are available within three (3) working days
(excluding public holidays) after / receipt of the specimens by the laboratory, unless the
case needs for ancillary staining (i.e histochemical stains, immunohistochemistry
stains), recut/deeper section, regross or send to external center for second opinion).
b) Target of achievement of all TAT is 80% of total workload in keeping with standard of
National Indicator Approach (NIA).
c) Results of frozen section will be immediately communicated to the surgeon via

telephone within one (1) hour from time of specimen received. The results will be
documented on the Frozen Section Request Form and kept in the lab. Confirmatory
results shall be conveyed according to standard procedures as other routine
histopathological specimens.
TURN AROUND TIME (TAT)

NO TYPES OF SPECIMENS
URGENT (*) ROUTINE
1. Small biopsies eg: pleural, wedge, trucut 3 working days 1 week
Medium sized tissue eg: appendix, fallopian

2. NA 2-4 weeks
tube, gall bladder
3. Large resected lesions eg: uterus, breast, colon NA

2-4 weeks
* Unless the case needs any ancillary staining, recut/deeper section, regross or second opinion
H. COLLECTION OF RESULTS
a) Reports of routine histopathological examination are made available through the Ward
Enquiry system which is accessible and available to Clinician of HTJS.
b) Only report for malignant cases will be dispatched to the respective specialist clinic by
PPK from Histopathology Unit.
c) Reports for referral cases from District Hospital will be collected by PPK from the
respective hospital.
H. SERVICE AFTER OFFICE HOUR
a) Specimen for routine histological examination should not be sent to Pathology

Laboratory after office hour. These specimens should be fixed in the usual manner,
kept in ward/clinic at room temperature and dispatched to the Histopathology
Laboratory during the next working day.
b) Frozen sections are available during office hour ONLY, except for Liver Transplant
cases whereby the frozen section service is available for 24 hours. Transplant Team
Sister shall communicate with the Histopathologist on-call for the request purpose.
19
I. REJECTION OF SPECIMEN
1. Rejection of histopathological specimens does not involve the return of specimen or

PER-PAT 301 form.
i) Clients shall be informed verbally and it is mandatory for the requestor to make
the necessary amendments in the Histopathology Laboratory immediately.
ii) Rejected specimen will be hold for processing until the rejection cause/s
rectified.
2. Rejection Criteria of Histopathology Examination (HPE) request are as follow :
NO. TYPE OF REJECTION REMARKS
Tiada tisu dalam bekas fiksatif (10% neutral buffered

1. No Specimen received
formalin/phosphate buffer saline) yang diterima
2. No request form received. Spesimen HPE tidak disertai dengan borang permohonan ujian
Maklumat pada borang permohonan ujian tidak lengkap termasuk:
3. Request form incomplete.
i. Identifikasi dan demografi pesakit termasuk lokasi wad / klinik /
hospital tidak lengkap
ii. Tiada sejarah klinikal dan maklumat pembedahan yang
relevan
iii. Tiada diagnosis
iv. Tiada jenis ujian yang dipohon/ jenis ujian tidak spesifik
v. Tiada nama Pegawai Perubatan yang memohon ujian
vi. Tiada jenis spesimen tisu yang yang dihantar.
vii. Tiada tarikh pengambilan spesimen
Tiada Nama Pesakit pada -

4.
borang dan/atau spesimen.
Tiada No. K/P atau No. -

5. Paspot atau No. HTJS pada
borang dan/atau spesimen.
Information on the request Identifikasi pesakit dan/atau jenis tisu pada borang permohonan
6. form and the specimen do ujian tidak sepadan dengan label spesimen
not match.
Jenis tisu tidak disenaraikan secara spesifik (itemised) apabila
Type of HPE tissues not lebih dari satu jenis tisu dihantar serentak menggunakan borang
7.
itemised in the request form permohonan ujian yang sama bagi pesakit yang sama
Type of HPE tissue not Tiada jenis spesimen tisu pada label spesimen dan/atau jenis tisu
8. written on the specimen
tidak ditulis dengan jelas
container
20
NO. TYPE OF REJECTION REMARKS
Tisu segar Ujian Immunofloresen tidak dihantar dalam bekas

Tissue for
mengandungi kertas turas/kain gauze yang direndam dengan
9. Immunofluoresence test not
phosphate buffer saline
send in buffered saline
Specimen not collected in Tisu untuk rutin HPE tidak dihantar dalam larutan 10% neutral
10. buffered formalin
10% Buffered Formalin
Tiada nama dan nombor kad pengenalan/paspot pesakit pada

11. Specimen not labelled.
label spesimen
Jenis ujian yang dipohon dalam borang permohonan adalah HPE

12 Wrong specimen. tetapi spesimen yang dihantar bukan tisu untuk HPE (i.e : tissue
culture/swab, body fluid)
Source : HTJS/AK/PAT/HISTO/12 Lampiran 1 Penolakan Spesimen di Unit Histopatologi,
Jabatan Patologi HTJS
21
TRANSFUSION MEDICINE SERVICES (PUSAT PERKHIDMATAN DARAH)
A. TRANSFUSION (CROSSMATCHING) LABORATORY
1. INTRODUCTION
The main purpose of this laboratory is to provide services to all clinicians in Hospital Tuanku
Jaafar Seremban, District hospitals and private hospitals in Negeri Sembilan. This user
guideline created to give pertinent information on blood transfusion practice. Procedures for
requesting and transfusing blood and blood products, in elective and emergency situation,
reporting of adverse transfusion reactions, storage and administration of blood and blood
products are also addressed.
2. LOCATION
This laboratory is located in Transfusion Medicine Unit and next to Radiology unit at the
ground floor of Hospital Tuanku Jaafar Seremban.
3. LIST OF TESTS
3.1 Section A
The following tests are performed in Transfusion (Crossmatching) Laboratory:
3.1.1 Pre-transfusion Testing

Blood Grouping (ABO)
Rhesus (D) Typing
Group, Screen & Hold (GSH) :
- Test comprises of Blood Grouping (ABO) & Rhesus (D) Typing and
Antibody Screening
Cross-matching / Blood compatibility test

Rhesus phenotyping (for all Rhesus (D) negative cases)
Extended Red Cell phenotyping (for transfusion dependant cases)
Antibody Identification
3.1.2 Post -transfusion Testing
Investigation of Adverse Transfusion Reaction
3.1.3 Anti Human Globulin (AHG) test / Coombs test Direct & Indirect test
3.2 Section B
However, the following tests may be sent to the referral laboratory (Pusat Darah Negara,
Kuala Lumpur) when necessary i.e. complex cases that were unable to be resolved in
Transfusion (Crossmatching) Laboratory HTJS:
3.2.1 Blood grouping (ABO) subgroups

3.2.2 Verification of Rh (D) grouping
3.2.3 Antibody Identification
22
4. REQUEST FORMS
Prescribing blood and blood products is the responsibility of the doctor managing the patient.
However, the treating doctor is encouraged to consult the medical officer in-charge of the
Transfusion Medicine Unit on the type of products to be issued, quantity, duration of infusion,
precautions and any other related issues.
The request form PPDK 5 Pin 1/97 as Appendix 3 should be filled in completely and contain
relevant patient information.
5. SPECIMEN COLLECTION
Most transfusion errors are due to taking samples from wrong patients, labelling samples
using other patients ID and administering blood to the wrong patients. Thus, the practical
precautions given in this section are extremely important to be followed:
5.1 Patient identification and blood sampling for compatibility testing

The process of taking and labelling blood samples must be done in one process at the
bedside, one patient only at one time. The doctor performing this must ensure:
5.1.1 Patient MUST be correctly identified. The doctor taking the blood sample must
Cross check the patients wristband, if available, and whenever possible, ask
the patient to state his/her forename, family name, and I/C no. This information
must be checked against the case notes or pre-printed patient identification
label.
5.1.2 Unconscious patients MUST be identified by the information given on the
patients wristband or confirmed by relatives.
5.1.3 An emergency casualty who cannot be reliably identified must be given an
wristband with a unique number. This number must be used to identify the
patient until full and correct personal details are available.
5.2 Labelling of sample

5.2.1 The person who takes the blood must labell the blood sample and fill up the
request form.
5.2.2 The sample must be labelled clearly and accurately at patients bedside
immediately after blood taking. The label must include :
The patients full name
IC number and Hospital Registration Number
* Sample and request form must be handwritten. Never use pre-printed label.
5.2.3 The person who takes the blood sample from the patient has to take full
responsibility in ensuring that the blood sample is placed in the correctly
labelled tube and signed in the request form. The doctors signature and name
on the request form also implies that he/she has ensured that the sample has
been accurately identified.
5.2.4 NEVER label samples from 2 or more patients at the same time.
23
5.3 Blood sample requirement for elective surgery or elective transfusion
Samples should be sent to the Transfusion (Crossmatching) Laboratory during office
hours at least 24 hours before the blood is required. The following is the requirement for
blood samples sent in for grouping and compatibility testing:
5.3.1 Samples from infant less than 4 months of age
5.3.1.1 Infants blood sample should be accompanied by mothers blood

sample.
5.3.1.2 1.0-2.0mL blood sample in EDTA tube from the infant and
2.0-3.0mL blood sample in EDTA tube from the mother.
5.3.1.3 Both samples are distinctively labelled and sent together to the
Transfusion (Crossmatching) Laboratory using two different
request form according to infant and mother.
5.3.2 Samples from patients above 4 months of age i.e. children and adult
5.3.2.1 2.0-3.0mL blood sample in EDTA tube accompanied by one

request form.
5.3.2.2 In cases of massive bleeding when many units of
blood/components are required more samples and request forms
may be needed.
5.3.2.3 If the patient requires repeated transfusions during the present
admission, a new blood sample is needed for each request.
5.4 Blood sample requirement for blood components such as platelets, fresh frozen
plasma and cryoprecipitate
5.4.1 Request for blood components other than red cells must be sent with a blood
sample and a request form. (Please use separate forms from red cell request)
Refer to item 5.2 and 5.3.
5.4.2 If a patient had received a transfusion of blood components within the previous
3 months in the same hospital (provided that procedure was completed without
any complication and the transfusion laboratory has at least 2 records of blood
group in their lab system) a new blood sample need NOT accompany requests
for more blood components other than red cells. A copy of old requests form
should then be attached to the new request form. For ABO mismatched
haemopoietic stem cell transplantation, this is not applicable. A new sample
must accompany all requests in the immediate post transplant period until the
patients blood group has change to that of the donor/
5.4.3 In all other circumstances or if the previous request form is not available,
2.0 3.0mL of blood sample in EDTA tube should be sent to the laboratory to
determine the patients blood group.
24
5.5 Blood sample requirement for other tests:
5.5.1 ABO grouping and Rh(D) typing:2.03.0ml of EDTA blood using PER.PAT
(301) form.
5.5.2 Antibody identification: Four tubes of EDTA blood (2.03.0ml each tube) using
PPDK 5 Pin 1/97 form.
5.5.3 Extended Red cell phenotyping: 2.03.0ml of EDTA blood using PER.PAT
(301) form.
5.5.4 Anti Human Globulin (AHG) test/ Coombs test (Direct & indirect test):2.03.0ml
of EDTA blood using PER.PAT (301) form.
(Note: 1. Refer 5.1 and 5.2 for blood sampling and labelling requirement)
2. The volume of 2.03.0ml blood required if depending on the type of
EDTA tube used).
5.6 Rejection of samples

Blood sample sent for compatibility testing should have the suggested minimum
requirements (please refer 5.2.1). Exceptions were given only in life threatening situation
after consulting and obtaining an approval from Transfusion Medicine Specialist or
Medical Officer in-charge of Transfusion Medicine Unit.
The blood samples should be rejected if:
5.5.5 The labels are not hand written.

5.5.6 Sample is inadequately labelled (at least Name and (I/C or RN) ), insufficient
sample (< 2mL), lysed or in a wrong container.
5.5.7 The request form has been inadequately filled of that essential patient
information (name, I/C and RN) is/are lacking in patients having all the three
identifiers.
5.5.8 There are many discrepancies between the information on the sample label and
the request form. Exceptions are made only in life threatening situation where
these discrepancies are corrected by the treating doctors.
6. DISPATCH OF SPECIMENS
6.1 Specimens should be sent to the Transfusion (Crossmatching) Laboratory reception
counter with a dispatch book.
6.2 Specimens without dispatch book are only allowed in an emergency situation but the
ward staffs need to write down the relevant information in a specific book provided in the
transfusion lab.
25
7. REPORTING RESULT
7.1 Both copies of request forms for crossmatching (GXM) and Group Screen & Hold (GSH)
will be maintained in the Transfusion (Crossmatching) Laboratory.
The copy of the forms will be handed in to the ward personnel who come to collect the
blood or blood components to be transfused.
7.2 Results for blood grouping (ABO/ Rh D), Direct & Indirect Coombs Test, antibody
screening, antibody identification and investigation of adverse transfusion event shall be
retrieved in the LIS.
8. ISSUING, STORAGE AND TRANSPORT OF BLOOD AND BLOOD PRODUCTS TO THE

WARD
8.1 Collection
8.1.1 The person collecting the blood must bring documentary proof of the patients
identity.
8.1.2 A properly filled form of HTJS/PATH/PPD/GXM-01must be submitted prior to

request of conversion from GSH to GXM.
8.1.3 If the request is one or two days earlier from the requirement, the crossmatched
blood is kept in Transfusion (Crossmatching) Laboratory.
8.1.4 Upon collection of blood/blood components, both the MLT and the ward staff must
check and ensure that the below information corresponds to both the request forms and
the recipient card / BHT sticker on the respective blood /blood components. The details
include: Blood /blood components product number
Type of blood / blood components

Blood group (ABO & Rh (D))
Name of the patient receiving blood /blood components
I/C no of the patient
RN of the patient (if available)
8.2 Storage and Transport

Blood and blood components should be kept in the transfusion laboratory until it is to be
transfused especially for platelets, FFP and Cryoprecipitate. If these blood / components
are not kept at the recommended temperature they will be unsuitable for use leading to
wastage.
Please refer Table 1 on page 29 for further instruction on handling the blood and blood
products in the ward.
26
9 ADMINISTRATION OF BLOOD
9.1 Used Blood or Remnants of Blood
Blood discontinued for any reason must not be used again and must be returned to the
Transfusion (Crossmatching) Laboratory as soon as possible. The details of the
transfusion and the reasons for discontinuing the transfusion must be stated on the
recipient card / BHT sticker attached to the bag. The discontinued blood unit must be
labelled USED BLOOD before it is returned to the Transfusion (Crossmatching)
Laboratory.
9.2 Return of Used Blood Bags

On completion of blood transfusion, the ward personnel must ensure that the recipient
card / BHT sticker attached to each bag of blood is filled completely. Used blood bags
must be returned to the Blood Transfusion Unit together with the completed card / BHT
sticker. Return the upper part of recipient card / BHT sticker to the laboratory. The details
of transfusion should be noted in the recipient card / BHT sticker. Detach the lower part of
recipient card / BHT sticker and attach it to patients file.
Used blood bags must be put in biohazard plastic bag and shall be handled according to
standard precaution to minimise biohazard. Proper documentations must be available.
9.3 Return of Untransfused Blood

9.3.1 The ward shall return all the untransfused blood immediately to the Transfusion
(Crossmatching) Laboratory with Blood Returning form (Borang pemulangan darah dan
komponen).
9.3.2 Untransfused blood that is returned to the Transfusion (Crossmatching) Laboratory

shall be discarded unless it is kept in an appropriate condition and temperature.
9.3.3 The ward shall inform the Transfusion (Crossmatching) Laboratory if any of the
unused blood returned has not complied to the storage of transportation temperature.
10 GROUP SCREEN AND HOLD PROTOCOL

10.1 A Group Screen and Hold (GSH) protocol consists of a blood grouping (ABO), Rhesus
(D) typing and an antibody screening on the patients plasma. The Sample is retained for
three (3) days at Blood Bank in the event that cross-matching blood is required at a later
stage. After three (3) days the request for crossmatching must be sent with a new blood
sample.
10.2 In circumstances where the likelihood of blood usage is minimal, a GSH protocol is
recommended in the first instance. If blood is required following a GSH, an emergency cross-
matched blood should be available for issue within 30 minutes of the request. A GSH protocol
should be used in conjunction with the Maximum Surgical Blood Order Schedule (MSBOS).
27
11 CROSS-MATCHING PROTOCOL
11.1 In the event of incompatible cross-match and antibody cases which were not able to be
resolved in Tranfusion (Crossmatching) laboratory, sample will be sent to Pusat Darah
Negara for antibody identification and supply of blood.
11.2 The clinician will be informed by Transfusion (Crossmatching) Laboratory staff or

Medical Officer On-Call regarding the situation. The clinician is also adviced to
communicate with either the Medical Officer or the Specialist on-call of the Transfusion
(Crossmatching) Laboratory regarding the urgency of the requirement for arrangement of
getting blood from PDN.
12 EMERGENCY REQUEST
The emergency supply is only done following requests by the clinicians. There are two
types of emergency request:
12.1 Emergency Cross-match

12.1.1 The cross-matching is being performed until the quick spin or saline phase method
with a group specific blood. This process takes about 15 minutes and blood can be
supplied within 30 minutes.
12.1.2 The second phase of cross-matching will then be continued and should there be
any incompatibility detected during this phase the staff will immediately contact the ward
to stop the transfusion.
12.2 Safe O (Group O Rh(D) Positive Packed cell)

Request made must be accompanied by a request form and a sample (2-3ml in EDTA
tube).
Safe O packed cell will be supplied immediately once the relevant information recorded
without any cross-matching.
Then the MLT will proceed with the crossmatching. Should there be any incompatibility
detected the staff will immediately contact the ward to stop the transfusion.
NOTE: For both situations, clinicians are responsible for the patients request. Thus, they
should sign and stamp their names on the request forms.
13 MAXIMUM SURGICAL BLOOD ORDERING SCHEDULE (MSBOS)

The Maximum Surgical Blood Order Schedule (MSBOS) is a schedule based on retrospective
analysis of actual blood usage associated with the individual elective surgical procedure. For
those procedures in which blood is not likely to be used, GSH is ordered. On the other hand,
a full cross-match is done for procedures in which blood will be used (Please refer Table 2
page 29 regarding standard MSBOS.)
28
Advantages
The introduction of an MSBOS has the following advantages:
1. More efficient use of blood stocks and a reduction in wastage due to out-dating.
2. Reduction in cross-matching workload of the blood transfusion lab, which allows more
time to respond to emergency requests, and also to investigate complex serological
problems.
3. Improve the quality of the blood in stock, as blood is not removed from the general pool
stock unless it is almost certain to be transfused.
14 ADVERSE TRANSFUSION EVENT

14.1 The Adverse Transfusion Event may include:
14.1.1 Immune Haemolytic Transfusion Reaction

14.1.2 Bacterial contamination
14.1.3 Febrile Non Hemolytic Transfusion Reaction
14.1.4 Transfusion Related Acute Lung Injury (TRALI)
14.1.5 Post Transfusion Infection
14.1.6 Post Transfusion Purpura
14.1.7 Transfusion Associated Graft Versus Host Disease (TA-GVHD)
14.1.8 Near misses (wrong sample, wrong label, clerical error etc.)
14.1.9 Others
14.2 What to do in such an event?
14.2.1 Temporarily stop the transfusion.

14.2.2 The compatibility label of blood unit should be checked again to ensure that it
corresponds with the patients name, registration number/IC, request form and
case note.
14.2.3 If a mistake is found, stop the transfusion completely. The Transfusion Lab
should be informed immediately.
14.2.4 All blood bags including unused bags and giving set (without needle) should be
returned to the blood bank for further tests. Make sure that the bag is properly
sealed to avoid spillage and send back as soon as possible.
14.2.5 Further investigation need to be executed immediately.
14.3 INVESTIGATION OF TRANSFUSION REACTIONS:

14.3.1 Investigation of transfusion reaction is performed on patients having reactions to
whole blood, packed cells, platelet concentrates, FFP or cryoprecipitate.
14.3.2 Samples labelled as POST TRANSFUSION SAMPLE 1 (taken immediately as

soon as transfusion reaction is noted)
29
If patient develops fever >380C:
1) 2.03.0 ml of venous blood in EDTA tube for repeat ABO blood grouping and
compatibility testing (Transfusion Laboratory.
2) Blood culture from patient (Microbiology Lab)
3) Remaining blood bag with contents and the giving set (without needle) should be
sent to Blood Transfusion Lab using standard precautions for blood culture.
[Including other unused crossmatched blood units for the patient (if any)].
If haemolytic transfusion reaction is suspected:
1) 2.03.0 ml of venous blood in EDTA tube for grouping and compatibility testing
(Blood Transfusion Lab).
2) Another 3.0 ml of venous blood in EDTA tube for URGENT FBP (Haematology Lab).
3) 2.03 ml venous blood in Heparin Tube for serum LDH, serum bilirubin and renal
profile (Chemical Pathology Lab).
4) Blood sample for DIVC screen (Haematology Lab).
5) Urine sample to look for haemoglobinuria.
24 HOURS or LATER- Samples labelled as POST TRANSFUSION SAMPLE 2
Only for suspected cases of acute haemolytic transfusion reaction or delayed

transfusion reaction:
1. Send 2.03.0ml of venous blood in EDTA tube (Blood Transfusion Lab)
2. Another2.03.0 ml of venous blood in EDTA tube for FBP.
3. 2.03 ml of venous blood in heparin tube for Bilirubin, LDH and Renal Profile.
4. Samples for DIVC screen test.
5. Urine sample to look for haemoglobinuria.
30
For patient who develops fever <380Cor mild skin rash/ pruritus or both
Samples labelled as POST TRANSFUSION SAMPLE1
1. 2.03.0 ml of venous blood in EDTA tube for grouping and compatibility testing.
(Blood Transfusion Unit).
Note: If reactions occur as above, transfusion of blood must be stopped temporarily.

Patient must be given paracetamol and/or anti histamine. If symptom and sign resolved
i.e. skin reaction or patients temperature is decreasing and vital signs are satisfactory,
transfusion can be continued with close observation.
The doctor in charge should draw the blood samples, fill the forms and ensure that the
samples, blood bags and forms reach Transfusion (Crossmatching) Laboratory,
biochemistry, microbiology and haematology laboratories at earliest possible time. The
doctors should complete the LAPORAN REAKSI KEPADA DARAH ATAU PLASMA
form in duplicates and write TRANSFUSION REACTION on all request forms.
15 TIME OF SERVICE AVAILABLE

24 hours daily.
16 REQUEST OF BLOOD FROM PRIVATE HOSPITALS

16.1 The procedures are the same as for requests from Hospital Tuanku Ja'afar,
Seremban.
16.2 However, the private hospital staff needs to make payment and produce a receipt of
payment made at Pejabat Hasil, HTJS during office hours (or stamp chop on the request
forms as a proof for payment).
16.3 After office hours, payment should be made at Admission counter. The requesting
clinician should consult the Haematologist or Medical Officer on-call.
17 PLATELET ANTIBODY TESTING

The following test will be sent to the referral Lab (Pusat Darah Negara, Kuala Lumpur) when
is requested and needs approval from PDN specialist on-call. Sample requirement are as
below:
A: BABY/ NEWBORN
Sample requirement for investigation of Neonatal Alloimmune Thrombocytopenia (NAIT):
1). Mother : 10 ml in EDTA i.e. 4 bottles of EDTA
10 ml in plain tube i.e. 3-4 bottles of plain tubes
2) Father : 10 ml in EDTA i.e. 4 bottles of EDTA
3) Baby : 1 ml in EDTA
B: ADULT
Samples requirement for investigation of platelet refractoriness:
1). 15-20 ml in EDTA i.e. 6-8 bottles of EDTA
2). 10 ml plain tube i.e. 3-4 bottles of plain tubes
31
Table 1
INSTRUCTION ON PROPER HANDLING OF BLOOD AND BLOOD PRODUCTS
RED CELLS PLATELET CONC. CRYO/FFP (thawed)

-Group specific
-Group specific / compatible -No crossmatching required

Supply After crossmatch
- No crossmatching required - Should be thawed
REQUEST ONLY WHEN REQUIRED
Blood box with ice

Collection Blood box without ice Blood box with ice
(avoid contact with ice)
As soon as possible (After

Use Transfuse immediately Transfuse immediately
reaching the ward)
2 6oC in suitable fridge.

Issued blood is required to Room temperature 20 24oC on
agitator
be kept in blood bank fridge
Storage until ready for transfusion
(except OT)
DO NOT STORE IN FRIDGE /
SHOULD NOT BE KEPT > DO NOT STORE OR KEEP IN THE
FREEZE
4 HOURS IN THE WARDS WARDS
Return Immediately if not

used. In OT, please store
Return Return immediately if not used Return immediately if not used
red cells in designated
blood fridge before use.
Fill up recipient card / BHT Fill up recipient card/ BHT sticker Fill up recipient card / BHT sticker and
sticker and return the upper and return the upper part together return the upper part together with
part together with empty with empty bag to Blood Bank as empty bag to Blood Bank as soon as
After Used
bag to Blood Bank as soon soon as possible. possible.
as possible
.
32
Table 2
MAXIMUM SURGICAL BLOOD ORDER SCHEDULE (MSBOS) REFERENCE CHART

(as agreed in Hospital Transfusion Committee Meeting 1/2006 14 April 06)
GENERAL SURGERY
Abdominal-perineal resection 4
Cholecystectomy GSH
Gastrectomy 2
Hemicolectomy GSH
Inguinal hemia repair GSH
Laparotomy GSH, 2-4
Mastectomy GSH
Splenectomy GSH, 2
Thyroidectomy GSH
Whipples procedure 2-4
Amputation 2
Burns, graft, debridement GSH, 2-4
Skin Biopsy GSH
GYNAECOLOGY
Hysterectomy GSH, 2-4
Myomectomy 2-4
Ovarian Cystectomy GSH, 2
Termination, D & C GSH, 2-4
MRP, Cone biopsy 2
33
NEUROSURGERY
Craniotomy 4
ENT
Laryngectomy 2
Tonsillectomy / Adenoidectomy GSH
ORTHOPAEDIC
Fractured humerus GSH,2
Fractures neck of femur GSH,2
Total hip replacement 2-4
Total knee replacement 2
MISCELLANEOUS
Liver, renal biopsy GSH
Note:
The surgeons or anaesthesiologists may individualize specific requests to accommodate
special needs and to improve blood order schedule to our local needs. The
communication between operating theatre and blood bank must be clearly defined where
adequate details of the patients condition and degree of urgency must be clearly indicated
so that the most appropriate compatibility tests can be carried out in the time available.
34
Table 3 : Turn Around Time (TAT)
No Test TAT Special Requirement/ Notes

Stat Routine
1 Group,Screen and Hold (GSH) NA 4 Hours Sample will be kept for 3 days.
2 Group, Screen and Crossmatch NA 2 Hours Crossmatch blood will be kept for 3 days
(GXM)
3 Emergency Crossmatch 30 min NA
4 Safe O Immediately NA Pre transfusion sample is required
5 Antibody Identification 4 Hours 7 working

days
6 Issue blood component (Platelet, 30 min 2 Hours To request component with Medical Officer
FFP, Cryoprecipitate and PPD oncall for Stat test
Cryosupernatant
7 ABO Grouping 1 Hour 1 working day
8 Coombs Test 4 Hours 3 working day To request test with Medical Officer PPD oncall
for Stat test
(TAT = Turn around time is the time taken from the sample received by PPD until blood is ready to be issued / report is ready)
35
CHEMICAL PATHOLOGY UNIT
pages
SECTION A
INTRODUCTION 37
LISTS OF TESTS 38
COMMUNICATION AND REQUEST FORMS 41
SPECIMEN COLLECTION 42
SPECIMEN CONTAINERS 43
DESPATCH OF SPECIMEN, REPORTING OF RESULTS, INQUIRY & 44

INFORMING OF TEST RESULTS
STAT SERVICE 45
SECTION B TABLE 1 : LIST OF TESTS OFFERED, SPECIMEN 46

REQUIREMENT, REFERENCE RANGES AND SPECIAL REQUIREMENTS
GENERAL CHEMISTRY 46
HORMONES 55
TUMOUR MARKERS 59
ANEMIA 60
THERAPEUTIC DRUG MONITORING: 61
LIMITED TOXICOLOGY 65
DRUG OF ABUSE IN URINE 66
SPECIAL PROTEINS 67
SECTION C SPECIAL TEST PROCEDURE 68
SECTION D LAB TESTS SENT TO THE REFERRAL LABORATORIES 103
JABATAN KIMIA, PJ 103
BIOCHEMISTRY UNIT, SDC, IMR 107
MOLECULAR DIAGNOSTIC AND PROTEIN UNIT, SDC, IMR 134
DIABETES AND ENDOCRINE UNIT, SDC, IMR 147
TOXICOLOGY AND PHARMACOLOGY UNIT, HRMC, IMR 148
MINISTRY OF HEALTH HOSPITALS 149
36
SECTION A
1.0 INTRODUCTION
The Chemical Pathology Unit offers its diagnostic services to all patients in Hospital Tuanku
Jaafar and all district hospitals and Klinik Kesihatan in the state of Negeri Sembilan.
The Diagnostic Services provided are: -
1. Emergency (STAT) service

2. Routine Services
2 Therapeutic Drug Monitoring (TDM)
3 Analysis of Drugs of abuse in Urine (DAU)
4. 24 hour Service
A wide range of biochemical tests are offered (please refer to list of tests)
As the demands for biochemical tests are heavy, users of biochemical service are urged to be
selective when requesting service. Requests should be confined to those tests, which are
useful for the diagnosis, treatment or management of patients.
Most tests are run daily, specimens which arrive in the early morning, are processed by midday
and most of the results will be ready by the end of the day for routine chemistry tests. Some of
immunoassay tests shall be analysed in batches for cost effectiveness purposes.
37
2.0 LIST OF TESTS
Tests listed are offered and done in Chemical Pathology Unit, HTJS.
* Tests available after office hour
** Tests require special procedure
GENERAL CHEMISTRY
Blood
1. Alanine transaminase (ALT)* 15. Glucose*

2. Albumin* 16. Iron
3. Alkaline phosphatase (ALP)* 17. Iron Binding Capacity, total (TIBC)
4. Ammonia** 18. Lactate
5. Amylase* 19. Lactate Dehydrogenase (LDH)
6. Aspartate transaminase (AST)* 20. Magnesium*
7. Bilirubin, direct* 21. Osmolality
8. Bilirubin, total* 22. Phosphate. Inorganic *
9. Calcium* 23. Potassium*
10. Chloride* 24. Protein, total
11. Cholesterol, High Density Lipoprotein (HDL) 25. Sodium*
12. Cholesterol, Total 26. Triglycerides
13. Creatine kinase* (CK) 27. Troponin I*
14. Creatinine* 28. Urea
Body Fluid (CSF, Pleural fluid. Peritoneal fluid, Ascitic fluid, Knee Aspirates)
1. CSF for biochemistry (Protein, Globulin, 3. Lactate (CSF)

Glucose, Chloride)
2. Other body fluid for biochemistry (Protein, 4. Albumin (Ascitic fluid)
Glucose, Chloride, Lactate Dehydrogenase)
38
2.0 LIST OF TESTS (cont)
GENERAL CHEMISTRY
Urine Spot/ 24 hours
1. Amylase (Diastase) 9. Phosphate (inorganic)

2. Calcium 10. Potassium
3. Creatinine 11. pH
4. Electrolytes (Sodium, Potassium, Chloride) 12. Protein
5. Glucose 13. Protein Creatinine Index
6. Magnesium 14. Sodium
7. Microalbumin 15. Urea
8. Osmolality 16. Uric acid
Therapeutic Drug Monitoring
1. Carbamazepine (Tegretol) 5. Theophylline

2. Digoxin 6. Valproic Acid (Epilim)
3. Gentamicin 7. Vancomycin
4. Phenytoin (Dilantin)
Limited Clinical Toxicology
1. Acetaminophen (Paracetamol)* 2. Paraquat* (urine)

3. Salicylate*
TOXICOLOGY
Drug of Abuse
1. Cannabis (Screening and Confirmation) 2. Morphine (Screening and Confirmation)
39
2.0 LIST OF TESTS (cont)
SPECIAL CHEMISTRY
Hormone
1. Cortisol 6. Progesterone
2. Estradiol 7. Prolactin
3. Follicle Stimulating Hormone, (FSH) 8. Thyroid stimulating hormone, (TSH)
4. Human Chorionic Gonadotrophin, Total 9. Thyroxine, Free (FT4)
(hCG)
5. Luteinising Hormone, (LH) 10. Triiodothyronine, Free (FT3)
Tumour Markers
1. Alpha Feto Protein (AFP) 3. CA 125

2. Carcinoembryonic Antigen (CEA) 4. Prostate Specific Antigen (PSA)
Special Proteins
1. Glycated HbA1c (HbA1c) 3. Complement 4 (C4)

2. Complement 3 (C3) 4. C-Reactive Protein (CRP)
Functional Tests and Others
1. Creatinine Clearance Test 5. Dialysate fluid

2. Dexamethasone Suppression Test 6. PET I, PET II, PET III
3. Glucose Tolerance Test 7. Anterior Pituitary Function Test
4. Synacthen Test 8. Posterior Pituitary Function Test
Anaemia Study
1. Ferritin 3. Folate
2. Vitamin B12
40
3.0 COMMUNICATION
For any inquiry of the service or tests provided by the Chemical Pathology Laboratory,
Hospital Tuanku Jaafar, kindly contact ext. 4225 (Chemical Pathology Lab), ext. 4221
(Scientific officer), ext. 4223 or personal mobile number (Chemical Pathologist).
4.0 REQUEST FORMS
In general, PER-PAT 301 is use for requesting Chemical Pathology tests. However, some
of the request shall follow the required request form as listed below:-
1. Therapeutic Drug Monitoring Request Form

2. Borang Permintaan Ujian Pengesahan Dadah Dalam Air Kencing (PER (LAB) -
SS 301A)
3. Borang Permohonan Bagi Pemeriksaan Forensik/ Toksikologi(Kimia 15-Pin
1/2004)
4. IEM Request Form
5. Request Form for Multiple Myeloma and Other Related Disorders
6. Request Form for Specific Proteins
7. Request for Molecular Diagnostics Services
8. Borang Perkhidmatan Genetik & Metabolik
9. Borang Ujian Saringan Congenital Hypothyroidism
Completed request form shall be signed by Medical Officers and accompanied by

properly collected specimens. Relevant information regarding provisional diagnosis and
treatment shall be provided. Incompletely filled request forms will be rejected by the
laboratory. All requests must specify names of tests required. For this purpose please
refer to the list of tests provided in this user manual. For tests which are not listed in this
manual, kindly contact the Chemical Pathology Laboratory, HTJS for further information.
41
5.0 SPECIMEN COLLECTION
All specimens must be sent in their respective containers, the use of inappropriate
containers will cause misleading results (refer to page 36 for the appropriate containers).
The following minimum information must be provided on the labels of specimens: -
Name of patient
I.C. number/Registration Number
Ward / Clinic
Name of test
Date
Blood collected in anti-coagulated tubes must be mixed gently and never shaken.
Urine specimens for Drug of Abuse requests for diagnostic and patient management
must be collected and sent directly to the Drug Laboratory, Pathology Department, HTJS.
Drug of Abuse requests for all other purposes must strictly follow the guidelines as in the
Manual for the Laboratory Detection of Drug of Abuse in Urine, Ministry of Health, 2002.
42
6.0 SPECIMEN CONTAINERS
The Chemical Pathology Unit, Hospital Tuanku Jaafar supplies the following containers for
specimen collections:
No Type of anti- Type of Containers Capacity Remarks

coagulant
1. Lithium Heparin Collection tube for 5 ml For most general chemistry
adult tests and Therapeutic Drug
1 ml
Monitoring (refer to Section B)
Microtainer tube for
peadiatric
2. Plain tube with Collection tube for 5 ml For Iron, IBCT , Hormones,
gel adult C3, C4, Tumour Markers and
CSF Biochemistry
1 ml
peadiatric
3. Potassium Collection tube for 3 ml For Blood glucose, CSF
Fluoride adult glucose and Lactate
1 ml
peadiatric
4. K2 EDTA Plastic 3 ml For HbA1C, IPTH, &
Ammonia
peadiatric
5. Plain urine Plain screw capped 30 ml For drug of abuse urine
Container Universal Urine specimen, spot urine
Container
6. Plain container Plain tube without gel 10 ml For bodyfluid testing

or Plain screw capped
universal bottle
6. 24 hours urine 24 hours Urine Send all the specimens For 24 hours urine testing
container Container with collected (in patients)
preservative (Thymol)
Send 25mls & mentioned
measured volume on
request form (out patients)
7. Glass bottle / Bijou bottle 5 ml CSF Biochemistry

plain tube
without gel
43
Request for urine containers can be submitted at the Main Reception Counter, Pathology
Department, Hospital Tuanku Jaafar.
Specimens of other body fluids (gastric, intestinal, pleural, peritoneal, oedema fluids from
subcutaneous tissues etc.) should be sent to the laboratory as soon as possible after collection or
kept refrigerated. Specify the actual analysis required. Send at least 10 ml of fluids.
7.0 DISPATCH OF SAMPLES/SPECIMENS
All samples/specimens (except for urine for Drugs of Abuse requests) shall be sent to the
Reception Counter, Department of Pathology, Hospital Tuanku Jaafar.
Any incomplete forms, label, wrong containers and inadequate samples/ specimens and
samples which do not fulfilled criteria of acceptance will be rejected.
8.0 REPORTING OF RESULTS
As soon as a batch of test results is completed, they are screened by a Biochemists /

Chemical Pathologist. All laboratory results must pass quality control criteria before they
are reported.
Clinics and wards that are linked to LIS may trace their results through the computer
provided, using WES passwords provided.
All the printed test reports will be placed in the pigeon holes (except for Drug of Abuse
reports and TDM reports) located at the main entrance of Pathology Department, several
times a day for the collection by wards, clinic and peripheral hospitals.
Ward and clinic staffs should come to the laboratory to collect printed test reports
regularly, preferably at least once in the morning and once in the afternoon, or even more
frequently.
9.0 INQUIRY & INFORMING OF TEST RESULTS
As most of the test results are numerical, tracing of results for routine tests via telephone
is not encouraged.
Notification of chemical pathology critical results shall be performed by the laboratory

personnel according to Quick Guide for Improving Notification of Critical Laboratory
results in MOH hospitals through telephone.
44
10.0 SHORT TURN AROUND TIME (STAT) SERVICE
The Chemical Pathology Laboratory offers a STAT Service for immediate management of
patients. When a test is requested STAT, the test will be carried out immediately. The
following procedure shall be followed in requesting STAT test.
1. The URGENT request form must be signed by a Medical Officer
2. Only critical results will be informed via telephone
1. Acetaminophen (Paracetamol)
2. Amylase
3. Blood glucose
4. CSF Biochemistry
5. Direct Bilirubin
6. Total Bilirubin
7. Troponin I (for Acute Coronary Syndrome (ACS) cases ONLY)
8. Calcium
9. Urea
10. Creatinine
11. Electrolytes (Na+, K+,Cl-)
12. Paraquat (urine)
13. Salicylate
14. TDM (for toxic cases only) *
15. Total hCG (for Ectopic Pregnancy cases) *
16. Thyroid Function Test (for new case of hyperthyroidism/ hypothyroidism and suspected
thyroid storm) *
* Consultation through phone call are required for the request after office hours or during
public holiday and permission shall be granted by Chemical Pathologist/ Science Officer
45
SECTION B
TABLE 1: LIST OF TESTS OFFERED, SPECIMEN REQUIREMENT, REFERENCE RANGE
AND SPECIAL REQUIREMENT
NO. TEST METHOD SPECIMEN CONTAINER SAMPLE REFERENCE NOTES TAT(Min/

VOLUME RANGE Hr/Day)
GENERAL CHEMISTRY (USE PER-PAT 301 FORM OR SPP FORM)
GENERAL CHEMISTRY FOR BLOOD, URINE AND BODY FLUIDS
1. Alanine Modified Plasma Lithium 3 ml 30-65 U/L Avoid haemolysis. 5 hrs

amino IFCC 37C heparin Also done as part of
transferase with liver profile
(ALT/ SGPT) Pyridoxal-5-
Phosphate
2. Albumin Bromocresol Plasma Lithium 3 ml 34 50 g/L Done as part of liver 5 hrs

purple heparin profile
3. Alkaline pNPP/ AMP Plasma Lithium 3ml 1 12 yrs : Also done as part of 5 hrs
Phosphatase buffer 37C heparin < 350 U/L liver and bone
(ALP) profile
13 17 yrs :
< 380 U/L
Adult :
50-136 U/L
4. Ammonia Enzymatic Plasma K2 EDTA in 2 ml Newborn : Appointment 1 day

GLDH ice slurry 64 -107 mol/L required via (routine)
/NADPH telephone before 60 mins
0 2 weeks : sending the
56 - 92 mol/L (STAT)
specimen. Please
> 1 mth : refer to Section C
21 50 mol/L Special Test
Procedures
Adult :
11 32 mol/L
5. Amylase 2-chloro-4 Plasma Lithium 3 ml 25 115 U/L Method response to 5 hours

nitrophenyl- heparin both pancreatic and (routine)
a-D- salivary amylase 60 mins
maltotriosid isoenzymes (STAT)
e (CNPG3)
37C Spot urine Plain screw 30 ml 30-201 U/l Known as Urine 1 day
capped Diastase (routine)
universal 60 mins
bottle (STAT)
24hrs Urine 24 hrs Urine 24 hrs 59-401 U/24hr

Container collection
6. Aspartate IFCC 37C Plasma Lithium 3 ml 15-37 U/L Avoid haemolysis 5 hrs
amino with heparin
transferase Pyridoxal-5-
(AST/ SGOT) Phosphate
46
SECTION B
NO. TEST METHOD SPECIMEN CONTAINER SAMPLE REFERENCE NOTES TAT(Min/

7. Bilirubin. Diazotized Plasma Lithium 3 ml Adult: Do not expose 5 hours

Direct Sulfanilic heparin specimen to light. (routine)
Acid Direct: <3 Avoid haemolysis
mol/L
Plain bullet 2 ml 60 mins
tube Newborn: (STAT)
Direct: <40
mol/L
8. Bilirubin. Diazotized Plasma Lithium 3 ml Adult: Do not expose 5 hours

Total Sulfanilic heparin Total : <17 specimen to light. (routine)
Acid mol/L Avoid haemolysis
Plain bullet 2 ml Newborn: 60 mins
tube Total:<200 (STAT)
mol/L
9. Calcium total O- Plasma Lithium 3 ml Adult: 5 hours

Cresolphtha heparin 2.12-2.52 (routine)
lein mmol/L 60 mins
complexone (STAT)
Children:
2.2 2.7
mmol/L
Spot Urine Plain screw 30 mls 0.5-4.4 mmol/l

capped
universal
bottle
24hrs Urine 24 hrs Urine 24 hrs 1.0 - 8.8 Acidify during

Container collection mmol/24h collection with 10 ml
(varies with of 1.0 M HCL
intake)
10. Chloride Indirect Ion Plasma Lithium 3.0 ml 98 107 Done as part of 5 hours
Selective heparin mmol/l Renal Profile (routine)
Electrode 60 mins
(ISE) 24hrs Urine 24 hrs Urine 24 hrs 110-250 Preserve urine in (STAT)
Container collection mmol/24hr 0.5g thymol
(varies with
intake)
CSF Bijou bottle 1 ml 116-128 5 hours

mmol/L (routine)
47
SECTION B

NO. TEST METHOD SPECIMEN CONTAINER SAMPLE REFERENCE NOTES TAT (Min/

11. Cholesterol, Cholesterol Plasma Lithium 3.0 ml NCEP ATP Done as part of FSL 5 hours
total oxidase heparin IIIAdult:
(CHD-PAP) Desirable: <5.2 Patient must fast at
mmol/L least 12 hours
Borderline : 5.2
6.2 mmol/L
High risk :
>6.20 mmol/L
Children
Desirable:
< 4.4 mmol/L
Borderline:
4.4- 5.15
mmol/L
High risk: >
5.15 mmol/L
12. Cholesterol, Direct Non Plasma Lithium 3 ml NCEP ATP Done as part of 5 hours
High Density immuno Heparin IIIHigh HDL-C FSL. Patient must
Lipoprotein logical > 1.55 mmol/L fast at least 12
(HDL-C) hours.
Low HDL-C
< 1.04 mmol/L
13. Cholesterol, Calculated Plasma Lithium 3 ml NCEP III ATP As part of Fasting 5 hours
Low Density value Heparin Low risk < 2.6 Lipid Profile (FLP)
Lipoprotein mmol/L
(LDL-C) Borderline 2.6-
4.2 mmol/L
High risk > 4.2
mmol/L
16. Creatine Dithio Plasma Lithium 3.0 ml Male: 5 hours

Kinase (CK) erythritol heparin 25-232 U/L (routine)
60 mins
(STAT)
Female:
21-215 U/L
48
SECTION B

17. Creatinine Alkaline Plasma Lithium 3 ml Newborn Done as part of 5 hours
picrate heparin ( 1-4 days ) : Renal Profile (routine)
(Modified 27 88 mol / 60 mins
Jaffe) L (STAT)
Infant :
18 35 mo/L
Children :
27 62 mol/L
Adolescent :
44 88 mol/L
19-72 yrs old:
Male:
71-115 mol/L
Female:
53-88 mol/L
24hrs 24 hrs Urine 24 hrs Male : Plasma Creatinine 1 day

Urine Container collection 5.3 22.1 shall be taken
mmol/ 24 hr within 24 hour of
Female : urine collection for
5.3 13.3 calculation of
mmol/24 hr creatinine clearance
18 Creatinine Alkaline Plasma Lithium 3 ml See above Plasma Creatinine 1 day

Clearance picrate heparin reference shall be taken
(Jaffe) range within 24 hour of
urine collection for
24hrs 24 hrs Urine 24 hrs Age dependent calculation of 1 day
Urine Container collection creatinine clearance
19 Globulin Calculated Plasma Lithium 3 ml As part of LFT 5 hours

value Heparin
Qualitative CSF Plain tube 3 ml Negative Part of CSF 5 hours

Pandy test with gel biochemistry
49
SECTION B

20 Glucose Hexokinase Plasma Fluoride 2 ml Plasma (ADA Please refer to 5 hours
Oxalate classification) Section C - Special (routine)
Normal Fasting Test Procedures for 60 mins
Plasma Glucose Tolerance (STAT)
Glucose Test
(FPG):
Children :
3.3 5.6 mol/L
Adult :
4.1 5.6
mmol/L
Impaired
fasting glucose
: 5.6 6.9
mmol/L
Diabetes
Mellitus:
FPG 7.0
mmol/L RPG
>11.1 mmo/L
CSF Fluoride 1 ml 2.2-3.9 mmol/L Part of CSF 5 hours

Oxalate Biochemistry.
Collect and send
with plasma
glucose drawn 2
hours prior to the
spinal tap
Urine spot Plain screw 10 ml 0.1-0.8 mmol/L 1 hour

capped
universal
bottle
24hrs Urine 24 hrs Urine 24 hrs <2.8 1 hour

Container collection mmol/24hr
21 Iron, total Ferene Serum Plain tube 3 ml Adult Avoid haemolysis. 3 days
with gel Males:11.6 Exhibit diurnal
31.3 mol/L variation, highest in
the morning.
Females:9.0
30.4 mol/L
22 Iron binding Ferene Serum Plain tube 3 ml 44.8 80.6 Usually done as Fe 3 days
capacity, total with gel mol/L & TIBC
50
SECTION B

23 Lactate Modified Plasma Potassium 2.0 ml Adult : 0.40 Appointment via 1 day
Marbach & Fluoride & 2.0 mmol/L telephone before
Weil Na2 EDTA in sending the
method ice slurry specimen. Please
(Lactate refer to Section C -
Pyruvate) Special Test
Procedures
CSF Bijou bottle 1.0 ml 0.6 2.2 Appointment via 1 day

mmol/L telephone
24 Lactate Substrate Plasma Lithium 3 ml 0.4-2.0 Males: 85-227 U/L 1 day

Dehydrogenase L-lactate heparin
(LDH) buffered Females: 81-234
U/L
25. Magnesium Modified Plasma Lithium 3 ml 0.74 0.99 Avoid haemolysis 5 hours
Methyl heparin mmol/L
thymol blue
24hrs Urine 24 hrs Urine 24 hrs 0.99 10.5 Add 10mL of 12M 1 day
Container collection mmol/24hr HCL in urine
container
26 Microalbumin Dye- Urine Urine 30 ml Normal 1 day

(Albumin: binding container Albumin <20
Creatinine Ratio high affinity mg/L
(ACR)) sulfo
nephthalein Creatinine 0.9-
26.5 mmo;/L
SIGN
2008:Normal:
Male : < 2.5
mg/mmol
Female: < 3.5
mg/mmol
Microalbumin
uria: Male :
2.530
mg/mmol
Female: 3.5-
30 mg/mmol
Macro
albuminuria
:>30mg/mmol
51
SECTION B
NO. TEST METHOD SPECIMEN CONTAINER SAMPLE REFERENCE NOTES TAT(Min/Hr

VOLUME RANGE /Day)

27 Osmolality Freezing Serum Plain tube with 3 ml 0.270 0.295 Please refer to 1 day
point gel Osm/kg Section C -
depression Special Test
Procedures
Urine Urine 5 ml 0.3-0.9
container Osm/kg
28 Phosphate Modified Plasma Lithium 3 ml Adult Avoid 5 hours

inorganic Phosphomo heparin (17-60 haemolysis.
lybdate years)0.81 Send to the lab
1.58 mmol/L within 1 hour of
collection
Children:
1.29 2.26
mmol/L
Urine spot Plain screw 20ml 8.7-28.0 5 hours

capped mmol/L
universal bottle
24hrs Urine 24 hrs Urine 24 hrs Adult 5 hours

Container collection (17-60
years)12-42
mmol/24hr
29 Potassium Indirect Ion Plasma Lithium 3 ml Adult : Done as part of 5 hours

Selective heparin 3.5-5.1 mmol/l Renal Profile (routine)
Electrode 60 mins
(ISE) New Born : (STAT)
3.7 5.9
mmol/L
24hrs Urine 24 hrs Urine 24 hrs 25-125 mmol/ 5 hours

Container collection 24hrs
30. Protein : Pyrogallol Urine spot Plain screw 20 ml SIGN 2008: 1 day
Creatinine red- capped Normal:
Ratio (UPCR) molybdate universal bottle < 15 mg/mmol
and Alkaline
Picrate Micro
albuminuria:
1544
mg/mmol
Macro
albuminuria:>
45 mg/mmol
52
SECTION B

31 Protein, total Biuret Plasma Lithium 3 ml Adult : 64-83 Done as part of
reaction end heparin g/L Liver Profile
point Newborn : 5 hours
46 70 g/L< 2
years :
55 75 g/L
Pyrogallol CSF Bijou bottle 1 ml 0.15-0.45 g/L Done as part of 1 day

red- CSF
molybdate biochemistry
24hrs Urine 24 hrs Urine 24 hrs SIGN 2008: Urine is 1 day

Container collection Normal: preserved in
< 0.15 g/24 hrs 0.5g thymol
Micro
albuminuria:
0.150.44 g/24
hrs
Macro
albuminuria:
>0.45 g/24 hrs
32 Sodium Indirect Ion Plasma Lithium 3 ml 135 145 Done as part of 5 hours
Selective heparin mmo/l Renal profile (routine)
Electrode 60 mins
(ISE) (STAT)
24hrs Urine 24 hrs Urine 24 hrs 40-220 mmol/ 1 day
Container collection 24hrs (varies
with intake)
33 Triglycerides Enzymatic Plasma Lithium 3 ml NCEP ATP III 5 hours

heparin Normal :
<1.7mmol/L
Borderline High
:1.7- 2.25
mmol/l
High risk :
2.26-5.64
mmol/L
Very high :
5.65 mmol/L
53
SECTION B

34 Troponin I One step Plasma Lithium 3 ml Normal: Sample should 5 hours
sandwich heparin <0.07g/L be taken after 4- (routine)
enzyme 8 hours of 60 mins
Immuno Risk symptom. (STAT)
assay stratification: Interpret result
> 0.14 g/L together with
AMI cut off: clinical
0.6-1.5 g/L symptoms and
ECG changes.
Markers of
myocardial
necrosis and
might be
increased in non
AMI e.g. chest
trauma,
pulmonary
embolism,
myocarditis,
cardiac and non
cardiac surgery,
CCF and acute
neurological
disease
35. Urea Urease Plasma Lithium Adult: 2.87.2

a. m Done as part of 5 hours
kinetic heparin mmol/l l Renal Profile (routine)
60 mins
Child: 1.7-6.4 (STAT)
mmol/l
24hrs Urine 24 hrs Urine 24 hrs 249-714 Urine is 1 day

Container collection mmol/L preserved in
0.5g thymol
36. Uric Acid Uricase Plasma Lithium 3ml Male: 5 hours

heparin 208-428 mol/l
Female:
155-357mol/l
24hrs Urine 24 hrs Urine 24 hrs 890-5890 Urine is 1 day

Container collection mol/24hrs preserved in
0.5g thymol
54
SECTION B
SPECIAL CHEMISTRY (USE PER-PAT 301 FORM OR SPP FORM)
HORMONES & METABOLITES
1. Cortisol Chemilumi Serum Plain tube 3.0 ml 7-9am: 119-618 Please refer 3-7 working
nescence with gel nmol/L to Section C. days
Special Test
3-5pm: 85-460 Procedures
nmol/L
24hrs Urine 24 hrs Urine 24 hrs 57.7-806.8 No

Container collection preservative
2. Estradiol Chemilumi Serum Plain tube 3 ml Male : Not Mid-cycle for 3-7 working
nescence with gel detected-146.1 pmol/l determining days
preovulatory
Menstruating surge,
Female:Follicular random
phase: 71.6 - otherwise
529.2 pmol/l
Midcycle phase:
234.5-1309.1 pmol/l
Luteal phase:
204.8-786.1 pmol/l
Post menopausal:
Not detected-118.2
pmol/l
3. Follicular Chemilumi Serum Plain tube 3 ml Male : 3-7 working

stimulating nescence with gel 1.4-18.1 IU/L days
Hormone
(FSH) Female:
Follicular phase:
2.5-10.2 IU/L
Midcycle phase:
3.4-33.4 IU/L
Luteal phase:
1.5-9.1 IU/L
Pregnant: <0.3IU/L
Post menopausal:
23.0-116.3 IU/L
55
SECTION B
4. Human Chemilumi Serum Plain tube 3 ml Non-pregnant<10.0 3-7 working

Chorionic nescence with gel IU/L days
Gonadotrophin, (ROUTINE)
Total (hCG) Pregnant
(gestational age) 4 hours
(IU/L) (STAT)
0.2-1 week:5-50
1-2 weeks:50-500
2-3 weeks:100-5000
3-4 weeks:500-10000
4-5 weeks:1000-
50000
5-6 weeks:10000-
100000
6-8 weeks:15000-
200000
2-3 months:10000-
100000
5. Luteinising Chemilumi Serum Plain tube 3 ml Male : Collect 3-7 working

Hormone (LH) nescence with gel 1.5-9.3 IU/L specimen days
according to
Female:Follicular the menstrual
phase: 1.9-12.5 IU/L cycle for
Midcycle phase: women.
8.7-76.3 IU/L
Luteal phase: Random for
0.5-16.9 IU/L men.
Pregnant:<0.1-1.5
IU/L
Postmenopausal:
15.9-54.0 IU/L
Contraceptives: 0.7-
5.6 IU/L
6. Prolactin Chemilumi Serum Plain tube 3 ml Male : 45-375 Random mid- 3-7 working
nescence with gel uIU/mL luteal days
preferred for
Female:Non- women.
pregnant: 56-619
uIU/mL Pregnant:
206-4420 uIU/mL
Postmenopausal: 38-
430 uIU/mL
56
SECTION B
HORMONES& METABOLITES
7. Progesterone Chemilumi Serum Plain tube 3 ml Male :0.9 -3.9 nmol/L Mid-luteal 3-7 working
nescence with gel days from +5 days
Female: to +9
Follicular phase : presumed
0.4-3.4 nmol/L ovulation.
Luteal phase:
10.6-81.2 nmol/L
Midluteal phase:
14.1-89.1 nmol/L
Post menopausal:
Not detected 2.3
nmol/L
Contraceptives:
0.7-5.6 IU/L
Pregnant:
1st Trimester:
35.7-286.2 IU/L2nd
Trimester: 81.2-
284.2 IU/L
3rd Trimester:
153.9-1343.6 IU/L
8. Thyroid Chemilumi Serum Plain tube 3 ml Adult (>18 yrs): Done as part 1-3 working
Stimulating nescence with gel 0.55-4.78 mIU/L of TFT. days
Hormone, TSH Adolescent Please refer
(12-18 yrs): to Section C -
0.51-4.94 mIU/L Special Test
Paediatric Procedures
(2-<18yrs):
0.64-6.27 mIU/L
Cord Blood Plain tube 3 ml Normal: use Borang Less than 2

with gel <21 mIU/L Ujian working
Borderline: Saringan days
21-60 mIU/L Congenital
High : hypo
21-60 mIU/L thyroidism
57
SECTION B
9. Thyroxine, Chemilumi Serum Plain tube 3 ml Adult : Done as part 1-3 working
Free (fT4) nescence with gel Euthyroid: of TFT. days
11.5-22.7 pmol/l Please refer
Hypothyroid: to Section C -
11.5-22.7 pmol/l Special Test
Hyperthyroid: Procedures
11.5-22.7 pmol/l
Pregnancy
1st trimester:
9.0-25.7 pmol/l 2nd
/3rd trimester: 6.4-
20.6 pmol/l
Baby <4days:
13.5-38.4 pmol/l
4-30days:
11.7-35.8 pmol/l
2-12mths:
9.4-30 pmol/l
Children
1-6 yrs:
11.1-29.1 pmol/l
7-12yrs:
10.7-22.2 pmol/l
> 2 weeks:
10.3-25.8 pmol/l
Cord Blood Plain tube 3 ml Normal: Less than 2

with gel <21 mIU/L working
Borderline: days
21-60 mIU/L
High: 21-60 mIU/L
10. Tri Chemilumi Serum Plain tube 3 ml Adult:3.5-6.5 pmol/l Done as part 1-3 working
iodothyronine, nescence with gel of TFT days
Free (fT3) Baby:<4days:
3.7-15.3 pmol/l
4-30 days:
4.2-12.6 pmol/l
2-12 mths:
3.8-11.8 pmol/l
Children:1-6yrs:
4.2-13.5 pmol/l
7-12yrs:
4.4-12.6 pmol/l
58
SECTION B
TUMOUR MARKERS
1. Alpha Chemilumi Serum Plain tube 3 ml <8.1 IU/ml Indicated for 3-7 working
Fetoprotein nescence with gel detection of open days
(AFP) neural tube defects
Managing non-
seminomatous
testicular cancers
2. Carcino Chemilumi Serum Plain tube 3 ml <5 ug/L Aid in the 3-7 working
Embryonic nescence with gel management of days
Antigen (CEA) cancer patients in
whom changing
concentrations
observed using this
assay
3. Prostatic Chemilumi Serum Plain tube 3 ml < 4.0 ug/L Aid in detection of 3-7 working
Specific nescence with gel Prostatic Cancer in days
Antigen, Total conjunction with DRE
(PSA) and monitoring of
patients with prostate
cancer
4. CA 125 Chemilumi Serum Plain tube 3 ml <35 U/ml Aid in the monitoring 3-7 working
nescence with gel of patients treated for days
ovarian cancer
5. CA 19-9 Chemilumi Serum Plain tube 3 ml <37 U/ml Aid in monitoring 3-7 working
nescence with gel patients previously days
treated for GI cancer
and in management
of GI cancer patients
normal metastatic
disease by
monitoring the
progression or
regression of disease
in response to
treatment.
59
SECTION B
ANAEMIA STUDY
1. Ferritin Chemilumine Serum Plain tube 3 ml Normal Adult : Avoid 3-7 working
scence with gel Male: 22-322 g/L haemolysis days
Female :
10-291 g/L
Iron deficiency :
0.7-34.5 g/L
Other Anaemias :
13.0-1391 g/L
Iron Overload :
335-8573 g/L
Renal dialysis :
31-1321 g/L
Chronic liver
disease :
8-12826 g/L
2. Vitamin B12 Chemilumine Serum Plain tube 3 ml 179-660 U/ml Avoid 3-7 working
scence with gel haemolysis days
Normal:
156-672 U/ml
Deficient:
24-181 U/ml
3. Folate Chemilumine Serum Plain tube 3 ml 9.5-45.2 U/ml Avoid 3-7 working
scence with gel haemolysis days
Normal:
>12.0 U/ml
Indeterminate:
7.64-12.19 U/ml
Deficient:
0.79-7.63 U/ml
60
SECTION B
NO. TEST METHOD SPECIMEN WHEN TO DRAW THERAPEUTIC TOXIC NOTES TAT (MIN/
SAMPLE RANGE RANGE HR/DAY)
GENERAL CHEMISTRY (USE THERAPEUTIC DRUG MONITORING REQUEST FORM)
THERAPEUTIC DRUG MONITORING (Sample volume: At least 3 ml, use Lithium heparin container/ plain tube)
1. Carbamazepine Particle Plasma Peak Effective plasma > 63 1 day

enhanced h concentration: mol/L
turbidimetric 3 hrseafter oral 17-51 mol/l
inhibition dosep
immunoassay a Effective
Trough monotherapy:
(PETINIA) r
Immediately
i 17-34 mol/l
before
n Effective
administration
) of combination
next oral dose. therapy:
Normal time to 34-51mol/l
steady state
2 weeks
2. Digoxin Magnetic Plasma Trough 1.15 2.56 > 2.56 1 day

particle nmol/L nmol/L
immunoassay Immediately
before
administration of
next oral dose.
Normal time to
steady state
1-2 weeks
depending on
renal function
May be prolonged
in patients with
renal dystunction
61
SECTION B
3. Gentamicin Homogenous Serum/ Peak Peak level for Trough May be 1 day
particle Plasma effective plasma: concentr delayed
enhanced IM: 60 min after intra 8.64-21.6 mol/l ation in
turbidimetric muscular injection >4.2 patients
inhibition IV: 30 min after end mol/l for with
immunoassay of 30 min IV infusion longer renal
(PETINIA) or immediately after a than 10 dysfuncti
60 min infusion. days on
Trough
Immediately before
next dose.
Normal time to
steady state
Adults (<30yrs) : 2.5-
15 hrs Adults
(>30yrs) : 7.5-75 hrs
Children:
2.5-12.5 hrs
Neonates: 10-45 hrs
4. Phenytoin Particle Plasma Generally trough 39.6 79.2 > 118.9 1 day
enhanced level should be mol/L mol/L
turbidimetric monitored to
inhibition measure the
immunoassay minimum serum
(PETINIA) concentration during
the dosing interval.
Trough concentration
should be measured
1 week after initiating
therapy and then
again 3 to 5 weeks
later. Peak
concentration may be
useful toconfirm
toxicity.
62
SECTION B
5. Theophylline Particle Plasma IV Therapy Vary > 111 1 day

enhanced significantly; mol/L
4 to 6 hrs after
turbidimetric
beginning the Effective
inhibition
infusion. 12 to 18 hrs concentration
immunoassay
after beginning 56-111mol/l
(PETINIA)
infusion, repeat
serum
measurements are
needed to ensure
therapeutic
concentration.
(minimum of 24-hr
interval)
Oral Therapy
Peak:
Sampling time
depends on
preparation:-
a) Solution or solid
with rapid
dissolution:- 2hr. after
oral dose.
b) Slow release
formulations: -4hrs
after oral dose.
c) Theo-Dur formula:
3 to 7 hrs. after dose.
Trough:
Immediately prior to
next oral dose.
Normal time to
steady state:
a. adult: 2 days
b. children:1-2 days
c. infants: gradually
decrease from 5
days to I day
d. Premature: 150hrs
63
SECTION B
5. Theophylline Particle Plasma e.Newborn: 120 hrs 1 day

enhanced
f. Time to steady
turbidimetric state is decreased
inhibition in adults who
immunoassay smoke and
increased in cardiac
decompensation or
hepatic failure
6. Valproic acid Particle Plasma Peak: Vary > 832 mol/L 1 day
enhanced significantl
turbidimetric Generally 1-3 hrs
after an oral dose. y;
inhibition
immunoassay Trough: Effective
(PETINIA) concentrat
Immediately before ion 346
nest oral dose. 693
mol/L
Normal time to
steady state:
Adults: 30-85 hrs
Children: 20-70 hrs
May be prolonged
in patients with
hepatic disease.
7. Vancomycin Particle Plasma Peak: > 55.2 mol/L Great 1 day

enhanced disparity
turbidimetric 2 hr after 12.1-17.4 in
inhibition completion of 60 mol/l therapeu
immunoassay minutes infusion tic
(PETINIA) 1 hr after ranges,
completion of 60 16.8-26.8 especiall
minutes infusion mol/l y with
peak
1/2 hr after therapeu
completion of 60 20.1- tic
minutes infusion 26.8mol/l ranges
Trough: 3.4-
Immediately prior to 6.6mol/l
next dose
64
SECTION B
NO. TEST METHOD SPECIMEN WHEN TO THERAPEUTIC TOXIC NOTES TAT (MIN/
DRAW RANGE RANGE HR/DAY)
SAMPLE
GENERAL CHEMISTRY (USE PER-PAT 301 REQUEST FORM)
LIMITED TOXICOLOGY
1. Acetaminophen Amidase Plasma Between 4 66.2 198.5 4hrs after 3 hours

(Paracetamol) reaction and 12 hrs mol/L ingestion : (STAT)
after >992.7 mol/l Only office
ingestion hours
12hrs after
ingestion :
>330.9 mol/l
2. Paraquat Saturated Urine Urine 20 ml negative 1-2 hours

(Qualitatative) NaOH Container
3. Salicylates Modification Plasma 1-3 hrs after 0.20-1.45 Associated 1 day

of Trinder intake mmol/L with toxic
colorimetric symptoms >
For antipyretic / 2.17 mmol/L
analgesic
conditions: 0.21 Lethal range
0.72mmol/L > 4.34
mmol/L
For anti-
inflammatory /
rheumatic fever
condition :
1.09
2.17mmol/L
65
SECTION B
NO. TEST METHOD SPECIMEN CONTAINER SAMPLE REFERENCE NOTES TAT

VOLUME RANGE (Min/Hr/
Day)
TOXICOLOGY (USE BORANG PERMINTAAN UJIAN PENGESAHAN DADAH DALAM AIR KENCING)
DRUG OF ABUSE
1. Morphine Enzyme Urine Urine container 30ml Cut off value 3-5 days
Immunoassay
Technology Screening:
(Screening) 300ug/L
Thin layer Confirmation:

Chromatograp 200ug/L
hy
(Confirmation)
2. Cannabis Enzyme Urine Urine container 30ml Cut off value 3-5 days
Immunoassay
Technology Screening:
(Screening) 50ug/L
Thin layer
Chromatograp Confirmation:
hy 25ug/L
(Confirmation)
66
SECTION B
TABLE 1 :LIST OF TESTS OFFERED, SPECIMEN REQUIREMENT, REFERENCE RANGE
NO. TEST METHOD SPECIMEN CONTAINER SAMPLE REFERENCE NOTES TAT

VOLUME RANGE (Min/Hr/
Day)
SPECIAL CHEMISTRY (USE PER-PAT 301)
SPECIAL PROTEINS
1. C-Reactive Particle- Plasma/ Lithium heparin/ 3 ml Age 4-74 yrs Raised 1 day
Protein (CRP) enhanced Serum Plain tube with gel :< 3.0 mg/L level is
turbidimetric non
immuno assay specific
(PETIA) and
should not
be
interpreted
without
clinical
history
Cannot be
use to
assess
CVD
2. Complement 3 Immuno Serum Plain tube with gel 3 ml 0.9- 2.07 g/L 1 day
(C3) turbidimetric
method
3. Complement 4 Immuno Serum Plain tube with gel 3 ml 0.17- 0.52 g/L 1 day
(C4) turbidimetric
method
4. Glycated HPLC Blood K2 EDTA 2.5 ml Ideal : < 6.5% This level 3
Haemoglobin (<48 should be working
(HbA1c) mmol/mol) used with days
caution in
Acceptable elderly
Control: patients,
6.6 7.0 % patients
(48-63 with CAD
mmol/mol) or patient
Poor Control : who
> 7.0% (>63 cannot
mmol/mol) tolerate
hypoglyce
mia
67
SECTION C : SPECIAL TEST PROCEDURES
Procedures for tests sent to referral laboratories may be subject to changes and
amendment made by the associated agencies. Kindly contact our lab personnel
for further enquiries.
1.1 24 HOUR URINE COLLECTION

Most quantitative assays are performed on urine specimen collected
over 24 hours. The 24 hour timing allows for circadian rhythmic changes
in excretion at certain time of day. Proper instruction to the patient will
reduce significant collection errors due to improper timing and missed
samples, which will cause over collection or under collection.
The 24 hour urine bottle which contains preservative for the required test
is available at the Main Counter, Pathology Department and provided on
request, with the accompanying request form.
Procedure of collection:
Day 1 : Instruct patient to void at 0800 am and discard the sample.
Collect the second and subsequent voided urine for the next
24 hours into the 24 hours urine container.
Day 2 : Include the final sample voided at 0800 am into the 24 hours
urine container.
For male patient, it is advisable NOT to void the urine directly
into the 24 hour urine bottle. This is to avoid possible chemical
burns.
At the end of 24 hour, the last urine voided is collected. For
best results, refrigerate if possible.
Label the container with
o Two identifiers (Name and I.C or R/N number)
o Date and time collection started
o Date and time collection completed as directed and
o Name of the test required (e.g. of tests: 24hr urine cortisol and 24hr
urine catecholamine)
Send immediately to the Main Reception Counter, Pathology
Department.
68
1.2 24 HOUR URINE CATECHOLAMINES (PUTRAJAYA HOSPITAL)
Follow procedure for 24hr urine collection.
Void urine into another clean container before pouring into the 24 hour
urine container provided.
Use urine container that has been added with 10ml of 25% HCl
preservative into the urine container to preserve the analytes. It is
important for the requesting physician to advise the patient NOT to
discard the preservative and to handle with caution.
Abstain from taking food that will increase catecholamines concentration
few days before urine collection such as:
o All beverages containing coffee, nescafe, tea or chocolate
o Citrus fruits (e.g. lemons, oranges, pineapples, apples etc.)
o Food containing vanilla, walnuts
Stop medications which will alter the metabolism of catecholamine at
least 48 hours prior to urine sampling i.e. Alpha-2 agonists, Calcium
channel blockers, ACE inhibitors, Bromocriptine,Methyldopa,
Monoamine oxidase inhibitors, Alpha blockers and Beta blockers,
Phenothiazines and Tricyclic antidepressants.
Advice patient to avoid stress, vigorous exercise and smoking prior to
and during urine collection.
Label the container with
o Two identifiers (Name and I.C or R/N number)
o Date and time collection started
o Date and time collection completed as directed and
o Name of the test required (e.g. of tests: 24hr urine cortisol and
24hr urine catecholamine)
Send immediately to the Main Reception Counter, Pathology Department.
69
1.3 LACTATE
Collection of a satisfactory specimen for lactate analysis requires
special procedure to prevent changes in lactate concentration while
and after the specimen is drawn. Please inform the laboratory at
least two hours prior to blood collection for the instruments to be
calibrated and ready for analysis on receipt of specimen.
Fast patient for at least for 6 hours.
Do not apply tourniquet
Collect 2 ml of blood is collected in a container with Potassium
fluoride and Na2 EDTA as anticoagulant (glucose tube).
Notes:
i. Patient should avoid from clenching their fist during blood collection.
ii. If the tourniquet has been applied very long, it should be removed
after the puncture has been performed and blood allowed circulating
for at least 2 minutes before the blood is withdrawn.
iii. Chill sample and transport in ice water.
iv. Send sample to the laboratory within 1 hour.
v. Avoid haemolysis as it may affect test results.
1.4 AMMONIA
Collection of a satisfactory specimen for ammonia analysis requires
special procedure to prevent changes in ammonia concentration while
and after the specimen is drawn.
Same as the collection of lactate but using K2 EDTA tube.
Notes:
Similar to the collection of Lactate
70
1.5 INTACT PARATHYROID HORMONE @ IPTH (IMR KUALA LUMPUR)

Collection tube: Potassium EDTA as preservative.
Volume of blood to be taken: 2 or 3 ml (depending on the brand)
Assay principle: 3rd Generation IRMA
Reference range: Normal: 5-39 pg/mL Hyperparathyroidism: >39 pg/mL
Cool the tube in a fridge for 15 minutes, prior to blood collection.
Fast patient at least for 8 hours.
Take blood sample and gently invert the tube 5-8 times.
On dispatching, keep the blood specimen tube in a sealed plastic
specimen bag inside an ice box.
Furnish information such as medication given *** and relevant clinical
history.
Ensure that the blood specimen reach the laboratory before 12 pm
during office day so that the analysis can be done on the same day.
Important notes:
* Under-filing of blood will lead to dilutional effect on PTH level.
** PTH levels are subject to diurnal variation with the level peaks at around
2.00am and lowest at around 2.00pm. Since serial assay of PTH will be
done for the dialysed patient, it will be a good practice to always adhere
to a standard procedure of blood collection.
*** Some prescription drugs affect the results of PTH tests.
Drug that increase blood PTH level include phosphate, anticonvulsant,
steroid, isonizid, lithium and rifampin.
Drug that decrease blood PTH level include cimetidine and propanolol.
71
1.6 GLUCOSE TOLERANCE TEST (GTT)
Instruction and Patients Preparation

Take a normal diet with adequate carbohydrate intake (>150g/day) for 3
days prior to specimen collection. No food or energy supplying
substances in any form should be consumed for at least eight hours
prior to the test but the patient must not be fasted longer than 16 hours.
Do not take alcohol 36 hours prior to collection and do not take
medications which will affect the results e.g. steroid, oral contraceptive,
diuretics, nicotinic acid, thyroid hormones and dilantin.
Fast the patient overnight at least for 10-16 hours. Plain water is
permitted throughout this period and during the test.
Rest at least 30 minutes and do not smoke before specimen collection.
Collection procedure:
0800 am : Collect fasting blood specimen and urine. Give patient 75g
glucose in 250 300 ml water and drink within 5 - 10 minutes. For
children the glucose dose is 1.75 g/kg body wt. to a maximum of 75g.
1000 am : Take 2nd blood specimen (i.e. 2 hours after first blood taken).
Interpretation:
Following the 75 g glucose load, the two-hour plasma glucose value
should be interpreted as follows:
Glucose concentration Interpretation
<7.0 mmol/l interpreted as Normal Glucose Tolerance

7.011.0 mmol/l interpreted as Impaired Glucose Tolerance
>11.1 mmol/l interpreted as Diabetes Mellitus
72
1.7 PROTOCOL FOR REQUESTING AND COLLECTING SAMPLES FOR

PLASMA RENIN ACTIVITY (PRA) AND PLASMA/ SERUM
ALDOSTERONE TESTS TO PUTRAJAYA HOSPITAL
Indication
Screening for Primary hyperaldosteronism in hypertensive patients with
spontaneous or diuretic-induced hypokalaemia
Suggested candidates for screening

Patients with hypertension and hypokalaemia
Patients with resistant hypertension
Young hypertensive (<40 years)
Patients with adrenal incidentaloma
Principle
The renin-aldosterone axis is primarily regulated by renal blood flow.
Subjects under investigation should therefore, not be taking any drugs that
interfere with fluid balance or potassium.
Patient Preparation
Drugs to avoid : Spironolactone, ACE inhibitors, ARB, beta-blockers,
cyclic progestogens, estrogens and licorice
Drugs that do not interfere with the renin-aldosterone axis include:
prazosin, verapamil and terazosin
Subject should be normally hydrated and has an adequate oral intake of
sodium
Avoid hypokalaemia as it suppress aldosterone secretion. Give
potassium replacement (Slow K) tabs) sufficient to raise plasma
potassium >4.0 mmol/L. replacement should be stopped on the day of
the test.
73
*Spironolactone must be stopped for 6 weeks to be certain that any
evaluation in plasma rennin activity is not due its inhibition of
aldosterone.
Ideally all interfering drugs should be stopped at least 2 weeks prior to
sampling.
Requirements
Potassium EDTA (K2 EDTA) tube for renin (DRA)
Potassium EDTA (K2 EDTA) tube for aldosterone
Blood samples should be sent rapidly to the laboratory but not in ice
(within 30 minutes) as cooling would cause cryoactivation, leading to
falsely raise rennin.
Procedures
The patient should remain seated for 10minutes prior to venipuncture.
Collect samples into 2 tubes of EGTA.
(Please use different tubes for Renin and Aldosterone. Suggest to
collect minimum 3ml blood per sample, as atleast 500l plasma need
for each analysis)
Fill up the PER. PAT 301 form. Oly single form is required for requesting
Aldosterone Renin Ratio(ARR).
Patients clinical history and drug history are MANDATORY.
Test should be requested by Specialist/Specialist Endocrine only.
Pleae record patients posture whether supine or upright.
Supine sample:
Sample taken in the early morning before the subject arises(if feasible)
Upright sample:
Subject should be upright for 2hours prior to sampling.
Samples should be taken between 8am to 10am
Interpretation
High aldosterone and suppressed plasma renin activity indicates primary
hyperaldosteronism.
Some patients with renal disease may give similar results.
74
1.7 (continue)
Instruction for Lab Personnel : Scientific Officer/ MLT of Referring Lab.

i. Upon arrival
Separate plasma (Renin or Aldosterone) immediately.
Transfers the plasma into a plastic/ secondary tube
Minimum volume for Plasma Renin and Plasma Aldosterone is 500 L of
Plasma for each analyte.
Samples for both renin and aldosterone should be frozen as soon as
possible (-20oC or lower)
Sample tubes shall have the following information: (barcoded or
manually labelled)
Requested test
Patients name
Identity card number
Medical Registration Number
Date of Collection
ii. Transportation of Sample
Samples should be sent frozen, packed in ice and place in a
sturdy insulated container.
Samples not received in optimum condition shall be rejected.
Causes of Rejection
1. Wrong container
2. Insufficient sample
3. Haemolysis or lipemic sample
4. Incorrect patient preparation
5. Incomplete request form
75
1.7 (continue)
Incomplete patient information

no test indication
no clinical history
no requesting doctors name and signature
Sample stability
60 days at -20C
1.8 GUIDELINES FOR THYROID FUNCTION TEST REQUEST
A. For Screening of Primary Thyroid Disease

Serum TSH alone is adequate for ruling out Primary
Hypothyroidism and Thyrotoxicosis.
In patients with elevated TSH >0.40 mIU/L, free T4 (fT4) will be
done. A low fT4 with elevated TSH confirm primary
hypothyroidism. A normal fT4 with elevated TSH suggest a sub
clinical hypothyroidism.
In patients with suppressed TSH < 0.01, thyrotoxicosis is most
likely and elevated fT4 confirm the diagnosis.
In patients with low TSH, ranging between 0.01 to 0.40 mIU/L;
possibilities are early thyrotoxicosis, sub clinical hyperthyroidism
or non-thyroidal illness. Measurement of fT4 may indicate either
sub clinical hypothyroidism or non-thyroidal illness. Measurement
of fT3 maybe indicated in these cases, if fT4 is normal or low.
If secondary thyroid disease (hypothalamic/ pituitary disease)
suspected, please indicate clearly in clinical summary on the
request form as fT4 need to be done together with TSH for
diagnosis.
B. Clinical Indication for fT3
76
Suspected thyrotoxicosis when fT4 is normal and serum TSH is
suppressed; to exclude T3 toxicosis.
Patients who are on antithyroid therapy who are clinically
hyperthyroid despite normal or subnormal fT4 levels.
Diagnosis of amiodarone induced thyrotoxicosis.
To detect early recurrence of thyrotoxicosis in the presence of
suppressed TSH after stopping the anti-thyroid drug therapy.
77
1.9 GUIDELINES FOR THYROID FUNCTION TEST REQUEST
C. To Monitor Patient on Treatment ( either with anti-thyroid drug

or L-thyroxine)
Do FT4 and TSH
Monitor level after 6-8 weeks after starting treatment
In stable patients, 6 monthly fT4 and TSH is adequate for monitoring.
In pregnancy, more frequent fT4 and TSH testing such as 1 2
monthly is justifiable.
For stable primary hypothyroidism, TSH alone can be used to guide
thyroxine replacement.
In patient with secondary hypothyroidism (hypothyroidism due to
pituitary or hypothalamus disease), fT4 alone is adequate for
monitoring response to treatment. TSH is of no value for monitoring
of treatment.
D. For Congenital Hypothyroidism Screening

Free Thyroxine (fT4) shall be analysed in a patient with borderline
value of cord blood TSH (21-60mU/L).
If fT4 is low (<15pmol/L), the babies shall be recall for repeat venous
blood TSH and or fT4.
E. For Congenital Hypothyroidism Confirmation

The follow-up and thyroid function tests for confirmed Congenital
Hypothyroidism patients shall follow the guideline by National
Screening Programme for Congenital Hypothyroidism MOH Malaysia
2011 as follows:
After initiation of L-Thyroxine 2 weeks, 4 weeks

(until normalization of results)
1-12 months 1-2 monthly
1-3 years 2-3 monthly
>3 years until growth is complete 6-12 monthly
78
1.9 PROTOCOL FOR INVESTIGATION OF ENDOCRINE

DISORDERS: ASSESSMENT OF ANTERIOR PITUITARY
RESERVE
a) Initial assessment
Morning serum Cortisol and ACTH or Cosyntrophin Stimulation Test

Thyroid Function Test (TSH, fT4)
Prolactin
LH, FSH
Testosterone (Men) or Estradiol (Women)
b) Combine Anterior Pituitary Function Test (Insulin Tolerance Test +

GnRH Stimulation Test + TRH Stimulation Test) or Triple Function/
Triple Bolus Test
Objective : Evaluation of anterior pituitary hormones

Usage : Evaluation of suspected hypopituitarism
Patients Preparation:
Fast the patient overnight.
Put patient be in a supine position throughout the procedure .

Insert an appropriate sized branula for injection of medicines,
sample collection and glucose infusion during emergency.
Take baseline blood samples for glucose, cortisol, growth
hormone (GH), luteinizing hormone (LH), follicle stimulating
hormone (FSH), thyroid stimulating hormone (TSH) and
prolactin (PRL).
Give 200 ug TRH, 100 ug GnRH and 0.10-0.15 unit/kg body
soluble insulin.
79
Collect samples into plain tubes and glucose tubes at 15, 20,
30, 60, 90 and 120 minutes and labels as follows:

1.9 PROTOCOL FOR INVESTIGATION OF ENDOCRINE DISORDERS:
ASSESSMENT OF ANTERIOR PITUITARY RESERVE
Time Tests Collection Tubes

0 min Glucose Glucose tube
(basal) Cortisol, GH, TSH, LH, FSH 1 plain tube
20 min TSH, LH, FSH 1 plain tube
Cortisol, GH 1 plain tube
45 min Glucose
Cortisol, GH, TSH, LH, FSH 1 plain tube
Send all samples after completion of the test to the Main Counter of
Pathology Department, after informing the laboratory through phone
call prior to sending.
Notes:
This test shall be performed under the close supervision of a medical
officer throughout the procedure and 50% IV dextrose shall be kept by the
bed side.Stop the test if patient suffers from severe hypoglycaemia.
Plasma glucose level must fall below 2.2 mmol/L and/ or clinical signs and
symptoms of hypoglycaemia (sweating, tachycardia, etc) are observed.
Additional intravenous insulin may be given if this does not occur by 30
min and sampling should be prolong for another 30 min.
80
Test is contraindicated for patient with seizure, IHD or cardiovascular
insufficiency and in young children. Normal ECG is mandatory.

DISORDERS: ASSESSMENT OF ANTERIOR PITUITARY RESERVE
Interpretation:
Normal response for each of the hormones levels are as follow:
a) Cortisol increase more than 200 nmol/L
b) GH increase at least 20 mU/L
c) TSH at least 3 time more than basal level
d) PRL increase more than 10 times basal value
e) LH increase more than 5 times basal value
f) FSH increase more than 3 times basal value
c) Insulin Tolerance Test (Insulin Induced Hypoglycaemia

Stimulation Test)
Rationale:
The stress of insulin-induced hypoglycaemia triggers the release of
GH and ACTH from the pituitary gland in normal subjects. GH
response is measured directly; cortisol is measured as the
indication of ACTH response.
Instruction and Patients Preparation:
Fast the patient overnight.
Put patient in a supine position throughout the procedure.

Prepare intravenous injection of 50% glucose (at least 50 ml)
or 20% glucose (at least 100ml) and intravenous
hydrocortisone beside patients bed for emergency usage.
81
Insert an appropriate sized branula for injection of insulin and
sample collection.

1.9 PROTOCOL FOR INVESTIGATION OF ENDOCRINE DISORDERS:
c) Insulin Tolerance Test (Insulin Induced Hypoglycaemia

Stimulation Test)
Take blood samples for basal level of glucose, cortisol and

growth hormone.
Give 0.1-0.15 units/kg body soluble insulin.

Collect samples into plain tubes and glucose tubes at 30, 60
and 90 minutes and labels as follows:

(basal) Cortisol, GH 1 plain tube
Send all samples after completion of the test to the Main
Reception Counter of Pathology Department, after informing the
laboratory through phone call prior to sending.
82
1.9 PROTOCOL FOR INVESTIGATION OF ENDOCRINE DISORDERS :
d) Gonadotrophin Releasing Hormones (GnRH Stimulation Test)
Rationale:
GnRH stimulates release of Luteinizing Hormone (LH) and
Follicular Stimulating Hormone (FSH) in normal individuals.
Subnormal responses are seen in some patients with pituitary or
hypothalamic disorders.
Take basal blood samples into plain tubes for LH and FSH.
Give 100 ug GnRh intravenously.
Collect samples into plain tubes at 15, 30, 60 and 90 minutes

after GnRH injection for LH and FSH and labels as follows:

0 min (basal) FSH, LH 1 plain tube
15 min FSH, LH 1 plain tube
Send all samples after completion of the test to the Main
Reception Counter of Pathology Department, after informing the
laboratory through phone call prior to sending.
83
1.10 PRE OPERATIVE ENDOCRINE TESTING (A SIMPLE APPROACH)
a) Initial assessment
Morning serum Cortisol or Short Synacthen Test

Thyroid Function Test (TSH, fT4)
Prolactin
LH, FSH
Testosterone (Men) or Estradiol (Women)
b) Shortly after pituitary surgery (2-4 days after surgery)
a) Corticosteroid coverage with hydrocortisone is administered immediately

before, during and after surgery.
b) If adrenal function is intact before surgery, hydrocortisone is stopped on
second or third post-operative day.
c) 24 hours after hydrocortisone is stopped, blood for cortisol is taken at
8.00 am.
d) If morning serum cortisol is less than or equal to 80nmol/L,
hydrocortisone is no longer required.
e) If morning serum cortisol is between 80-250nmol/L, Insulin Tolerance
Test should be performed to confirm intact Hypothalamic Pituitary-
Adrenal axis.
c) Follow up after surgery
One month after surgery, evaluate:

f) Thyroid Function Test (TSH, fT4)
g) Testosterone (Man) and Estradiol (Woman)
h) Synacthen Test
After pituitary irradiation, evaluate every 6 months
i) Thyroid Function Test (TSH, fT4)
j) Testosterone (Man) and Estradiol (Woman)
k) FSH, LH, Prolactin
l) ACTH Stimulation Test
84
SECTION C :SPECIAL TEST PROCEDURES
DISORDERS : ASSESSMENT OF POSTERIOR PITUITARY
a) For Polyuria Cases
Document polyuria ie. Urine volume > 2.5 L/day.

Avoid nicotine, alcohol, caffeine.
Exclude glycosuria, hypercalcaemia and hypokalaemia.
Measure urine creatinine (for estimation of completeness of urine
collection).
Measure plasma osmolality and plasma sodium
If plasma osmolality 295 mOsm/kg and sodium 145 mmol/l
Primary Polydypsia (Psychogenic) is unlikely
Perform Water Deprivation test (see protocol) if plasma osmolality
is less than 295 mOsm/kg.
b) Protocol for Overnight Water Deprivation Test
Rationale
Dehydration provides a strong stimulus for Antidiuretic Hormone
(ADH) release which can be assessed indirectly by measuring urine
osmolality or directly by measuring plasma ADH. If urine remains
hypoosmolal during water deprivation, the administration of ADH helps
to differentiate between Cranial Diabetes Insipidus (CDI) and
Nephrogenic Diabetes Insipidus (NDI).
Pre-Analytical Procedure:
Inform Science Officer in charge in the Chemical Pathology Lab.
Write the clinical summary, basal plasma osmolality, sodium and
body weight at 10.00 pm a day before the test and name of test on
the request form.
85
1.10 PROTOCOL FOR INVESTIGATION OF ENDOCRINE DISORDERS
: ASSESSMENT OF POSTERIOR PITUITARY
Note: If the patient is clinically dehydrated, it m ay be dangerous /

unnecessary to perform water deprivation test. Serum and urine
osmolality will show whether the kidneys are able to concentrate the
urine.
Procedures:
Allow fluids overnight before the test and give light breakfast with
no fluid. No smoking permitted.
Weigh the patient.
No fluids shall be allowed for 8 hours. Patient must be under
supervision within this time.
Every 2 hours;
Weigh patient every 2 hours. Care should be taken to ensure
that body weigh does not decrease by more than 5% (Test
should be terminated if this occur).
Patient empties bladder and measure both urine volume and
osmolality(it is very important to write time of collection).
Measure serum osmolality (stop test if osmolality >300mmol/kg)
When urine osmolality is stable (a change of more than
30mOsm/kg for 2 consecutive hours (usually takes 8-12 hours
to occur), specimens are collected for plasma osmolality and
plasma sodium.
After 8 hours, allow patient to drink, but not more than twice the
urine volume of period of fluid deprivation; to avoid acute
hyponatraemia.
Give 2 ug desmopressin intramuscularly.
Measure urine for osmolality every 4 hours for a further 16 hours.
Send the samplesand request forms to Main Reception Counter,
Pathology Department, after informing the laboratory through
phone call prior to sending.
86
ASSESSMENT OF POSTERIOR PITUITARY
Interpretation:
Normal person
Reduction of 3% or less of body weight
Do not develop elevated plasma sodium or plasma osmolality
Will produce concentrated urine (urine osmolality > 400 mOsm/kg)
with no further increased in urine osmolality after ADH injection.
Patients with Hypothalamic Diabetes Insipidus
Shows increase in plasma sodium and osmolality
Urine will be less concentrated (< 400 mOsm/kg, but less than
plasma)
Urine osmolality will increase by 10% or more after ADH injection
Patients with Nephrogenic Diabetes Insipidus
Shows increase in plasma sodium and osmolality
Urine will be less concentrated (< 400 mOsm/kg)
No significant changes in urine osmolality after ADH injection
87
Algorithm for the investigation of polyuria
polyuria measure: abnormal diagnosis

glucose
creatinine
potassium
calcium
normal
fluid deprivation
test
Urine osmolality (mmol/kg) after:

8 h fluid deprivation desmopressin
<300 >750
Cranial diabetes insipidus
<300 <300
Nephrogenic diabetes
>750 >750 insipidus
Primary polydipsia
300-750 <750
*Non-diagnostic
88
c) Diagnosis of Syndrome of Inappropriate Antidiuretic Hormone

(SIADH)
Document serum osmolality less than or equal to 275 mOsm/kg and

hyponatremia less than or equal to 130 mmol/L.
Exclude cardiac, hepatic, renal, thyroid or adrenal failure, pituitary
surgery, diuretic therapy and medication known to stimulate ADH
secretion.
Measure urine sodium and osmolality. Presence of urine osmolality
> serum osmolality and urine sodium more than 60 mmol/L
indicates the possibility of SIADH.
Suggest to proceed with Water Loading Test.
d) Protocol for Water Loading Test
Rationale
An excess ADH leads to hyponatremia. This dynamic test is useful if
SIADH is suspected in patient with normal or near normal serum
sodium and serum osmolality or in a patient with reset osmomat.
This test should not be performed in a patient who is already
significantly hyponatremic because water load will worsen the
hyponatremia.
Procedures:
Note: Exclude apparent hyponatremia which may be due to
hyperproteinaemia or hyperlipidaemia by measuring serum
osmolality. (serum osmolality will be normal in these patients).
Give patient a light breakfast.
After 2 hours, collect serum and urine osmolality.
89
d) Protocol for Water Loading Test
Give patient water to drink (20ml/kg) over 15 to 30 minutes period;

lightly salted crackers may be given with water if needed.
Keep patient in recumbent position.
Repeat specimen collection for serum and urine osmolality hourly for
the next 4 hours and label all containers with patients information,
time of collection and name of test.
Measure total urine output and document on request form.
Plasma ADH may be measured at 90 or 120 minutes after water loading
to confirm the diagnosis of SIADH.
Send samples with request forms to Main Reception Counter, Pathology
department, after informing the laboratory through phone call prior to
sending.
Interpretation:
Normal person
Plasma osmolality should decrease by greater than or equal to 5
mOsmol/kg.
Urine osmolality should be less than or equal to 100 mOsm/kg.
90% or more water load excreted in 4 hours.
SIADH
Excretion of water load less than 90%.
Urine osmolality remains greater than 100 mOsm/kg.
Subnormal responses are seen in glucucorticoid deficiency, hypothyroid and
renal disease.
90
SECTION C :SPECIAL TEST PROCEDURES
1.11 ASSESSMENT FOR FUNCTIONAL STATUS OF ADRENAL

CORTEX
a) Adrenocorticotrophic Hormone (ACTH)
ACTH is easily oxidized by enzyme in serum in-vitro and stick strongly

to glass tube. Level is much influenced by biological variation, therefore
blood collection should be done following strict procedure for the result
to be useful for clinical interpretation.
Rationale:
To distinguish between ACTH dependent Cushings Syndrome and
ACTH independent Cushings Syndrome.
Avoid corticosteroids, stress or other factors that can influence
secretion.
Collect morning sample at 0800am.
Use plastic EDTA tube, chilled by keeping overnight in the
refrigerator (4C) before use.
Immerse collection tube in ice after blood taking and send
Fill in some blood into lithium heparin tube for plasma cortisol. Send
together with ACTH sample to the Main Reception Counter,
Pathology department.
b) Midnight Plasma Cortisol
Rationale:
To determine the presence or absence of cortisol diurnal rhythm.
91

CORTEX
b) Midnight Plasma Cortisol
Take sample 48 hours after admission.
Do not insert a cannula nor inform the patient that a midnight

sample will be taken to avoid unnecessary stress.
Request the patient to retire to bed by 2030 pm on every night of
his/her admission.
Take midnight sample within 5 minutes of waking the patient.
Notes:
o Where possible, collect two midnight samples after admission
o It is recommended that both midnight cortisol and Low Dose
Dexamethasone Suppression Test (LDDST) be performed as may
miss 2% of the cases LDDST.
c) STIMULATION TEST
Useful in documenting hyposecretion of adrenocortical hormone.

Rapid Synacthen / Cosyntrophin Stimulation Test
Rationale:
Administration of ACTH to normal individuals results in rapid rise in the
serum cortisol concentration. Patients with adrenal destruction
(Addisons disease) show no change in serum cortisol concentration after
ACTH administration. Patient with atrophy of adrenal cortex caused by
exogenous glucocorticoid treatment or dysfunction of pituitary gland or
hypothalamus may show a slight rise in serum cortisol concentration.
92

CORTEX
c) STIMULATION TEST

Patient preparation:
Ask patient to bring all their medications, including over the
counter medications and creams and check whether they have any
recent joint injections.
Usual medications may be taken on the morning of the tests, but
individual taking inhaled steroids, topical creams, nasal steroids,
inhalers and oral steroids should be drawn to attention of the
referring consultants to assess whether to proceed for the test.
Patients taking more than 7.5 mg Prednisolone or equivalent are
highly likely to be adrenally suppressed and so, the test may not
be appropriate or even necessary.
Take blood sample for baseline cortisol level (0 min) at 0900 am.
Give 250 microgram Cosyntropin/ Synacthen (synthetic ACTH)
intramuscularly or intravenously.
Take blood samples at 30 min and 60 min after injection for
cortisol level and label samples and fill in the request forms
accordingly.
Send samples and request forms to Main Reception Counter,
Pathology department after informing the laboratory through phone
Time Test Collection tubes

0 min (basal) Cortisol 3ml blood in plain tube with gel
30 min Cortisol 3ml blood in plain tube with gel
60 min Cortisol 3ml blood in plain tube with gel
93

CORTEX
c) STIMULATION TEST

Interpretation:
Adrenal insufficiency is excluded by an incremental rise in cortisol of
>200 nmol/L and a 30 min value >550 nmol/L. The baseline cortisol
should exceed 190 nmol/L.
d) SUPPRESSION TESTS
1) Overnight Low Dose Dexamethasone Suppresion Test (OLDDST)
Rationale:
Dexamethasone, a cortisol analogue, suppresses ACTH and cortisol
production in normal subjects but not in patients with Cushings
Syndrome.
Indication
First screening test for all subjects suspect of having Cushings
Syndrome.
Procedure:
Give 1 mg Dexamethasone orally at 2300 pm.
Fill the request form with relevant clinical summary.
Collect blood at 0900 am the next morning for determination of serum
cortisol
Send the samples and the request forms to the Main Reception
Counter, Pathology Department, after informing the laboratory through
phone call prior to sending.
Interpretation :A normal response is shown by suppression of 0900hr

cortisol to <50 nmol/L.
94

CORTEX
d) SUPPRESSION TESTS
1) Overnight Low Dose Dexamethasone Suppresion Test (OLDDST)
a. A level more than 50 nmol/L can be seen in cases of stress, obesity,

infection, severe depression, acute or chronic illness, alcohol abuse,
oral contraceptive, pregnancy, estrogen therapy, failure to take
dexamethasone or treatment with drug which enhance the
metabolism of dexamethasone (e.g. phenobarbitone)
Notes:
Patients on enzyme inducing drugs eg. anticonvulsants and
rifampicin may rapidly metabolize dexamethasone and give a false
positive results i.e no suppression.
Women on estrogen therapy may fail to suppress adequately due to
increased cortisol binding globulin, if so, progress to 2mg
dexamethasone suppression test.
2) Low Dose Dexamethasone Suppression Test (LDDST)-Liddle
Rationale:
Normal subjects show lowering of serum cortisol concentrations under
the condition of low dose dexamethsone suppression.
Procedure:
Collect blood for serum cortisol at 0900 am on the 1st day of test.
Immediately after sampling, give 0.5mg dexamethasone orally every
6 hrs for 2 days (8 times).
95

CORTEX
2) Low Dose Dexamethasone Suppression Test (LDDST)-Liddle
Collect blood for serum cortisol at 0900 am on day 3 (6 hours after

the last dose of 0.5mg dexamethasone) and send to Main Receiving
Counter Pathology Department, after informing the laboratory
through phone.
Ensure the times are followed strictly and with full compliance as
below and label sample accordingly.
Send samples and request forms to Main Reception Counter,
Day 1 Day 2 Day 3
Sample taken for serum 0900 am None 0900 am

cortisol (basal)
Drug given: 0.5mg 0900 am 0300 am 0300 am (last
dexamethasone every 6 dose)
hours (8 times)
1500 pm 0900 am -
2100 pm 1500 pm -
- 2100 pm -
Interpretation:
In normal person, serum cortisol will be suppressed to <50 nmol/L.
96
CORTEX
3) High Dose Dexamethasone Suppression Test (HDDST)
Rationale:
To differentiate Cushings disease (pituitary adenoma) from other
causes of Cushing Syndrome (adrenal tumour and ectopic ACTH
tumour).
Procedure:
i. Day 1: Collect blood at 0900 am and 1200 midnight for cortisol level.
ii. Day 2: Give 2.0mg dexamethasone orally every 6 hours starting on
day 2 and continues for 8 doses.
iii. Day 5: Collect blood at 0900 am and 1200 midnight for cortisol level.
iv. Ensure the times are followed strictly and with full compliance as
below and label sample accordingly.
v. Send samples and request forms to Main Receiving Counter,
Day 1 Day 2 Day 3 Day 4 Day 4

Sample taken for 0900 None None None 0900 am
serum cortisol am and and 1200
1200 midnight
midnight
Drug given: None 0900 am 0300 am 0300 am 0300 am
2.0mg 1500 pm 0900 am
dexamethasone
every 6 hours (8 2100 pm 1500 pm
times) 2100 pm
97
CORTEX
3) High Dose Dexamethasone Suppression Test (HDDST)
Interpretation:
Patient with Cushing disease due to an ACTH producing pituitary tumour
usually shows:
Lack of diurnal variation of serum cortisol
Serum cortisol of less than or equal to 276 nmol/l at 0900 on day 4
OR
Suppression of more than 50% in serum cortisol compare to basal
level is seen in 78% of patients with Cushings Diseaseand 11% in
patients with ectopic ACTH secretion
1.11 WORKFLOW OF INVESTIGATION FOR SUSPECTED CUSHINGS

SYNDROME
1st step: Clinically Cushing Syndrome

Perform a screening test :
A) 24 hours urine free cortisol.
If less than 300 nmol/day: Cushings Syndrome excluded
If level is greater than 300 nmol/day: suggestive of diagnosis of
Cushings Syndrome
Diagnostic accuracy is 90%
False positive results may occur in over collection of specimen,
patients on diuretics, high salt administration, depression and stress
OR
B) Perform OLDDST (see Protocol) to confirm the presence of
hypercortisolism.
98
1.11 WORKFLOW OF INVESTIGATION FOR SUSPECTED CUSHINGS
SYNDROME
2nd step: Review post OLDDST Cortisol.

Cortisol level <50nmol/L Cushings Syndrome excluded.
Cortisol level >50nmol/L - Hypercortisolism demonstrated.
Perform the differential diagnostic tests: plasma ACTH &
Cortisol at 0900 am.
3rd step: Review ACTH & Cortisol results

If ACTH not detected or suppressed and post OLDDST cortisol
result is > 50nmol/l - most likely to be adrenal Cushings. Serum
Cortisol will not be suppressed during the HDDST.
Do imaging investigation to rule out adrenal tumour
Do other investigation to rule out other causes of pseudo
Cushing Syndrome if suspected clinically.
If ACTH detected or elevated to rule out pituitary Cushings.
For cases Post Overnight LDDST Cortisol > 50nmol/l and ACTH
detected or elevated.To rule out Pituitary disease.
1st DOA Plasma glucose, Renal profile, Blood gas analysis
2nd DOA Perform circadian rhythm ACTH & Cortisol
(At 9.00am, and mid night)
3rd -7th DOA Perform LDDST-Liddle (0.5mg orally 6hrly for 48 hrs
see protocol), followed by HDDST (2mg orally 6hrly for
48 hours see protocol). Cushings disease will usually
not suppress with LDDST-Liddle but suppressed with
HDDST. In Adrenal Cushings or ectopic ACTH, serum
cortisol will not be suppressed during the LDDST-Liddle
and HDDST.
*DOA=Date of Admission
99
1.13 Ujian Myoglobin
Container Volume Special Indication Specimen tat

Specimen
required instruction of transport
type
diagnosis guidelines
1.10ml urine
collected in a
container that
contain 200mg Refer Transport
Universal 10ml lampiran sample 7days
Urine of sodium
container bicarbonate(2% B on dried
final ice
concentration)
2.refrigerate
after collection
1.14 Protocol for requesting and Collecting Samples for Calcitonin Test
Procedures for tests sent to referral laboratories may be subject to

changes and amendment made by the associated agencies. Kindly
contact our lab personnel for further enquiries
i. Patient preparation
Patient should be fasting 5 hours prior to blood taking.

The determination of human Calcitonin should be performed on
serum sample.
4mL of blood is required
ii. Instruction for Ward/Clinic Personnel
Collect a blood into a tube containing no additives (plain tube)
100
Sample should be labeled with patients name, i/c or R/N and name
of test requested.
Fill-up the PER.PATH 301 forms (2copies). Please include the
patients clinical history. Specialist signature is also required.
Allow the blood to clot in an ice or refrigerator, or send immediately to
the lab in ice pack.
Send the specimen to Pathology Department, National Cancer
Institute immediately, keeping the samples below 8C all the
Time (please use ice pack)
iii. Instruction for Lab Personnel (Scientific Officer / MLT of Referring

Laboratory)
Please note that samples for Calcitonin must be kept cold and
centrifuged in cold (preferably using refrigerated centrifuge)
Separate serum immediately into a plain test tube / secondary
tube.
Samples should be frozen as soon as possible in -20C.
Avoid repeated freezing and thawing.
Keep the specimen frozen during transportation.
Sample tubes should each have the following information: (barcode
or manual label)
i. Requested test
ii. Patients name
iii. Identity card number / Medical Registration Number (MRN)
iv. Date of collection
iv. Causes of Rejection
Name of the test is not mentioned in the request form.

Incomplete request form (e.g : Name of the patient and identification
is not filled up, Name and address of client is not stated (doctors
name ).
Request form is not accompanied with specimen.
Information about patient identificationdoes not match with the label
at the specimens container.
The specimen container is not labeled or information on the label
does not tally with the information in the request form.
Broken or empty specimen container.
101
Insufficient volume of specimen for the test requested. Minimum
volume of 2mL of serum (for external sample) or 4mL of blood (for
internal sample) is required.
Grossly hemolysed and lipemic specimen.
Samples from pateients receiving radioisotopes for diagnostic or
therapeutic purposes.
Contamination of the samples or aasay tube with 1251 or other
radioisotopes.
Specimen not cold, not suitable for analysis.
Others :
The referring laboratory should include contact number and formal e-

mail address that can be used to send the laboratory reports.
102
SECTION D : TESTS SENT TO THE REFERRAL LABORATORIES
(1) SERVICES PROVIDED BY JAB. KIMIA, PETALING JAYA
The following laboratory tests and services are provided by Jabatan Kimia,
Petaling Jaya (Medico-legal case). To obtain service, contact 4225 to get
the necessary Form Kimia 15A.
TABLE 2 : Amount of Fluids Required for Trace Metal & Alcohol Analysis
ANALYSIS SAMPLE REQUIRED SAMPLE

REQUIRED VOLUME
REQUIRED
1. Arsenic Blood (not-clotted in EDTA tube) 7 10 ml

Urine (plain container) 25 ml
Hair 1 cm
Nail 1 cm
2. Aluminium Plasma (Lithium heparin tube) 5 ml
3. Cadmium Plasma (Lithium heparin tube) 5 ml

Urine (plain container) 25 ml urine
4. Selenium Plasma (Lithium heparin tube) 5 ml

Urine (plain container) 25 ml urine
5. Copper Serum ( plain tube) 3 5 ml

24hr Urine (plain container) 25 ml
6. Lead Blood (not clotted in EDTA tube ) 7 10 ml
7. Manganese Blood (not clotted in EDTA tube ) 7 10 ml
8. Mercury Blood (not clotted in EDTA tube ) 7 10 ml

9. Zinc Serum (plain tube) 3 5 ml

Blood (not clotted in EDTA tube ) 7 10 ml
103
SECTION D :TESTS SENT TO THE REFERRAL LABORATORIES
b. Types of specimen to be sent to Toxicological Examination.
i. Vomits and stomach contents (if available) are to be sent in

every case whatever the nature of the suspected poison.
ii. Details of other specimens required see Chemistry 15A
pin.1/69
Notes: 1) Post-Mortem specimens (organs only) should be preserved in

saturated saline.
2) Do not add FORMALIN OR FORMAL SALINE
104
INSTRUCTION FOR THE SUBMISSION OF SPECIMENS AND EXHIBIT

FOR TOXICOLOGICAL EXAMINATION
A. General
All specimens and exhibits for toxicological examination are to be sent

to the Dept. of Chemistry together with a Chemistry 15A form completed
in full by the Medical Officer in charge of the case.
B. Specimen to be sent
Depending on the nature of the poison suspected. All the specimens

listed are to be sent.
Note: Vomits and stomach contents (if available) are to be sent in
every case whatever the nature of the suspected of poison.
i. General Vomit, Stomach and contents, Brain, Liver, Blood, Urine.

ii. Volatile and non-volatile organic poisons Brain, Liver, Blood, Urine,
Stomach and contents.
iii. Corrosives Vomit, Stomach and contents.
iv. Salicylate, Liniments Blood, Urine, Stomach and contents, Brain.
v. Sulphur Drugs Blood, Stomach and contents, Urine.
vi. Barbiturates Bromides, etc Blood, Urine, Stomach and contents, Brain.
vii. Acute heavy metal poisoning Kidney, Liver, Stomach and contents.
viii. Chronic heavy metal poisoning Blood, Urine, Bone, Nails, and Liver.
ix. Gaseous Poisons Blood, Lung.
x. Phenols (Disinfectants) Liver, Kidney, Stomach and contents, Urine.
xi. Phosphorous Stomach and contents, Liver, Kidney.
xii. Insecticides Stomach and contents, Liver, Fatty Tissues.
105
INSTRUCTION FOR THE SUBMISSION OF SPECIMENS AND EXHIBIT

FOR TOXICOLOGICAL EXAMINATION
B. Specimen to be sent
xiii. Acetanilide, Aniline, Chlorates, Nitrates, Nitrobenzene - Blood, Stomach

and contents.
xiv. Clinical arsenic poisoning 24 hours urine (minimum 500 ml)
xv. Delayed death (from any cause) - Urine, Blood, Brain, Liver, Kidney
xvi. Kerosene Mineral oil Lung, Stomach and contents.
C. Size of the Specimen
Wherever possible the whole organ is to be submitted and each organ

to be submitted in 3 separate jars. In the case of blood and urine as
much as possible is to be sent. The blood may be collected from the
heart and or head sinuses.
C. Preservatives
i. Preservatives should be added only when the specimen cannot reach

the laboratory on the day of the postmortem, if the preservative must be
used then either alcohol (rectified spirit, not methylated) or saturated
saline is to be used.
Note: Under no circumstances is formalin or formal saline added to
toxicological specimens.
ii. Specimen of blood should have either solid sodium oxalate or sodium
citrate at anticoagulant.
iii. A sample (about 200 ml) of the preservative used is to be sent as a
separate exhibit.
106
(2) SERVICES PROVIDED BY BIOCHEMISTRY UNIT, SPECIALISED

DIAGNOSTICS CENTRE (SDC). IMR
General Procedure for Submission of Specimen

1. Please refer to the Tables 3 (a-e) for the type and amount of specimen,
including the appropriate preservative/anticoagulant, required for each test.
2. Blood specimens meant for this laboratory should be processed and

delivered immediately after collection. Separate the plasma immediately
without delay and transfer the specimen into a clean container. Apart from
tests which are performed on whole blood, only heparinised plasma should
be sent.
3. An early morning urine specimen is the best specimen to be collected when

random urine is required. The specimen should be collected with great care
and preserved with the appropriate preservative. Send an aliquot of about
20ml to the laboratory.
4. If the specimen cannot be delivered within 4 hours after collection, freeze the
specimen and transport frozen in dry ice to prevent denaturation,
decomposition or bacterial growth.
5. Plasma, Urine and CSF should be transported frozen in dry ice (-80C) to
the Biochemistry Laboratory. Specimens not frozen may show
"abnormalities" due to chemical, biochemical or bacterial action. If your
laboratory has problems sending samples on dry ice, please contact the
laboratory for advice.
6. Labeling
Container for specimen should be labeled with patients name, I/C or R/N,
and type of specimen and test required. Please record date & time of
collection of the specimen in the request form.
107
(2) SERVICES PROVIDED BY BIOCHEMISTRY UNIT, SDC, IMR
General Procedure for Submission of Specimen
7. Urgent Requests
We respond to urgent clinical requests and manage our work lists
accordingly. To enable this we need either adequate clinical notes or a
telephone consultation. In some cases the clinical information or initial
results obtained may indicate the need for other, additional but appropriate
tests to be performed. We reserve the right to arrange for follow up testing.
All significantly abnormal results are communicated immediately by

telephone to the requesting physician by our Pathologist or one of our senior
scientists.
8. Urgent Same Day Testing

Certain tests are handled as emergencies. If this is required, contact our
Biochemical Geneticists directly.
9. Request Forms
All specimens must be accompanied by IEM request form (Appendix 1)
completed with FULL CLINICAL DETAILS and current drug therapy. All the
information is useful in determining any alternative and fruitful line of
investigation. Appropriate tests are carried out regardless of whether these
were requested or not on specimens received from government hospitals.
For specimens from private hospital/laboratory, follow through extra tests will
be suggested to the sender.
Specific Requirements
1. ACUTE IEM (AMINO ACIDS DISORDERS, ORGANIC ACIDURIAS

AND FATTY ACIDS OXIDATION DEFECTS)
a. Screening of acute IEM for newborn

Screening is available for 20 to 30 diseases of acute IEM (Table 3a) in
an asymptomatic baby aged 48 to 72 hours by analysis of
acylcarnitines and amino acids in dried blood spot using Tandem Mass
Spectrometry.
108
Specific Requirements
2. ACUTE IEM (AMINO ACIDS DISORDERS, ORGANIC ACIDURIAS

AND FATTY ACIDS OXIDATION DEFECTS)
Spectrometry. It is important to collect blood at this age for the
screening of fatty acids oxidation defect (FAOD) as the acylcarnitines
values will be high during this period.
b. Screening of acute IEM for newborn
Screening is available for 20 to 30 diseases of acute IEM (Table 3a) in

an asymptomatic baby aged 48 to 72 hours by analysis of
Spectrometry. It is important to collect blood at this age for the
screening of fatty acids oxidation defect (FAOD) as the acylcarnitines
values will be high during this period.
Older babies, more than 1 week old have lower level of acylcarnitines
than neonates. So screening for older babies will not be accurate.
Furthermore the reference ranges developed by this laboratory is only
for neonates.
Sample: Whole blood spotted on filter paper (903 Whatmann). The filter
paper can be obtained from this laboratory. Please refer to :Procedure
for collection of Blood Spot.
c. Screening of Galactosemia
Total Galactose (TG) will be screened first. If TG is high, Galactose -1-

uridyl transferase (GALT) will be done. Please refer to Appendix 2 for
sample collection.
109
d. High risk screening or follow-up testing of acute IEM
Any babies aged more than 1 week old that are suspected of having
acute IEM (based on clinical history and routine laboratory investigation)
or those with positive screening tests, should be investigated further.
Both urine and plasma is needed for further analysis.
Note: Routine biochemistry tests like urine ketones, blood glucose,

blood gases, blood ammonia, liver function tests, serum pyruvate and
lactate are the most important routine chemistry tests and they should
be done on samples from patients suspected of having acute IEM
before sending the samples to this laboratory for further confirmatory
tests.
e. Plasma Amino Acids Analysis
For the diagnosis of most amino acids disorders, fasting morning

blood specimens are preferred to avoid post-prandial increase of most
of the amino acids. Samples from young infants, who are fed at frequent
intervals, should be collected immediately before the next scheduled
feed. For a baby with hyperammonemia, postprandial blood is more
suitable since an elevation of blood ammonia may be intermittent and
present only in the fed state.
Certain amino acids are maintained at higher concentration in red blood

cells compared to plasma. Thus haemolysis often increases levels of
certain amino acids in plasma or serum.
Improper handling of specimens (such as leaving unspun blood at room

temperature, prolonged storage and unclean specimen tubes) can
result in artefactual changes in the amino acids contents.
110
Plasma obtained from whole blood anticoagulated with heparin has

been reported to be the best material for investigation of the steady
state of amino acid concentration.
Precautions:
The presence of heparin in excess will lead to haemolysis. The use of

EDTA as an anticoagulant can lead to artefacts caused by the presence
of ninhydrin positive contaminants in the anticoagulant, and
contaminants which also react with derivatisation reagents in HPLC
methods. Insufficient anticoagulation leads to partial clotting of the
sample and a mixture of plasma and serum.
Recommendation:
i) Collect whole blood directly into heparinised tube;

ii) Centrifuge and separate from cells immediately after collection;
iii) Freeze the sample (-200C) if it cannot be sent to the laboratory
within 4 hours;
iv) Transport frozen in dry ice to the laboratory.
f. Urine Organic Acid Analysis
Generally performed on untimed random urine preferably early morning

samples. Please provide accurate and complete information on the
clinical status, dietary manipulations and full drug history of the patient
because all these factors can also change the normal organic acid
profile. If possible collect the urine samples before any dialysis and
fasting is carried out.
111
e. Urine Organic Acid Analysis
i) Collect a 5-10 ml random urine specimen in a sterilised tube or

bottle without preservative.
ii) Freeze the specimen (-200C) if it cannot be transported within 4
hours to the laboratory.
iii) Transport frozen in dry ice to prevent bacterial overgrowth and loss
of volatile substances. Some of the compounds of interest are
photo sensitive, so please protect the specimen from light by
wrapping it with dark plastic bag.
iv) Please contact the laboratory if dry ice is not available.
g. Other Specialised Tests
These specialised tests are mainly to help with the diagnosis of amino
acids disorders and fatty acid oxidation defects. Indications for other
specialised Biochemical Genetic Tests, their specimen collection,
handling and transportation, are listed down in Table 4.
Please request test according to clinical symptoms and signs and DO

NOT ORDER EVERY TESTS.
112
2. LYSOSOMAL STORAGE DISEASES AND PEROXISOMAL

DISORDERS
Only a patient who is suspected of having storage disorders or with

clinical symptoms of storage disorder like dysmorphism,
hepatosplenomegaly and mental retardation should be investigated for
MPS, Oligosaccharidosis, Glycogen storage disease, Gaucher, POMPE,
Fabry, VLCFA and other tests.
These tests are highly specialised and expensive and should not be
treated as a screening test to exclude IEM diseases.
Please refer to Table 3d for a guide on sample collection and indication.
113
(2)SERVICES PROVIDED BY BIOCHEMISTRY UNIT, SDC, IMR
TABLE 3 : a) Screening of Inborn Error Metabolism (IEM) (use Request Form as Appendix 1)
Biochemical Method Indications Preanalytical Procedure TAT

Genetics Test (working
days)
1. Screening for IEM Quantitative by 3 circles of 1cm diameter of dried blood 3
(Amino acids & Tandem Mass Neonatal screening of 25 IEM spot on Whatmann 903 special filter
Acylcarnitines in Spectrometry diseases: paper transport at RT
blood spot) Organic acidurias
Fatty acid oxidation defects
Hypoglycaemia
Amino acids disorders
2. Total Galactose Quantitative by Dried blood spot on Whatmann 903 5
and GALT enzyme assay Suspected disorders of galactose filter paper (transport at RT) or 1ml
metabolism: whole blood in Paediatric EDTA bottle
(transport at 4C )
Acute liver failure, prolonged
jaundice, cataract. hypoglycaemia
3. Biotinidase Quantitative Suspected Biotinidase deficiency Dried blood spot on Whatmann 903 10
enzyme activity filter paper (transport at RT) or 1ml
whole blood in Paediatric EDTA bottle
(transport at 4C )
114
TABLE 3 : b) Amino Acids Disorders (use Request Form as Appendix 1)
TAT
Biochemical
Method Indications Preanalytical Procedure (Working
Genetics Test
Days)
10
1. Plasma amino acids Quantitative by Selective screening 2mls of heparinised plasma. Morning
HPLC (fasting) or 4 hours after last meal.
Hyperammonemia Centrifuge and freeze immediately.
Transport frozen in dry ice
Metabolic acidosis
Amino acids disorders
Mitochondrial disorders
Epileptic
Encephalopathy
2. Urine amino acids Quantitative by Hyperammonemia (Cystinuria, 5mls early morning urine. 10
HPLC HHH, LPI, Hperlysinemia)
Renal disorders
3. CSF amino acids Quantitative by Epileptic Encephalopathy 0.5 mls CSF in sterile bottle. Send
10
HPLC
together with plasma. Transport frozen
Suspected Non-ketotic in dry ice
Hyperglycinemia (NKH)
115
TAT
Biochemical
Genetics Test
Days)
116
TAT
Biochemical
Genetics Test
Days)
4. Urine Orotic acids Quantitative by Suspected: 2mls urine, no preservative (transport 5
HPLC frozen in dry ice)
Urea Cycle defects,
Hyperammonemia,
purine& pyrimidine disorders.
Suspected OTC carrier:
Vomiting, protein intolerance,
mildly retarded
5. Total Plasma HPLC Suspected homocystinuria: 2 mls heparinised plasma. Centrifuge 10
Homocysteine immediately to get accurate result.
Marfan-like syndrome Transport frozen in dry ice
Epilepsy
Mental retardation
Progressive myopia
Thromboembolism
Cobalamin disorders
117
TAT
Biochemical
Genetics Test
Days)
6. Urine Cystine Qualitative/ Suspected: 5 ml fresh urine in universal bottle 5
colorimetry (protect from light)
Cystinuria
Hyperargininemia
Generalized aminoaciduria
7. Urine Qualitative/ Classical homocystinuria, 5 ml fresh urine in universal bottle
5
Homocystine colorimetry (protect from light)
118
TAT
Biochemical
Genetics Test
Days)
8. Urine Quantitative Suspected sulfite oxidase or 1 ml, early morning urine.

sulfocysteine by Ion- molybdenum cofactor
exchange deficiency: Sterile bottle, no preservative (
HPLC transport frozen in dry ice)
Early neonatal seizure 5
Microcephaly
Psychomotor retardation
9. Urinary Pterins Quantitative Hyperphenylalaninemia 1 ml, early morning urine. Sterile
by HPLC- (other than PKU). bottle, no preservative.
fluorometry
Suspected neurotransmitters Protect from light, transport frozen
defect. in dry ice) 10
BH4 test
119
TABLE 3 : c) Organic Acidurias & Fatty Acids Oxidation Defects (use Request Form as Appendix 1)
TAT
Biochemical
Method Indications Preanalytical Procedure (working
Genetics Test
days)
1. Urine Organic Qualitative by Selective screening 5-10mls random (morning) urine. 5
acids analysis GCMS
Organic acidurias Sterile bottle.
Amino acids disorders Preferably freeze immediately

and transport frozen in dry ice.
Fatty acids oxidation
Mitochondrial disorder
Or with 2-3 drops of chloroform
Unexplained metabolic crisis, acidosis, and transport at room
ketosis, high anion gap, hypoglycaemia temperature.
Systemic intoxication, coma, seizures
Undiagnosed hepatopathy
Neurological/neuromuscular disorders
Epileptic Encephalopathy
Multi-systemic disorders
Unexplained mental retardation.
120
TABLE 3 : c) Organic Acidurias & Fatty Acids Oxidation Defects (use Request Form as Appendix 1)
TAT
Biochemical Preanalytical
Method Indications (working
Genetics Test Procedure
days)
2. Urine Quantitative Suspected Tyrosinemia Type I 1 ml, early morning urine in 5
Succinylacetone by GC or sterile bottle. Protect from
GCMS light. No preservative.
Transport frozen in dry ice
3. Total and free End-point Carnitine deficiency (primary or 2 ml heparinised plasma. 5
Plasma Carnitine enzymatic secondary) Transport frozen in dry ice.
assay
Fatty acids oxidation defects
Organic acidurias.

121
TABLE 3 : d) Lysosomal Storage Diseases (use Request Form as Appendix 1)
TAT
Biochemical
Genetics Test
days)
1. Screening Urine GAG quantitation Suspected Lysosomal 5 mls, early morning urine in 5
Glycosaminoglycan by Dimethyl- storage diseases/ sterile bottle. No preservative.
(GAG) or methylene blue mucopolysaccharidosis Transport frozen in dry ice)
Mucopolysaccharides
Done together with HRE
2. Characterization of High resolution Suspected Lysosomal 5mls, early morning urine in 10

urinary GAG Electrophoresis storage diseases/ sterile bottle. No preservative.
mucopolysaccharidosis Transport frozen in dry ice.
Dysmorphism, mental
retardation, hepatomegaly
3. Plasma /Serum Quantitative Screening for Gauchers 2ml serum or plasma. Transport 10
chitotriosidase Enzyme assay by and other LSD frozen.
spectrofluorometer
Organomegaly, anaemia,
bleeding tendency,
skeletal deformities, pain
and osteopenia.

TABLE 3 : d) Lysosomal Storage Diseases (use Request Form as Appendix 1)
122
TAT
Biochemical
Genetics Test
days)
4. Alpha Galactosidase Quantitative Suspected Fabry disease: Dried blood spot on Whatmann 15
enzyme assay by Pain/parasthesia, 903 filter paper (transport at RT)
spectrofluorometer angiokeratomas, OR 1ml whole blood in
cardiomyopathy, renal Paediatric EDTA bottle
failure, and stroke. (transport at 4C )
5. Acid Alpha Quantitative Suspected Pompe Dried blood spot on Whatmann 15

Glucosidase enzyme assay by disease: FTT, severe 903 filter paper (transport at RT)
spectrofluorometer (cardio) myopathy with OR 1ml whole blood in
hypotonia, slow & Paediatric EDTA bottle
progressive muscle (transport at 4C )
weakness
6. Total and free Sialic Quantitative by Dysmorphism, mental & 1ml, early morning urine. Sterile 15
Acid spectrophotometer growth retardation, bottle, no preservative (
hypotonia, seizure transport frozen in dry ice)
7. Urine oligosaccharide Thin Layer Suspected 2ml early morning urine. Sterile 15
/ tetrasaccharide Chromatography Oligosaccharidosis, bottle, no preservative.
Glycogen Storage Transport frozen in dry ice.
Disease
123
TABLE 3 : e) Other IEM (use Request Form as Appendix 1)
Biochemical Genetics TAT (Working

Method Indications Preanalytical Procedure
Test Days)
1 Urine Delta ALA Quantitative Suspected: 25mL of 24h urine 10 mL glacial 10

acetic acid for 24h urine (protect
Spectrophotometer Tyrosinemia Type I, from light)
Porphyrias
2 Urine Porphyrin/ Qualitative Suspected: 5 ml fresh random urine in 5
Porphobilinogen/ universal bottle (protect from light)
Corpophophyrin Tyrosinemia type I
Porphyrias
3 Plasma VLCFA & Phytanic Quantitative by GC Suspected Peroxisomal dis.: Heparinised plasma or EDTA. 10
acids or GCMS Transport frozen in dry ice
FTT
Neuroregression
Seizure
Facial dysmorphism
Skeletal abnormalities
124
Biochemical Genetics TAT (Working
Method Indications Preanalytical Procedure
Test Days)
Hepatopathy
Hypotonia
125
TABLE 3 : e) Other IEM (use Request Form as Appendix 1)
TAT
Biochemical
Genetics Test
Days)
3 Plasma VLCFA & Quantitative by GC Suspected Peroxisomal Heparinised plasma or EDTA. 10
Phytanic acids or GCMS disorders: Transport frozen in dry ice
FTT
Neuroregression
Seizure
Facial dysmorphism
Skeletal abnormalities
Hepatopathy
Hypotonia
4 Urine 5-HIAA Quantitative by Suspected: 25ml of 24h urine in 10ml 25% HCL 10
HPLC with
Electrochemical Carcinoid tumour
Detector Neurotransmitter disorder
126
TABLE 4 :Acute IEM Disorders (use Request Form as Appendix 1)
ELEVATED AMINO
A AMINO ACID DISORDERS
ACIDS
1 Argininaemia Arginine
2 Argininosuccinic acidaemia Citrulline
3 Citrullinaemia type 1 Arginine, citrulline
4 Citrullinaemia type 2 Citrulline, methionine
5 Cystathionine beta-synthase deficiency Methionine
6 Glycine encephalopathy Glycine
7 Maple syrup urine disease Valine. Leucine
8 Phenylketonuria Phenylalanine Phe/Tyr
ratio
9 Tyrosinaemia type 1 Tyrosine
10 Tyrosinaemia type 2 Tyrosine
ELEVATED
B ORGANIC ACIDURIAS
ACYLCARNITINE
1 2-methylacetoacetyl CoA thiolase deficiency C5:1
2 HMG CoA Lyase Deficiency C5OH
3 3-methylcrotonyl CoA carboxylase deficiency C5OH
4 3-methylglutaconyl CoA hydratase deficiency C5OH
5 Biotinidase deficiency C5OH, C2
6 3-hydroxy-3-methylglutaric aciduria C6DC
7 Ethylmalonic encephalopathy C4, C5

8 Glutaryl CoA dehydrogenase deficiency C5DC
9 Holocarboxylase synthetase deficiency C5:1, C3, C5OH
10 Isovaleric acidaemia C5
11 Malonyl CoA decarboxylase deficiency C3DC
127
TABLE 4: Acute IEM Disorders (use Request Form as Appendix 1)
ELEVATED
B ORGANIC ACIDURIAS
ACYLCARNITINE
12 Methylmalonic aciduria/homocystinuria/ C3
Cobalamin disorders
13 Methylmalonyl CoA mutase deficiency C3
14 Propionic acidaemia C3
ELEVATED
C FATTY ACIDS OXIDATION DEFECT
ACYLCARNITINE
1 Carnitine acylcarnitine translocase deficiency Free carnitine (low)
C16
2 Carnitine palmitoyl transferase 1 deficiency free carnitine; C16
(CPT I) (low); C18 (low)
3 Carnitine palmitoyl transferase 2 deficiency Free carnitine (low)
(CPT II) C16, C18
4 Carnitine uptake defect Free carnitine (low);

C16 (low); C18 (low)
5 Short chain 3-hydroxy acyl-CoA dehydrogense C4OH
deficiency (SCHAD)
6 Short chain acyl CoA dehydrogenase C4
deficiency (SCAD)
7 Medium chain acyl CoA dehydrogenase C10, C8; C8/C10; C6
deficiency (MCAD)
8 Long-chain hydroxy acyl-CoA dehydrogenase def C16OH
(LCHAD)
C18:1OH
9 Very long chain acyl CoA dehydrogenase deficiency C14:1
(VLCAD)
10 Multiple acyl CoA dehydrogenase deficiency C5DC; C5, C6; C8, C10;
(GLUTARIC ACIDURIA TYPE II) C12
128
Procedure for Collection of Dried Blood Spot on Whatmann Filter

Paper.
1. Filter Paper
Whatmann 903 filter paper is required which has special

thickness and is manufactured solely for blood collection. It is
commercially available. Please contact the laboratory for further
details.
2. Time of collection
Timing of collection is critical. It is recommended that the DREID

BLOOD SPOT sample for Newborn screening of IEM be
collected from already fed baby at the age between 48-72 hours.
If a baby is to be discharged before 48 hours of age, blood can still
be collected but a repeat sample at >48-72 hours may be
required. This allows for early metabolic changes and the
commencement of milk and protein feeds. FAOD is best
diagnosed if sample is taken within this period.
Samples collected too early may give false negative results.

Samples collected too late may place children with health
problems at risk of irreversible damage.
A blood spot sample for High risk IEM screening in older baby can
be taken from heel-prick, finger prick or venepuncture depending
on the age of the baby.
3. Procedure:
3.1 Making Dried blood spots (DBS) from Heel-prick or finger

prick.
For normal newborn baby without any symptoms it is advisable to

collect blood from heel prick.
129

Paper.
3.1.1 Label each card with babys identifications and date of collection
and any other pertinent information.
3.1.2 Wear gloves and warm the foot with warm cloth/towel
3.1.3 Clean the side area (see photo) with either alcohol swab then dry
with a clean gauze or cotton wool swab.
3.1.4 Puncture heel with sterile lancet (point <2.4 um) on medial or
lateral plantar surface.
3.1.5. Allow puncture to ooze and wipe away first drop of blood with
cotton swab.
3.1.6. Gently massage above the puncture to encourage blood flow and
drop a big spot of blood onto each of the 3 circles on the filter
paper
3.1.7 Continue step 5 and 6 until all the circles are filled. One full drop
of blood equivalent to 50ul is required to fill each circle. Blood
must soak through the card to the other side. Do not drop more
than one drop of blood on one circle.
3.1.8 Completely dry the card at ROOM TEMPERATURE (25C TO
30Con a clean, flat, non-absorbent surface or a drying rack
designed for the purpose, for more than 4 hours or
overnight.Minimum time needed for drying is 4 hours.
3.1.9 To avoid contamination of the sample, Do not touch the blood
spot circle with bare hand.
3.1.10. Place dried filter paper in an individual envelope or plastic bag
for mailing or transport. It is recommended that the filter paper
(dried blood spot) is store away from any source of heat, liquid
and organic fumes.
130
3.2 Making DBS from blood collected from Venepuncture
3.2.1 Label each card with patient reference, sample collection date
and any other pertinent information.
Collect blood in heparinised tube (green top). If blood is drawn in a

syringe, transfer it into a green tube.
Set a hand-held pipettor to 50 ul volume and fill the pipette tip with
blood. (Note: If the tube has been sitting still for more than 2
minutes, it must be mixed by inverting it up and down few times
before pipetting)
Point the pipette tip at the centre of a circle on the filter paper card.
Gradually discharge the blood and let it soak into the paper,
filling the circle completely.
Complete steps 3.1.8 to 3.1.10.
Note 1: The filter paper card(s) must be completely dry before

dispatch. Protect them from moisture or condensation at all
times.
Note 2: Store at 4C if the card is transported the next day after

it is dried. Freeze at -20C for long-term storage.
Note 3: The DBS must be prepared at least 4 hours ahead of

transportation to allow complete drying
131

Paper.
4. Quality of Dried Blood spot
4.1 Acceptable blood sample cards
Each blood spot is checked for acceptability. Blood spot should

be dry, the pre-printed circles filled and appear as an even dark
colour on both sides of the card without lighter discoloration.
Acceptable DBS
Inadequate, but still

acceptable for a
single run.
Will not be able for
duplicates run.
4.2 Unsuitable DBS will be rejected such as follows:
a. Wet specimen
b. Lack of blood coverage (Quantity insufficient for testing
Blood spots diameter is too small)
c. Layering of blood
d. Incomplete blood saturation
e. Separation of red blood cells and serum
f. Blood spot contaminated with fungus
g. Blood spot is diluted/contaminated with water
132

Paper.
4. Quality of Dried Blood spot
a) Wet Blood spot b) Lack of blood coverage
c) Layering of blood spot d) Incomplete blood saturation FRONT
d) Incomplete blood saturation BACK e) Separation RBC and serum (maybe due to
placing a sample which is not thoroughly dried
into an envelope may cause it to sweat)
f) Contamination with fungus/diluted with water
133
(3) SERVICES PROVIDED BY MOLECULAR DIAGNOSTIC AND

PROTEIN (UMDP), SDC, IMR
General Procedure for Submission of Specimens
Please refer to the tables for the type and amount of specimen, including
the appropriate preservative/anticoagulant, required for each test. Blood
specimen meant for this laboratory should be processed and delivered
immediately after collection. Apart from tests which are performed on
whole blood, only serum or plasma should be sent. To prevent
denaturation or bacterial growth, pack the plasma or serum specimens in
ice during transportation.
Timed urine specimens should be collected with great care and preserved
with appropriate preservatives. The total volume of urine voided should be
measured and recorded clearly on the label stuck to the container.
A duly filled request form must accompany every specimen submitted for
test. For tests such as Multiple Myeloma Profiling, Transferrin Isoform/
CDG (Phenotyping) and DNA Mutational Analysis/Molecular
Diagnostics,aspecial request forms have to be filled up. Forms could be
obtained from the laboratory or at IMR website; www.imr.gov.my.
Container for specimen should be labelled with patients name, new I/C or
R/N, and name of the test requested.
Specimen Collection and Preparation
a. Blood
Collect blood into a plain container or one with the appropriate

anticoagulant/preservative in it. Separate the plasma or serum (after
the blood has been allowed to clot) as appropriate and transfer the
specimen into a clean container.
For DNA Mutational Analysis, collect the blood specimens (in EDTA
tube) and send immediately after collection. DO NOT SEPARATE
THE WHOLE BLOOD. If stored overnight, hold at 4C and deliver to
the laboratory as soon as possible. Send at room temperature.
134
(3) SERVICES PROVIDED BY MOLECULAR DIAGNOSTIC AND

PROTEIN (UMDP), SDC, IMR
Note: If possible, all specimens must arrive at the laboratory on the

same day of collection.
b. Urine
A timed urine specimen is required for most tests performed in this

laboratory. The specimen should be collected with great care and
preserved with the appropriate preservative. The total volume of urine
voided should be measured and recorded, both on the label stuck
onto the specimen bottle and on the request form.
Specific Specimen Collection Procedures
a. Paraprotein, serum
Collect 10 ml of blood into a plain bottle or serum tube. To harvest

serum, allow blood to clot (15-30 minutes) for completion of
coagulation before centrifugation.
If cryoglobulin is suspected to be present, blood collection and serum

separation must be carried out using instruments and containers that
have been pre-warmed to 37oC and kept at that temperature until it
reaches the protein laboratory. Cryoglobulin test is only done by
appointment from the UMDP specific protein laboratory.
b. Paraprotein, urinary
Collect a 24-h urine specimen of the patient according to the correct

procedure. Measure the volume and transfer 25 ml of this urine into
a screw-capped universal bottle and send to our laboratories
immediately otherwise store at 4C and deliver to the laboratory as
soon as possible.
Alternatively, a random sample of early morning urine may be sent. Urine

specimen sent to the protein laboratory must be accompanied by the
patients serum.
135
TABLE 5 : (3) SERVICES PROVIDED BY UMDP. IMR(CONTACT NUMBER :03-26162796/ 2518)
SPECIFIC METHOD SPECIMEN PREANALYTICAL PROCEDURE REFERENCE TAT

PROTEINS TEST REQUIRED VALUES (WORKING
DAYS)
SPECIFIC PROTEINS DIAGNOSTICS (use Request Form as Appendix 2)
Serum Agarose-gel 2.5 ml Plain / serum tube. Qualitative 10
1. Electrophoresis electrophoresis serum Serum must reach the lab not more Refer to
(AGE) than 7 days (at 2C-8C) after Immuno-
collection date globulin
interpretation
Urine Electrophoresis Agarose-gel 25 ml of Urine is refrigerated after collection. Qualitative 10

2. electrophoresis 24h urine Urine must reach the lab not more than
(AGE) (accompanie 5 days (at 2C-8C) after collection
d by date
2.5 ml
serum
3. Protein 1. Biuret / PRM 2.5 ml Serum & urine must reach the lab not Refer as above 12
Electrophoresis ( 2. AGE serum & more than 5 days (at 2C-8C) after
Screening Profiling) 25 ml of collection date
- Serum 24h urine
- Urine
4. Immunofixation Agarose-gel 2.5 ml Qualitative 20

Electrophoresis immunofixation serum &
- Serum electrophoresis 25 ml
- Urine (AGIE) 24h urine
136

DAYS)
Paraprotein 1. Biuret / PRM 2.5 ml Serum in plain tube. Must reach the Absent
5. Quantitation 1. AGE Serum & lab not more than 7 days (at 2C-8C)
2. AGIE 25 ml after collection date.
3. Densitometry 24h urine Urine is refrigerated after collection.
Urine must reach the lab not more than
7 days (at 2C-8C) after collection
date
Protein 4. Biuret / PRM 2.5 ml Serum & urine must reach the lab not Refer as above 25
6. Electrophoresis ( 5. AGE serum more than 5 days (at 2C-8C) after
Confirmatory 6. AGIE & collection date
Profiling) 7. Densitometry 25 ml of
- Serum 8. Nephelometry 24h urine
- Urine (Igs
quantification)
Electrophoresis Immuno-isoelectric 1.0 ml Plain tube. Qualitative 10

7. - CSF Oligoclonal focusing CSF CSF & serum must reach the lab not
Band electrophoresis & 1.0 ml more than 7 days (at 2C-8C) after
serum collection date
137

DAYS)
1. Serum Alpha-1- Nephelometry 1.0 ml serum Plain tube. Must reach the lab not 1.30 - 2.90 7
antitrypsin more than 7 days (at 2C-8C) after
(Quantitation) collection date. g/L
2. Serum Alpha-1- Immuno-isoelectric 1.0 ml serum Plain tube. Must reach the lab not Qualitative 10
antitrypsin focusing more than 7 days (at 2C-8C) after
Phenotyping electrophoresis collection date.
3. Serum Transferin Immuno-isoelectric 3.0 ml Plain / serum tube. Qualitative 10

Isoform for CDG focusing
Type I & Type II electrophoresis serum Serum must reach the lab not more
Screening than 7 days (at 2C-8C) after
collection date
4. Serum Transferin Immuno-isoelectric 3.0 ml Plain / serum tube. Qualitative 14

Isoform for CDG Focusing
Type I Confirmatory Electrophoresis serum Serum must reach the lab not more
Profiling than 7 days (at 2C-8C) after
SDS-PAGE collection date
138
TEST METHOD SPECIMEN PREANALYTICAL PROCEDURE REFERENCE TAT

REQUIRED VALUES (WORKING
DAYS)
5. Serum Cryoglobulin 1. Immuno- 1 ml serum Plain / serum tube at 37 oC Qualitative 12
chemistry
2. AGE
6. Electrophoresis 1. Pre-treatment 3.0 ml Plain / serum tube. Qualitative 10
- Lp(a) 2. AGE serum Serum must reach the lab not more
than 7 days (at 2C-8C) after
collection date
MOLECULAR DIAGNOSTIC TESTS (DNA MUTATIONAL ANALYSIS) (use Request Form as Appendix 4)
1. Fragile-X syndrome PCR and 4 X 2.5 ml EDTA/ Qualitative 14-30
(FRAX A) sequencing blood
Send at room temperature.
2. Confirmation of Methylation-specific 4 X 2.5 ml
FRAX A PCR blood If > 24hours, keep sample
cooled/refrigerated
3. Fragile-X syndrome PCR and 4 X 2.5 ml
(FRAX E) sequencing blood
4. OTC PCR and 2 X 2.5 ml 30-37
sequencing blood
139

DAYS)
5. MSUD PCR and 2 X 2.5 ml EDTA. Send at room temperature. 30-37
sequencing blood
If > 24hours, keep sample
6. ETHE-1 PCR and 2 X 2.5 ml cooled/refrigerated Qualitative 21-30
sequencing blood
7. SURF-1 PCR and 2 X 2.5 ml
sequencing blood
8. NARP PCR and 2 X 2.5 ml Qualitative 4-7
sequencing blood
9. MERRF PCR and 2 X 2.5 ml
sequencing blood
10. MELAS PCR and 4 X 2.5 ml Qualitative 21-30
sequencing blood

140
DAYS)
11. LHON PCR and 4 X 2.5 ml EDTA/ Qualitative 60-90
sequencing blood
Send at room temperature.
12. Leigh Syndrome PCR and 4 X 2.5 ml Qualitative 30-60
sequencing blood If > 24hours, keep sample
cooled/refrigerated
13. Whole mitochondrial PCR and 4 X 2.5 ml Qualitative >60
DNA sequencing blood
14. Prader Willi/ Methylation Specific 1-2 X 2.5 ml Qualitative 14
Angelman Syndrome PCR blood
15. Spinal Muscular PCR/RE 1-2 X 2.5 ml
Atrophy (SMA) blood
16. Mitochondrial Lateral-flow 4 X 2.5 ml Quantitative 7
Functional Analysis immuno-assays blood &
on Oxidative
phosphorylation Buccal cheek
(OXPHOS) enzyme swab
Complexes I, IV and
PDH
141
DAYS)
17. Mitochondrial DNA: Multiple Ligation 4 X 2.5 ml EDTA/ Quantitative 7
Probe Amplification blood
1. Gene Re- Send at room temperature. If >
arrangement (MLPA) 24hours, keep sample
cooled/refrigerated
2. Gene Depletion
18. Fragile-X syndrome Multiple Ligation 4 X 2.5 ml 14-30

(FRAX A & E) Probe Amplification blood
(MLPA)
142

DAYS)
19. Citrin Deficiency: 1. PCR/ RFLP 4 X 2.5 ml EDTA/ Qualitative >2 months
and sequencing blood
1. Screening Send at room temperature. If >
2. Micro-satellite 24hours, keep sample
2. Large marker
insertion/dele-tion cooled/refrigerated
20. Lesch Nyhan 1. PCR and 4 X 2.5 ml Qualitative 14

Syndrome sequencing blood
1. Mutation analysis 2. Multiple Ligation
Probe Amplifi-cation
2. X-inactivation (MLPA)
analysis
21. Pearson Syndrome MLPA 4 X 2.5 ml Qualitative
/KSS/CPEO blood
(Deletion)
22. SOTOS Syndrome 1. Long range PCR 4 X 2.5 ml Qualitative >3 months
and sequencing blood
(42 exons)
2. MLPA
143

DAYS)
23. CDG Genotyping 1. PCR and 4 X 2.5 ml EDTA.Send at room temperature. If > Qualitative 1-2 months
sequencing blood 24hours, keep sample
cooled/refrigerated
24. MPS lll 1. PCR and 4 X 2.5 ml EDTA tube. Send at room Qualitative >2 months
sequencing blood temperature. If > 24hours, keep
(Type A, B, C, D) sample cooled/refrigerated
25. NKH 1. PCR and 4 X 2.5 ml EDTA tube.Send at room temperature. Qualitative >3 months
sequencing blood If > 24hours, keep sample
(AMT, GLDC & cooled/refrigerated
GCSH) 2. MLPA
26. MSUD 1. PCR and 4 X 2.5 ml EDTA tube. Send at room Qualitative >2 months
sequencing blood temperature. If > 24hours, keep
sample cooled/refrigerated
27. SUOX Deficiency 1. PCR and 4 X 2.5 ml EDTA/ Qualitative 2-4 weeks
sequencing blood
Send at room temperature. If >
24hours, keep sample
cooled/refrigerated
144

DAYS)
28. DNA Extraction and 4 X 2.5 ml EDTA/ Qualitative 2-4
Quantitation blood
Send at room temperature. If >
24hours, keep sample
cooled/refrigerated
145
TABLE 6 : (4) SERVICES PROVIDED BY DIABETES AND ENDOCRINE UNIT (CaRC). IMR
(CONTACT NUMBER :03-22979425) (use Request Form PER-PAT 301)
HORMONE TYPE OF VOLUME TIME OF REFERENCE VALUES TAT

TUBE REQUIRED (ML) COLLECTION (WORKING
DAY)
1. Insulin like growth plain 0.5 Random Prepubertal : 42 98 ng/ml 4 weeks
factor-1 (IGF-1)
Pubertal : 152 565 ng/ml
20 30 yrs : 172 - 473 ng/ml
30 40 yrs : 155 378 ng/ml
40 50 yrs : 103 291 ng/ml
50 80 yrs : 111 192 ng/ml
2. 17-OH Progesterone plain 0.2 Random 3 days-3 months : 1.59 48 nmol/L 4-5 weeks
3 months -5 yrs : <3.3 nmol/L
6 yrs - 11 yrs : < 3.0 nmol/L
12 yrs 20 yrs : < 6.0 nmol/L
3. Thyroglobulin plain 0.5 Random Normal Reference Value: < 40 g/L 4-5 weeks
4. Intact Parathyroid Potassium- 0.5 Fasting Normal Reference Value : 5 39 pg/ml 4-5 weeks
Hormone (iPTH) EDTA
(preferred) Hyperparathyroidism : >39 pg/ml
146
SECTION D : TESTS SENT TO THE REFERRAL LABORATORIES :
TABLE 7 : (5) SERVICES PROVIDED BY TOXICOLOGY AND PHARMACOLOGY UNIT, HERBAL

MEDICAL RESEARCH CENTRE (HMR), IMR
(CONTACT NUMBER :03-26162629/ FAX NUMBER : 03-26919724) ) (use Request Form PER-PAT 301)
SPECIMEN REFERENCE TAT

TEST VOLUME PRESERVATIVE METHOD
REQUIRED VALUES (WEEKS)
Lead Blood 1 ml EDTA/Heparin <10 g/dl GFAAS 3-4
Mercury Urine 10 ml HNO3, pH 2 <50 mol/24hrs Flow injection Analysis 3-4
Copper Urine 5 ml HNO3, pH 2 <0.9mol/24hrs GFAAS 3-4
Copper Serum 0.5 ml none 11-20 mol/L GFAAS 3-4
Biochem
6 Organic acid urine bottle fresh urine 20ml IMR/HKL
Peads
147
SECTION D :TEST SENT TO REFERRAL LABORATORIES :
TABLE 8 : (6) SERVICES PROVIDED BYMINISTRY OF HEALTH (MOH HOSPITALS)(Request Form PER-PAT301)
NO TEST CONTAINER SPECIMEN VOLUME CENTRE/ UNIT
1. Adrenocorticorticotrophic Hormone K2 EDTA send in Plasma 2.5 ml HKL, Chem Path lab
(ACTH) iced slurry
2. Alcohol (non medico-legal) Plain tube with gel Serum 3ml HKL, Drug lab
3. Aldosterone K2 EDTA/Plain Plasma 3ml Hosp. Putrajaya,
Chem Path lab
4. Alpha-1 antitrypsin Plain tube with gel Serum 3ml HKL, Drug lab
5. Amikacin Plain tube with gel Serum 3ml HKL, Drug lab
6. Amino Acid Lithium heparin Plasma 2 ml
IMR, SDC/ HKL,
Paediatric lab
Urine container Fresh urine 20ml
7. Amphetamine Type Stimulant Urine container Urine 10ml HKL, Drug lab
8. Anti Acetylcholine Receptor Antibody Plain tube with gel Serum 3ml IMR, AIRC Unit
9. Beta 2 Microglobulin Plain tube with gel Serum must reach the 3mls Hosp. Ampang, Chem
referral lab not more than 7 Path lab
days (at 2C-8C) after
collection date
148
SECTION D :TEST SENT TO REFERRAL LABORATORIES : TABLE 8 : (6) SERVICES PROVIDED BY
MINISTRY OF HEALTH (MOH HOSPITALS)(Request Form PER-PAT 301)
10. Cancer Antigen 15-3 Plain tube with gel Serum 3ml HKL, Drug lab
12. Catecholamines 24hrs urine 24 hrs Urine 25ml Hosp. Putrajaya,

container with 10ml Chem Path lab
of 6M HCL * check pH<6 before send
13. Caeruloplasmin Plain tube with gel Serum 3ml HKL, Drug lab
14. C-Peptide Plain tube with gel Serum 3ml HKL, Chem Path lab
15. Cyclosporin K2 EDTA Whole blood 2.5ml HKL, Drug lab

16. Dehydroxy epiendosterone Sulphate Plain tube with gel Serum 3ml HKL, Chem Path lab
(DHEA-S)
17. Fasting C-Peptide Plain tube with gel Serum 3 ml HKL, Chem Path lab
18. Fasting Insulin Plain tube with gel Serum 3 mls HKL, Chem Path lab
19. Free Light Chain Plain tube with gel Serum must reach the lab 1 ml Hosp Ampang, Chem
not more than 7 days (at Path lab
2C-8C) after collection
date
149
SECTION D :TEST SENT TO REFERRAL LABORATORIES : TABLE 8 : (6) SERVICES PROVIDED BY
MINISTRY OF HEALTH (MOH HOSPITALS)(Request Form PER-PAT 301)
20. Fructosamine (Hosp Ampang) Plain tube with gel Serum 3 mls HKL, Chem Path lab
21. Gamma Glutamyl Transferase Lithium heparin plasma 3 mls HKL, Chem Path lab
22. Growth hormone Plain tube with gel serum 3 mls HKL, Chem Path lab
23. Haptoglobin Plain tube with gel Serum 3 mls HKL, Drug lab
24. Homocysteine Plain tube in ice Serum 3ml HKL, Chem Path lab
25. Insulin Plain tube with gel Serum 3ml HKL, Chem Path lab
26. Netilmycin Plain tube with gel Serum 3 ml Hosp. Selayang,
Chem Path lab
27. Organic acid Urine bottle Fresh urine. Packed with ice 20ml HKL, Paediatric lab
during transportation.
28. Paraprotein Plain tube with gel Serum must reach the lab 2.5 ml Hosp Ampang, Chem
not > 7 days (at 2C-8C) Path lab
after collection date.
Urine is refrigerated after
24h urine collection & must reach the 25 ml
referral lab not > 7 days (at
2C-8C)
150
SECTION D :TEST SENT TO REFERRAL LABORATORIES : TABLE 8 : (6)
SERVICES PROVIDED BY MINISTRY OF HEALTH (MOH HOSPITALS)(Request Form PER-PAT 301)
29. Phenobarbitol Plain tube with gel Serum 3mls HKL, Drug lab
30. Protein Electrophoresis Plain tube with gel CSF 1-2mls Hosp Ampang, Chem
Path lab
must reach the lab not more
than 7 days (at 2C-8C)
after collection
Plain tube with gel Serum 3mls Hosp Ampang, Chem
Path lab
30. Protein Electrophoresis Urine container urine must reach the refferal 25mls Hosp Ampang, Chem
lab not more than 5 days (at Path lab
2C-8C) after collection
31. Purine Urine container Fresh urine 20ml HKL, Paediatric lab
32. Pyrimidine
33. Reducing Sugar (urine, stool) Urine container Fresh urine 20ml HKL, Paediatric lab
34. Renin Chilled K2 EDTA Plasma 3mls Hosp. Putrajaya,
Chem Path lab
35. Sirolimus K2 EDTA Whole blood 2.5mls HKL, Drug lab
151
SECTION D :TEST SENT TO REFERRAL LABORATORIES : TABLE 8 : (6)
SERVICES PROVIDED BY MINISTRY OF HEALTH (MOH HOSPITALS)(Request Form PER-PAT 301)
36. Sulphocysteine Urine bottle Fresh urine 20ml HKL, Paediatric lab
37. Tacrolimus (FK506) K2 EDTA Whole blood 2.5mls HKL, Drug lab
38. Testosterone Plain tube with gel Serum 3mls HKL, Chem Path lab
39. Transferrin Plain tube with gel Serum 3ml HKL. Drug lab
40. Vitamin D Plain tube with gel Serum 3ml Hosp. Putrajaya,
Chem Path lab
152
SECTION D : TESTS SENT TO THE REFERRAL LABORATORIES :
TABLE 7 : (5) SERVICES PROVIDED BY TOXICOLOGY AND PHARMACOLOGY
UNIT, HERBAL MEDICAL RESEARCH CENTRE (HMR), IMR(CONTACT
NUMBER : 03-26162629/ FAX NUMBER : 03-26919724) ) (use Request
Form PER-PAT 301)
SPECIMEN REFERENCE TAT

TEST VOLUME PRESERVATIVE METHOD
REQUIRED VALUES (WEEKS)
Lead Blood 1 ml EDTA/Heparin <10 g/dl GFAAS 3-4
Mercury Urine 10 ml HNO3, pH 2 <50 mol/24hrs Flow injection Analysis 3-4
Copper Urine 5 ml HNO3, pH 2 <0.9mol/24hrs GFAAS 3-4
Copper Serum 0.5 ml none 11-20 mol/L GFAAS 3-4
Biochem
6 Organic acid urine bottle fresh urine 20ml IMR/HKL
Peads
TABLE 8 : (6) SERVICES PROVIDED BY MINISTRY OF HEALTH (MOH) HOSPITALS
(use Request Form PER-PAT 301)
1. Adrenocorticorticotrophic Hormone K2 EDTA send in Plasma 2.5 ml HKL, Chem Path lab
(ACTH) iced slurry
2. Alcohol (non medico-legal) Plain tube with gel Serum 3ml HKL, Drug lab
3. Aldosterone K2 EDTA/Plain Plasma 3ml Hosp. Putrajaya,
Chem Path lab
4. Alpha-1 antitrypsin Plain tube with gel Serum 3ml HKL, Drug lab
5. Amikacin Plain tube with gel Serum 3ml HKL, Drug lab
6. Amino Acid Lithium heparin Plasma 2 ml
IMR, SDC/ HKL,
Paediatric lab
Urine container Fresh urine 20ml
7. Amphetamine Type Stimulant Urine container Urine 10ml HKL, Drug lab
8. Anti Acetylcholine Receptor Antibody Plain tube with gel Serum 3ml IMR, AIRC Unit
9. Beta 2 Microglobulin Plain tube with gel Serum must 3mls Hosp. Ampang, Chem
reach the referral Path lab
lab not more than
7 days (at 2C-
8C) after
collection date
12. Catecholamines 24hrs urine 24 hrs Urine 25ml Hosp. Putrajaya,

container with 10ml Chem Path lab
of 6M HCL * check pH<6
before send
13. Caeruloplasmin Plain tube with gel Serum 3ml HKL, Drug lab
153
TABLE 8 : (6) SERVICES PROVIDED BY MINISTRY OF HEALTH (MOH HOSPITALS)
14. C-Peptide Plain tube with gel Serum 3ml HKL, Chem Path lab
15. Cyclosporin K2 EDTA Whole blood 2.5ml HKL, Drug lab

16. Dehydroxy epiendosterone Sulphate Plain tube with gel Serum 3ml HKL, Chem Path lab
(DHEA-S)
17. Fasting C-Peptide Plain tube with gel Serum 3 ml HKL, Chem Path lab
18. Fasting Insulin Plain tube with gel Serum 3 mls HKL, Chem Path lab
19. Free Light Chain Plain tube with gel Serum must 1 ml Hosp Ampang, Chem
reach the lab not Path lab
more than 7 days
(at 2C-8C) after
collection date
20. Fructosamine (Hosp Ampang) Plain tube with gel Serum 3 mls HKL, Chem Path lab
21. Gamma Glutamyl Transferase Litium heparin plasma 3 mls HKL, Chem Path lab
22. Growth hormone Plain tube with gel serum 3 mls HKL, Chem Path lab
23. Haptoglobin Plain tube with gel Serum 3 mls HKL, Drug lab
24. Homocysteine Plain tube in ice Serum 3ml HKL, Chem Path lab
25. Insulin Plain tube with gel Serum 3ml HKL, Chem Path lab
26. Netilmycin Plain tube with gel Serum 3 ml Hosp. Selayang,
Chem Path lab
27. Organic acid Urine bottle Fresh urine. 20ml HKL, Paediatric lab
Packed with ice
during
transportation.
28. Paraprotein Plain tube with gel Serum must 2.5 ml Hosp Ampang, Chem
reach the lab not Path lab
more than 7 days
(at 2C-8C) after
collection date.
Urine is
24h urine refrigerated after 25 ml
collection & must
reach the referral
lab not more than
7 days (at 2C-
8C) after
collection date
29. Phenobarbitol Plain tube with gel Serum 3mls HKL, Drug lab
30. Protein Electrophoresis Plain tube with gel CSF 1-2mls Hosp Ampang, Chem
Path lab
must reach the
lab not more than
7 days (at 2C-
8C) after
collection
Plain tube with gel Serum 3mls Hosp Ampang, Chem
Path lab
154
TABLE 8 : (6) SERVICES PROVIDED BY MINISTRY OF HEALTH (MOH HOSPITALS)
30. Protein Electrophoresis Urine container urine must reach 25mls Hosp Ampang, Chem
the refferal lab Path lab
not more than 5
days (at 2C-8C)
after collection
31. Purine Urine container Fresh urine 20ml HKL, Paediatric lab
32. Pyrimidine
33. Reducing Sugar (urine, stool) Urine container Fresh urine 20ml HKL, Paediatric lab
34. Renin Chilled K2 EDTA Plasma 3mls Hosp. Putrajaya,
Chem Path lab
35. Sirolimus K2 EDTA Whole blood 2.5mls HKL, Drug lab
36. Sulphocysteine Urine bottle Fresh urine 20ml HKL, Paediatric lab
37. Tacrolimus (FK506) K2 EDTA Whole blood 2.5mls HKL, Drug lab
38. Testosterone Plain tube with gel Serum 3mls HKL, Chem Path lab
39. Transferrin Plain tube with gel Serum 3ml HKL. Drug lab
40. Vitamin D Plain tube with gel Serum 3ml Hosp. Putrajaya,
Chem Path lab
155
HEMATOLOGY LABORATORY
SECTION A
INTRODUCTION
This laboratory offers services to all clinicians mainly from wards in Hospital Tuanku Jaafar,
Seremban and Out-patients referred by the Specialist Clinics. It also serves any request for
special tests from Peripheral Hospitals and Klinik Kesihatan in Negeri Sembilan.
LIST OF TEST
Refer Table A: List of tests done in HTJS (page 157-163)
Refer Table B: List of tests outsourced to other referral hospitals (page 154-173)
REQUEST FORMS
Refer Appendix 1 & 2(please refer to page ). Relevant clinical history is crucial for all tests especially
tests needing clinical interpretations.
SPECIMEN COLLECTION & CONTAINERS

General
Venous Blood specimens are preferred. To ensure consistent and accurate results follow strictly
to the volume of blood required for the type of test as specified on the label or fill up to the mark
on the label of the specimen tube. Refer Table C for specific containers used for different tests.
To prevent haemolysis:
Avoid vigorous mixing
Remove needle from syringe before squirting the blood into containers.
Send the specimen as soon as possible to the lab after collection.
Avoid clot formation by:
Ensuring a smooth venipuncture and steady flow of blood into the syringe.
Ensuring the anticoagulant in the specimen bottle not dry off.
Introducing blood in the anticoagulant bottle as soon as blood is withdrawn.
Immediately mix gently by inverting tube at least 6 10 times.
Specimen labels
Self-adhesive labels should be used and carry the following information:
Name of Patient
Identity Card Number
Hospital Registration Number
Clinic or Ward
Specimen and test required
Date
156
DISPATCH OF SPECIMENS
Specimens should be dispatched to the respective laboratories as soon as possible.
REPORTING OF RESULTS
In-patients results can be collected from the pigeon holes of respective wards placed in the
laboratory .
For those wards linked with LIS System, their results will not be printed.
Ward personnel may collect urgent results from the laboratory, preferabaly immediately following
completion of test.
Short Turn Around Test (STAT) SERVICE
Please identify stat requests by stamping/ writing the word URGENT/ STAT in red at the top
portion of the request form. Preferably the specimen is sent to the laboratory by a ward staff. The
test will be carried out as soon as possible and results are available within 1 hour.
List of STAT/ urgent tests for Haematology Lab:
Full Blood Count (FBC)

Prothrombin Time (PT) / Activated Partial Thromboplastin Time (APTT)
Disseminated Intravascular Coagulopathy (DIVC) Screen
Full Blood Picture (FBP) on special cases
SERVICE AFTER OFFICE HOURS
The Haematology Laboratory provides service after office hours (24 hours) to all wards. Only
tests, which are deemed necessary, should be requested to avoid work overload during call
hours. Please refer list of STAT/ urgent tests for Haematology Lab .The results of the tests will be
placed in the pigeon hole for collection by the ward staff at regular intervals.
157
SECTION B:
Reference range for FBC analysis
TABLE 1: Haematological values for normal adults expressed as a mean 2SD (95% range)
(Dacie and Lewis, Practical Haematology, 10th edition)
Red blood cell count

Men 5.0 0.5 1012/l
Women 4.3 0.5 1012/l
Haemoglobin
Men 150 20 g/l
Women 135 15 g/l
Packed cell volume (PCV) or Haematocrit (Hct)
Men 0.45 0.05 (l/l)
Women 0.41 0.05 (l/l)
Mean cell volume (MCV)
Men and women 92 9 fl
Mean cell haemoglobin (MCH)
Men and women 29.5 2.5 pg
Mean cell haemoglobin concentration (MCHC)
Men and women 330 15 g/l
Red cell distribution width (RDW)
As coefficient of variation (CV) 12.8 1.2%
As standard deviation (SD) 42.5 3.5 fl
Red cell diameter (mean values)
Dry films 6.77.7 mm
Red cell density 10921100 g/l
Reticulocyte count 50100 109/l (0.52.5%)
White blood cell count 4.010.0 109/l
Differential white cell count
Neutrophils 2.07.0 109/l (4080%)
Lymphocytes 1.03.0 109/l (2040%)
Monocytes 0.21.0 109/l (210%)
Eosinophils 0.020.5 109/l (16%)
Basophils 0.020.1 109/l (<12%)
158
TABLE 2: Haematological values for normal infants (amalgamation of data derived from
various sources; expressed as mean 2SD or 95% Range)
Birth Day 3 Day 7 Day 14 1 Month 2 Months 36

Months
Red blood cell count (RBC) 5.3

1012/l 6.0 1.0 1.3 5.11.2 4.91.3 4.2 1.2 3.7 0.6 4.7 0.6
Haemoglobin g/l 180 40 80 30 1754 1654 140 25 112 18 126 15
Packed cell volume (PCV) 0.60 0.56 0.54 0.51 0.43 0.35 0.35
l/l 0.15 0.11 0.12 0.2 0.10 0.07 0.05
Mean cell volume (MCV) fl 110 10 105 107 19 105 19 104 12 95 8 76 8

13
Mean cell Hb (MCH) pg 34 3 34 3 34 3 34 3 33 3 30 3 27 3
Mean cell Hbconc (MCHC) 330 30 330 330 50 330 50 330 40 320 35 330 30
g/l 40
Reticulocytes 109/l 120400 50350 50100 50100 2060 3050 40100
White blood cell count

(WBC) 109/l 18 8 15 8 14 8 14 8 12 7 10 5 12 6
Neutrophils 109/l 414 35 36 37 39 15 16
Lymphocytes 109/l 38 28 39 39 316 410 412
Monocytes 109/l 0.52.0 0.51.0 0.11.7 0.11.7 0.31.0 0.41.2 0.21.2
Eosinophils 109/l 0.11.0 0.12.0 0.10.8 0.10.9 0.21.0 0.11.0 0.11.0
159
TABLE 3: Haematological values for normal children (amalgamation of data derived from
various sources; expressed as mean 2SD or 95% Range)
1 Year 26 Years 612 Years
Red cell count 1012/l 4.5 0.6 4.6 0.6 4.6 0.6
Haemoglobin g/l 126 15 125 15 135 20
Packed cell volume (PCV) l/l 0.34 0.04 0.37 0.03 0.40 0.05
Mean cell volume (MCV) fl 78 6 81 6 86 9
Mean cell Hb (MCH) pg 27 2 27 3 29 4
Mean cell Hbconc (MCHC) g/l 340 20 340 30 340 30
Reticulocytes 109/l 30100 30100 30100
White cell count 109/l 11 5 10 5 94
Neutrophils 109/l 17 1.58 28
Lymphocytes 109/l 3.511 69 15
Monocytes 109/l 0.21.0 0.21.0 0.21.0
Eosinophils 109/l 0.11.0 0.11.0 0.11.0
Platelets 109/l 200550 200490 170450
160
TABLE 4: Pre-analytical Variables Affecting Full Blood Count (FBC) And Full Blood Picture (FBP) Testing
CLOTTED SAMPLE: IMPROPER COLLECTION DELAY IN PROCESSING
Should be processed within 3-4 hours of

collection especially for FBP
Falsely low result especially platelet count 1) Release of thrombin initiate clotting
due to platelet consumption during clot pathway clotted sample Storage changes
formation.
2) Platelet activation formation of
plateletclump falsely low platelet count .
Normal RBC
morphology
INADEQUATE SAMPLE SAMPLING PROXIMAL TO IV DRIP

Crenated RBC and pyknotic
WBC- unable to comment on
cell morphology
-Analyzer unable to aspirate the adequate - Dilutional effect Falsely low cell count
amount of sample for testing falsely low especially RBC and hemoglobin
RBC loss of central pallor,
cell count measurement.
mimicking spherocytes
can be misdiagnosed as
Immune Haemolytic anaemia
- Inadequate ratio of sample to anti
coagulant Excess EDTA RBC shrink-
reduce Mean Cell Volume and
Hematocrit. Degraded WBC unable to
differentiate different type of
WBC
161
TABLE 5: Pre-analytical variables affecting coagulation testing
Proper blood taking Correct anti-coagulant Avoid clotted sample Avoid delayed processing
Prolonged application of tourniquet Gently invert the tube Should process

for more than 1 min: 4-5x after filling within 4 hours of
Leads to activation of platelet & 3.2% trisodium collection
clotting factor citrate Micro clot Lead to
Shortened result citrate Shortened result deterioration of
binds to calcium labile clotting factor
Excessive stress & prevent Large clot-Loss of (factor V and VII)
Vigorous fist clenching: clotting of blood coagulation factors to Prolonged result
form clot Prolonged
Will increase FVIII &vWF result
Shortened result
Incorrect blood to anticoagulant ratio: High haematocrit Sample contamination Other:
Relatively low plasma volume Lipaemia/icterus: interfere

Optimum 9:1 ratio of blood to Excess citrate in the tube will bind with optical clot detection Expired tube:
anticoagulant to calcium added during testing method inadequate filling
Inadequate calcium for coagulation Hemolysed sample: due to partial loss
possible activation of of vacuum force
(up to black indicator line) Prolonged result
clotting factor, interfere under filling tube
with clot detection Prolonged
+/- 10% Heparin contamination: result
Under filling tube clues:
Marked prolong APTT
Excess citrate in the tube will bind to with a normal or slightly
calcium added during testing prolong PT & repeat
Inadequate calcium for coagulation sample form fresh bleed
Prolonged result shows normal result
Overfilling tube If Hct > 0.55- adjust volume of
citrate
Inadequate anticoagulant to prevent
clot formation clotted sample
Shortened result C= 1.85x10-3(100-hct) x 3mls
162
C: citrate need to be removed
TABLE A : List of tests done in Hematology Lab (HTJS)
TAT Method of collection Special requirement / Notes

No. Test Specimen Container
STAT Routine
1. Full Blood Count 2-3 ml EDTA tube 1 hour 3 hours Fill up blood to the Care has to be taken to avoid pre-
(FBC) whole blood marked level +/- 10% analytical variables that may affect
Mix gently by the result (Refer to Table 4)
inverting 6 10
times.
Cap bottle tightly. FBC results that fulfilled the criteria
for critical limit will be informed
immediately to the respective
ward/clinic. Please refer to Appendix
4: Critical limit for FBC result
For abnormal FBC result, which

fulfilled morphology screening
criteria, peripheral blood smear will
be performed on the same sample.
The smear will be reviewed and
reported within 2 working days using
the same barcode number. Please
refer to Appendix 6: Criteria for
morphology review. This represents
FBP. So, FBP need not be
requested then to prevent
unnecessary wastage.
2. Reticulocyte 3 ml whole EDTA tube N.A 3 hours NA
blood
3. Full Blood Picture 3 ml whole EDTA tube 24 7 working For urgent case, please request
blood hours days through medical officer on call with
adequate clinical history.
163
STAT Routine
Indication for urgent FBP:
- Acute leukaemia/ Acute

PromyelocyticLeukaemia (APML)
- Thrombotic thrombocytopenic
purpura
- Acute haemolysis
- Aplastic crisis
- Sickle cell crisis
Require fresh sample < 4 hours to

avoid storage changes.
4. Hb. Analysis 3 ml whole EDTA tube N.A 4 weeks Adequate clinical history including:
blood - Clinical history: Age of presentation,
blood transfusion history, any
splenectomy done
- family history
- Physical examination: jaundice,
presence of hepatosplenomegally
For family screening: to state the

identification (I/C or passport
number) &diagnosis of the index
case (to specify the type of
thalassaemia or
haemoglobinopathies.Eg: /-
thalassemia)
5. Erythrocyte 1.2 ml 3.2% N.A 3 hours NA
Sedimentation Rate Sodium
(ESR) Citrate
164
STAT Routine
6. G6PD Screening Blood spot Filter paper N.A 3 hours Apply a drop of Send specimen before 9.00 am
blood to a piece of
filter paper
Allow it to dry
completely
Dispatch to the lab
attached with the
request form.
7. Coagulation profile: 3 ml whole 3.2% 1 hour 3 hours Fill up blood to the Send specimen immediately to
blood Trisodium marked level +/- 10% the laboratory.
Prothrombin time citrate Mix gently by PT/ APTT results that fulfilled
(PT) inverting 4-6 times. the criteria for critical limit will be
Activated Partial Cap bottle tightly. informed immediately to the
Thrombin Time Write date and time respective ward/clinic. Please
(APTT) specimen taken. refer to Appendix 5: Critical limit
for routine coagulation testing
Care has to be taken to avoid
8. DIVC Screening: 3 ml whole 3.2% 1 hour 3 hours pre-analytical variables that may
blood Trisodium affect the results. Please refer to
Prothrombin time citrate Table 5: Pre-analytical variables
(PT) affecting coagulation testing
Activated Partial
Thrombin Time
(APTT)
Fibrinogen
D-Dimer
9. Thrombin Time (TT) 3 ml whole 3.2% 1 hour 3 hours

blood Trisodium
citrate
165
STAT Routine
10. Fibrinogen 3 ml whole 3.2% 1 hour 3 hours Fill up blood to

blood Trisodium the marked
citrate level +/- 10%
Mix gently by
inverting 4-6
times.
11. D-Dimer 3 ml whole 3.2% 1 hour 3 hours Cap bottle
tightly.
blood Trisodium
Write date and
citrate time specimen
taken.
12. Mixing Study 3 ml whole 3.2% NA 24 hours Test done after discussion with
blood Trisodium Haematologist to decide on the
citrate indication and urgency
Indication: prolong coagulation profile

after exclusion of pre-analytical
variables such as under filled tube with
no identifiable clinical cause such as
chronic liver disease, on anticoagulant
treatment etc
13. Factor VIII & IX 3 ml whole 3.2% NA 7 working Test done after discussion with
Assay blood Trisodium days Haematologist to decide on the
citrate indication and urgency. Adequate
166
STAT Routine
14. Factor VIII & IX 9 ml whole 3.2% NA 7 working clinical history including bleeding history
Inhibitors/ screening blood Trisodium days (age of presentation, site, frequency,
for inhibitor citrate ?spontaneous onset, family history of
bleeding disorders etc)
For paediatric case at least 4 -5

paediatric tubes
15. Enumeration of 3mls whole EDTA tube N.A 5 working Fill up blood to the Complete clinical history is required.
CD4/CD8 blood days marked level. Test done on Wednesday only.
Mix gently by
inverting 6 10
times.
Cap tightly and place
in biohazard bag
NOTE:
For reliable flow

cytometry analysis
(e.g.- CD4, CD8 T cell
enumeration) blood
must be sent
immediately to the lab.
Specimens kept for
more than 6 hours are
not suitable for analysis.
167
STAT Routine
16. Urine Hemosiderin 10 ml fresh Urine N.A 5 working NA Test done by appointment
urine container days
17. Sickling Test 3 ml whole EDTA tube N.A 24 hours NA Test done by appointment
blood
18. Osmotic Fragility 3 ml whole Heparin N.A 1 week NA Test done by appointment
Test (OFT) blood tube
19. Serum Cryoglobulin 10 ml whole Plain tube N.A 5 working Take fasting blood in Test done by appointment
blood days plain tube. Patient is not on heparin or any
Make sure all the other anticoagulants.
syringe, needle and
3 ml whole EDTA tube tube are pre-warm in
blood 37OC for half an
hour.
20. Kleihauer 3 ml whole EDTA tube N.A 5 working Send sample Test done by appointment
blood days immediately to the lab. Require babys sample in
maternal paediatric tube for positive
control
sample.
21. Neutrophilsalkaline 3 ml whole EDTA tube NA 5 working Requirefreshsampleless Test done by appointment
phosphatase (NAP) blood days than 4 hours
score
168
STAT Routine
22. Bone Marrow Bone Direct NA Acute NA Test done by appointment.

Aspiration marrow smear done leukaemia: 2 copies of request form with
by JTMP 24 hours complete clinical history.
TAT may be longer for cases that may
from
Others: require correlation with trephine
hematology biopsy report.
10
lab
Working
days
23. Human Semen Semen Sterile Urine NA 5 working Patient preparation for 1. The test is done in the morning.
Analysis (HSA) Container days semen collection:
2. Sample container can be collected
1. Abstinence from from hematology unit on the day of the
sexual activity for 3-5 test.
days the collection of
sample. 3. Collected sample should be send
2. All ejaculated semen immediately to the lab and must be
should be collected
processed within 1 hour of collection.
for accurate result.
3. The usage of cream,
gel and oil are not
allowed.
24 Intrauterine Semen Sterile Urine NA 4 hours NA Test by appointment with Hematology
Insemination (IUI) Container Lab.
169
TABLE B : List of tests outsourced to Referral Labs
- Transportation is provided by Pathology Department only on Monday & Thursday or the next working day if Monday / Thursday is a public
holiday.
- Turn around time (TAT) is depending on Referral Lab TAT
PusatDarah Negara
No. Test Specimen Container Request Form Special requirement
Special coagulation tests (Haemostasis Lab 03-26955598)
1. Lupus Anticoagulant Whole blood 3.2% Trisodium PDN/HA/QP- -Proper mixing of the specimen
(LA) and citrate 01/01
Antiphospholipid 3-4 tubes (10mls) -Specimen must be sent immediately
antibody (APA) (Pink form) after collection.
-Serum should be separated within 2

hours of collection.
2. Protein C or Protein S or Whole blood 3.2% Trisodium
Activated Protein C citrate -Adequate clinical history of patient is
Resistance (APCR) 3-4 tubes (10mls) required.
3. Thrombophilia Study Whole blood 3.2% Trisodium

citrate
(LA, APA, Protein C, 6-7 tubes (15mls)
Protein S,APCR)
4. Factor V Leiden Whole blood 3.2% Trisodium

mutation citrate
3 tubes (10mls)
170
Special coagulation tests (Haemostasis Lab 03-26955598)
5. Factor Assays Whole blood 3.2% Trisodium

citrate
3 tubes (10mls)
6. Inhibitor Assays Whole blood 3.2% Trisodium

citrate
3 tubes (10mls)
7. Von Willebrand Factor Whole blood 3.2% Trisodium

citrate
3 tubes (10mls)
8. Haemophilia carrier Whole blood 3.2% Trisodium -Must include index case with
study citrate confirmed diagnosis of haemophilia
3 tubes (10mls) and sample form both parents.
for each patient
- Require fresh sample. To discuss
with lab. staff to arrange for sample
transportation.
171
Special haematology test, Pusat Darah Negara
1. G6PD assay 1tube ( 3mls) EDTA tube PDN/HA/QP- -Proper mixing of the specimen
01/01
-Adequate clinical history of patient is
(Pink form) required.
Blood bank, Pusat Darah Negara
1. Platelet antibody For investigation of EDTA tube PDN/HA/QP- - Requires approval from PDN
testing 01/01 specialist on call
Neonatal Allo- and plain tube - For casessuspected NAIT to
immune (Pink form) include the following history
Thrombocytopenia: Full obstetric history such as
gravida/ para, any
Mother : miscarriage or fetal/ neonatal
death
4 tube (10 mls)- in
Bleeding history such as
EDTA tubes intracranial bleed.
4 tube (10 mls)- in History of fever / sepsis
plain tubes Platelet count mother and
Father: baby
4 tube (10 mls)- in History of transfusion
EDTA tubes Previous history of NAIT
-Clinical history for other indication:
Baby:
I ml EDTA tube Bleeding history,transfusion
Other cases: 6-8 history, previous history of
tubes EDTA (15- ITP, platelet count.
20mls)
172
Hospital Kuala Lumpur
Special Haematology tests- (Haematology Lab extension: 6374/ 6853)
1. Immunophenotyping for Bone marrow EDTA tube PER PAT FORM -Full clinical history is mandatory
Acute Leukaemia / specimen 301
Lymphoma -Proper mixing of specimen
3-4 tube (10 mls) (Green form)
* Peripheral blood
can be used if
bone marrow
specimen is not
available after
discussion with
pathologist
2. Immunophenotyping for Peripheral blood EDTA tube PER PAT FORM -Post transfusion sample is not
PNH study 301 advisable
1 tube
(Green form) -If unavoidable, to write on the form
Post transfusion sample
Chromosomal test ( Cytogenetic Lab extension: 5637)

1. Conventional 3 ml peripheral Lithium heparin Cytogenetic Test done by appointment
cytogenetic analysis/ blood request
karyotyping for form,KKM
congenital anomaly
Molecular genetic Lab (Institute Paediatric extension: 6900/6901)
173
1. MLPA: Duchene 3 ml peripheral 1 tube EDTA Cytogenetic -Test done by appointment
Muscular Dystrophy blood request form, -Specimen stable for 1 week at 40C
(DMD) KKM -Prefer fresh sample
-Transport in ice (avoid direct contact)
2. DNA sequencing: 3 ml peripheral 1 tube EDTA Cytogenetic -Test done by appointment

blood request form, -Specimen stable for 1 week at 40C
- Reed Syndrome KKM -Prefer fresh sample
- Muenky Syndrome -Transport in ice (avoid direct contact)
Molecular analysis ( Molecular haematology Lab extension: 6883)
1. DNA Testing for Alpha 3ml whole blood EDTA tube PER PAT FORM -Complete request form ( includes
Thalassaemia (1 tube) 301 medical history, transfusion history
and complete diagnosis of
* 2 tube : for family (Green form) thalassaemia
screening with
index case that -FBC and Hb analysisreport should
has been be attached with the request forms.
confirmed with
alpha -for family screening with index case
thalassaemia. confirmed alpha thalassaemia, please
attached the identification ( IC/
Passport number) and molecular
diagnosis of the index case.
174
Hospital Ampang
Molecular analysis
1. BCR ABL 1 fusion gene 3- 5 ml bone EDTA tube Request form -For case suspected Chronic Myeloid
marrow specimen from H.Ampang Leukaemia.
( Real time and reverse /peripheral blood -must received sample within 3 days,
transcriptase) preferable fresh sample within 24
hours
-Follow up case, 6 mthly for glivec
monitoring
2. PML-RARA fusion 3- 5 ml bone EDTA tube Request form -For case suspected acute
marrow specimen from H.Ampang promyelocyticleukaemia (APML)
( Real time and reverse /peripheral blood -must received sample within 3 days,
transcriptase) preferable fresh sample within 24
hours
3. JAK 2 3- 5 ml bone EDTA tube Request form -For case suspected
marrow specimen from H.Ampang myeloproliferative neoplasm
/peripheral blood (polycythaemiavera, essential
thrombocythaemia and myelofibrosis)
- must received sample within 3 days,

preferable fresh sample within 24
hours
175
Hospital UniversitiKebangsaan Malaysia
Special Haematology tests(Blood bank extension :6747)
1. Serum erythropoietin Peripheral blood Plain tube with gel PER PAT FORM -Full clinical history is mandatory
(Blood bank) 2 tube ( 6mls) 301 -Proper mixing of specimen
(Green form) -Fresh sample
-To be transported in ice (4-60C)
Hematology Lab (SeksyenUjian G6PD Kuantitatif)

03-91455835/ 5834
1. G6PD quantification 3 ml whole blood/ EDTA tube/ PER PAT FORM -By appointment
cord blood Paediatric tube 301 -Complete clinical history
(Green form) (Any haemolysis, age , family history
and contact no)
-Complete ID of requesting doctor
(name, stamp and signature)
176
Institute Medical Research
Molecular analysis(Genetic molecular lab at 03-26162726)
1. DNA analysis for Beta Wholeblood EDTA tube PER PAT FORM -Patient sample (2.5-3mls)
thalassaemia 301
2.5-3 mls -Samples from both parents ((2.5-
( Green form) 3mls each)
-Complete request form ( includes

medical history, transfusion history
and complete diagnosis of
thalassaemia major or intermedia.
- FBC and Hb analysisreport should

be attached with the request forms
Cytogenetic analysis (Genetic Lab, Hematology Unit, Cancer Research Center (CaRC)03-2616711)
1. Conventional Bone marrow Lithium heparin/ -please send at least 2mls of FIRST
karyotyping for specimen -3 mls sterile transport bone marrow aspirate
haematological medium. Bone marrow
malignancy cytogenetic -Transport as soon as possible
request form,
2. Chromosomal breakage 10mls peripheral Lithium heparin IMR By appointment from IMR. Please
study blood contact Genetic laboratory for further
instruction.
177
Institute Medical Research
Test for Transplantation & Disease Association
Please call 03-26162776 between 8.30 10.00 am or 3.00 4.45 pm or fax a request to 03-26912019 giving full contact details.
1. HLA typing (Molecular 3 ml whole blood x EDTA tube REQUEST FOR -If patient is anaemic, TWBC less
Class I and II) for Bone 2 tubes BMT HLA- than 1.5 x 103 cells per ml, please
marrow and solid organ MOLECULAR send 15 ml of blood.
transplantation TYPING (PCR)
form -Patient must not have had a
transfusion in the 3 weeks preceding
blood collection.
-The blood must be sent at room

temperature
2. HLA Cross matching Donor:18 ml blood Sodium Heparin REQUEST FOR -The blood must be sent at room
HLA- B27/ B5 temperature
Patient: 5 ml blood Plain tube (PCR METHOD)
form
3. Panel Reactive 5 ml blood Plain tube -The blood must be sent at room
Antibodies (PRA) temperature
178
TABLE C: Specimen containers for Haematological testing
EDTA: Citrated tube (9:1) :

FBC
FBP All hemostasis
Hb analysis tests:
DNA analysis PT, APTT, Fibrinogen, D
CD4/CD8 dimer, thrombophilia,
Kleihauer factor assay, inhibtor
NAP score
G6PD FBC ( plt
clumping)
Citrated tube (4:1): Heparinised tube:

ESR Cytogenetic test
179
Critical limit for Full Blood Count Results
Values for Adults:
Lower Critical Limit FBC parameters Upper Critical Limit
6.0 g/dl Haemoglobin 19.0 g/dl
0.20 l/l Hematocrit 0.60 l/l
2 x 103 / ul White Blood Cells 50 x 103 / ul
20 x 103 / ul Platelets 1000 x 103 / ul
Values for Paediatric age group:
Lower Critical Limit FBC parameters Upper Critical Limit
7.0 g/dl Haemoglobin (Paed) 20.0 g/dl
8.0 g/dl Haemoglobin (Neonate) 22.0 g/dl
0.20 l/l Hematocrit (Paed) 0.40 l/l
0.25 l/l Hematocrit (Neonate) 0.70 l/l
2 x 103 / ul White Blood Cells 50 x 103 / ul
50 x 103 / ul Platelets 1000 x 103 / ul
Reference: Quick Guide List Critical Result, Ministry Of Health, Malaysia 2010
180
Critical Limit For Coagulation Result
Values for Adults:
Lower Critical Limit Coagulation parameters Upper Critical Limit
- APTT 80 second or>2x

upper reference range
- PT >2.5 upper limit
- INR (ratio) >5
100 mg/dl Fibrinogen -
Values for Paediatric:
Lower Critical Limit Coagulation parameters Upper Critical Limit
- APTT 80 second or >2x

Upper reference range
- PT >2.5 upper limit
- INR (ratio) >5
70mg/dl Fibrinogen -
Reference: Quick Guide List Critical Result, Ministry Of Health 2010
181
Criteria For Morphology Screening
FBC Parameters Frequency Lower Limit

Upper Limit
Hemoglobin First time 7.0 g/dl 18.0 g/dl
encountered
abnormal result
White Blood Cells First time 7 x 103 / ul 30 x 103 / ul

encountered
abnormal result
Platelets First time 100x 103 / ul 1000 x 103 / ul

encountered
abnormal result
Exclusion criteria:
1. Confirm dengue infection

2. Repeated case where slide review has been done during first time encounter abnormal
result.
3. Patient on chemotherapy
4. Dialysis patient
5. Transfusion dependent thalassemia
182
MICROBIOLOGY
1. INTRODUCTION
The Microbiology Unit, HTJS provides the following services:
a) Diagnostic microbiological services which comprise bacteriological, serological,

parasitology, immunology and mycological examinations of pathological specimens
from the patients of the whole Hospital Tuanku Jaafar as well as other MOH
institution, within Negeri Sembilan.
b) Participation in hospital wide infection control activities related to surveillance, control

and prevention of nosocomial infections.
c) Provision of microbiologic studies of the hospital environment and sterility testing.
d) Diagnostic services for medico legal cases including rape and post mortem cases.
2. REQUEST FORM
a) Every specimen must be accompanied by the designated request form (PER-PAT-

301).
b) Completed request form should also provide relevant information regarding history,
provisional diagnosis, treatment given (esp. antimicrobials) and should be
signed and stamp by the requested doctor.
c) The date, time and site of specimen collected should be stated.
d) The following information must be provided on the labels of specimen containers.
Name : Name of test requested :
I/C No : Date specimen taken :
Ward :
183
3. Table 1 : LIST OF TESTS
Air sampling CMV IgG

Anaerobic culture & ID CMV IgM
Body fluid (C & S) Denggue NS1 Ag (ELISA)
Blood (C & S) : Aerobic &
Dengue Virus IgM (ELISA)
Anaerobic
CSF (C & S) Dengue virus IgG (ICT)
Stool (C & S) HIV EIA combo( screening )
Genital (C & S) HIV-PA( Supplementary)
Peritoneal fluid (C & S) Hep. A IgM
BACTERIOLOGY
(C & S) Pus/Swab (C & S) Hep B e antigen
Respiratory (C & S) Hep B e Antibody
Sterility A-Test Hep B - anti HBs
Sterility (C & S) VIROLOGY Hep. B surface Antigen
TB AFB direct smear (SEROLOGY) HBcIgM
TB Culture HBcTotal
Tissue and bone (C& S) Hep C antibody (screening)
Hep C - PA (Supplementary)
Urine (C & S)
Herpes Simplex I & II IF
Chlamydia trachomatis IF Rubella IgG
CSF Bacterial antigen Rubella IgM
Leptospira IgM Toxoplasma IgG
Mycoplasma pneumoniae IgM Toxoplasma IgM
Respiratory viruses detection
TPHA/TPPA
BACTERIOLOGY IF
(SEROLOGY) VDRL/RPR
Rotavirus Latex-stool
ASOT
Typhidot Anti dsDNA
Anti Nuclear Antibodies
IPT IMMUNOLOGY (ANA)
Rheumatoid Factor (RF)
Microfilaria
Malaria Parasite (BFMP) Fungal Culture
Stool Ova & Cyst Cryptococcal Antigen
MYCOLOGY
Giardia microscopy
Fungal ID & sensitivity
Pneumocystis Carinii IF
PARASITOLOGY Leishmania spp. (Giemsa
H1N1 RT-PCR
stain)
C. diffifile toxin MERS Coronavirus PCR
Occult Blood MOLECULAR Influenza A
Microsporadium / Influenza B
Cryptosporadium Zika RT-PCR
184
4. SPECIMEN COLLECTION AND HANDLING
4.1 General guidelines
4.1.1 The quality of laboratory results depends greatly on the proper collection and handling of the
specimens as well as obtaining satisfactory material for examination.
4.1.2 The clinical specimens must be material from actual infection sites and must be collected with
minimum contamination from adjacent tissues, organs or secretions.
4.1.3 Ideally the specimens must be collected before the commencement of antibiotic therapy.
4.1.4 A sufficient quantity of specimens must be obtained in order to perform the examination
required.
4.1.5 Appropriate collection devices, specimen containers and culture media must be used to
ensure optimal recovery of micro organisms.
4.1.6 All specimen containers must be closed tightly and labelled with patients name, I/C, ward,
etc.
4.1.7 The specimen container that has been properly labelled must be accompanied by a properly
completed laboratory request form.
4.1.8 Specimens are best transported immediately to the laboratory.
4.1.9 Sterile swabs and special containers with transport medium or culture broth can be obtained
from Microbiology Laboratory. (Please refer to Table 2).
185
4.2. Table 2: SPECIFIC GUIDELINES FOR SPECIMEN COLLECTION, CONTAINER, & STORAGE
CONDITIONS.
Specimen type Collection Container / Transport Storage LTAT Comment

guidelines volume time time/ T0
Abscess
General Remove surface Tissue/aspirate is
exudates by always superior to a
wiping with swab specimen. If
sterile saline or swabs must be used
70% alcohol (aerobic culture
only), collect 2, 1
for culture & 1 for
gramstain. Preserve
material on swab by
placing in Stuarts
or Amies medium.
Open Aspirate if Swab <2 hr, RT <24h. RT 3-5days A sample of the
possible or pass transport base of the lesion &
deep into the system one of the abscess
lesion to firmly wall are most
sample the productive
lesions fresh
border.
Closed Aspirate abscess Sterile <2 hr, RT <24h. RT 3-5days
material with container /
needle and anaerobic
syringe. transport
Aseptically medium.
transfer all
material into
sterile container
(preferably
anaerobic
transport
medium).
Bite wound See abscess Do not culture
animal bite wound
<12h old (agents
are usually not
recovered) unless
signs of infection
are present.
186
Blood Disinfect culture Blood <2 hr, RT <2h, RT 3-5days for Endocarditis, acute:
bottle; apply 70% culture positive 3 sets from 3
isopropyl alcohol bottles for cultures from separate sites,
or chlorhexidine bacteria: the day of within 1-2h, before
to rubber adult, positivity. antimicrobials if
stoppers & wait 1 20ml/set 5days for possible.
minute. (higher vol negative Fever of unknown
Disinfect the most cultures. origin: 2-4 sets from
venipuncture productive): 4weeks for separate sites
site: Infant & fungal.
1.Cleanse site child, 1- 6weeks for
with 70% alcohol 20ml/set Mycobacteriu
2. Swab depending m.
concentrically, on weight of
starting at the patient. (1%
center, with of patients
tincture of iodine total blood
or chlorhexidine volume)
(not for infants
<2months).
3. Allow the
disinfectant to
dry.
4. Do not palpate
vein at this point
without sterile
glove
5. Collect blood
6. After
venipuncture,
remove iodine
from the skin
with alcohol.
Bone marrow Prepare puncture blood <24h, RT <24h, RT Same as
aspirate site as for surgical culture above
incision bottle
Burn Cleanse & Tissue & <24h, RT <24h, RT 3-5days Process for aerobic
debride the burn aspirates in culture only.
sterile screw- Cultures of surface
cap samples of burns
container. may be misleading.
Swab
exudates in
Amies
medium
Catheter
Intravenous 1. Cleanse the Sterile <15 min,RT <2h, 40C 3-5days Controversial
skin around the screw-cap whether culture of
catheter site with tube. catheter tips is
alcohol. clinically relevant.
2. Aseptically Acceptable
remove catheter intravenous
& clip 5cm of catheters for
distal tip directly semiquantitative
into a sterile culture (Maki roll
tube. method): central,
3. Transport CVP,
immediately to Hickman,Broviac,
lab to prevent peripheral, arterial,
drying. umbilical,
hyperalimentation,
Swan-Ganz.
187
Foley Do not culture, Not acceptable for
since growth culture.
represents distal
urethral biota
Cellulitis, aspirate 1. Cleanse site by Sterile <15 min,RT <24h, RT 3-5days Yield of potential
from area of wiping with screw-cap pathogens in
sterile saline or container. minority of
70% alcohol. specimens cultured
2. Aspirate the
area of maximum
inflammation
with a needle &
syringe. Irrigation
with a small
amount of sterile
saline may be
necessary.
CSF 1. Disinfect site Sterile Bacteria: <24 hr, 3-5days Obtain blood for
with iodine or screw-cap never RT culture also. If only
chlorhexidine tubes. refrigerate< one tube of CSF is
preparation. Minimum 15 min,RT collected, it should
2. Insert a needle amount be submitted to
with stylet at L3- required: microbiology first;
L4,L4-L5, or L%-S1 Bacteri > 1ml otherwise, submit
interspace. Acid fast > tube 2 to
3. Upon reaching 5ml microbiology.
the subarachnoid Aspirate of brain
space, remove abscess or a biopsy
the stylet & may be necessary
collect 1-5 ml of to detect anaerobic
fluid into each of bacteria or
leakproof tubes. parasites.
Decubitus ulcer A swab is not the Sterile tube/ <2 hr, RT <24 hr, 3-5days Since a swab
specimen of container RT specimen of a
choice. (aerobic) or decubitus ulcer
1. Cleanse surface anaerobic provides no clinical
with sterile system information, it
saline. (tissue). should not be
2. If a biopsy submitted. A tissue
sample is not biopsy sample or
available, needle aspirate is
aspirate the specimen of
inflammatory choice.
material from the
base of the ulcer.
Dental culture: 1. Carefully Anaerobic <2 hr, RT <24 hr, 3-5days Periodontal lesions
gingival, cleanse gingival transport RT should be
periodontal, margin & system. processed only by
periapical,, supragingival laboratories
Vincents tooth surface to equipped to
stomatitis remove saliva, provide specialized
debris & plaque. techniques for the
2.Using a detection &
periodontal enumeration of
scaler, carefully recognized
remove pathogens.
subgingival lesion
material and
transfer it to an
anaerobic
transport system.
3. Prepare smear
188
for staining with
specimen
collected in the
same fashion.
Ear,
Inner Tympanocentesis Sterile tube, <2 hr, RT <24 hr, 3-5days Results of throat or
reserved for swab RT nasopharyngeal
complicated, transport swab cultures are
recurrent, or medium, or not predictive of
chronic persistent anaerobic agents responsible
otitis media. system for otitis media &
1. For intact should not be
eardrum, clean submitted for that
ear canal with purpose.
soap solution &
collect fluid via
syringe aspiration
technique
(tympanocentesis
).
2. For ruptured
eardrum, collect
fluid on flexible
shaft via an
auditory
speculum
(aerobic culture
only)
Outer 1.Use a Swab <15 min,RT <24 hr, 3-5days For otitis externa,
moistened swab transport RT vigorous swabbing
to remove any is required since
debris or crust surface swabbing
from the ear may miss
canal. streptococcal
2. Obtain a cellulitis.
sample by firmly
rotating swab in
the outer canal.
Eye
Conjunctiva 1. Sample both Direct Plates:<15 <24 hr, 3-5days If possible, sample
eyes with culture min, RT RT both conjunctivae,
separates swabs inoculation: Swabs: <2h, even if only one is
(premoistened Blood agar & RT infected, to
with sterile Chocolate determine
saline) by rolling agar indigenous
over each Laboratory microbiota. The
conjunctiva. inoculation: uninfected eye can
2. Medium may swab serve as a control
be inoculated at transport. with which to
time of collection. compare the agents
3. Smear may be isolated from the
prepared at time infected eye.
of collection. Roll
swab 1-to-2 cm
area of slide.
Corneal scrapping 1. Specimen is Direct <15 min,RT <24 hr, 3-5days Conjunctival
collected by culture RT specimen is
ophthalmologist. inoculations; collected before
2. Using a sterile Blood agar, anesthetic
spatula, scrape Chocolate application, which
ulcers or lesions, agar & SDA may inhibit some
and inoculate bacteria. Corneal
189
directly onto scrappings are
medium. obtained after
3. Prepare 2 anaesthesia.
smears by Include fungal
rubbing material media. Scraping for
from spatula onto virus isolation &
1-to 2 cm area of ameba detection
slide. should be
submitted in a
sterile container.
Vitreous fluid Prepare eye for Sterile <15 min,RT <24 hr, 3-5days Include fungal
aspirates needle aspiration screw-cap RT media. Anesthetics
of fluid. tube or may be inhibitory to
direct some etiological
inoculation agents.
of small
amount of
fluid onto
media.
Feces
Routine culture Pass specimen Clean, leak Unpreserve <24 hr, 3-5days Do not perform
directly into a proof, wide d <1h, RT 40T routine stool
clean, dry mouthed Holding <48hr, cultures for patients
container. container or medium RT or whose length of
Transport to use Cary- <24h, RT 40C hospital stay is >3
microbiology Blair holding days & the
laboratory within medium admitting diagnosis
1 hr of collection (>2g) was not
or transfer to gastroenteritis
Cary-Blair holding without
medium. consultation with
physician.
Test for Clostridium
difficile should be
considered for
these patients.
Swabs for routine
pathogens are not
recommended
except for infants.
C.difficile Pass liquid or soft Sterile, leak <1h, RT 2 d, 40C, 3-5days for Patients should be
stool directly into proof, wide 1-24h,40C for culture; passing > 5x liquid
a clean, dry mouthed >24h -200C culture 24h for toxin or soft stools per 24
container. Soft container, or colder 3 d, 40C test. hr.
stool is defined as >5ml or Testing of formed
stool assuming longer at or hard stool is not
the shape of its -700C for acceptable except
container. Swab toxin for toxic
specimens are test. megacolon.
not Freezing at -200C or
recommended above results in
for toxin testing. rapid loss of
cytotoxin activity.
E.coli (O157:H7) Pass liquid or Sterile, leak Unpreserve <24 hr, 3-5days Bloody or liquid
& other Shiga bloody stool into proof, wide d <1h, RT 40T stools collected
toxin producing a clean, dry mouthed Swab <24h, <24hr, within 6 days of
serotypes container. container or RT or 40C RT onset from patients
Cary-Blair with abdominal
holding cramps have the
medium highest yield.
(>2g)
190
Rectal swab 1. Carefully Swab <24hr, 3-5days Reserved for
insert a swab transport RT detecting Neisseia
aprox. 1 in. gonorrhoeae,
beyond the anal Shigella,Campyloba
sphincter. cter, HSV, & anal
2. Gently rotate carriage of group B
the swab to Streptococcus &
sample the anal other beta-
crypts. haemolytic
3. Feces should streptococci, or for
be visible on the patients (usually
swab for children) unable to
detection of pass a specimen.
diarrheal
pathogens.
Fistula See abscess
Fluids: Abdominal, 1. Disinfect Anaerobic <15 min, RT <24hr, 3-5days for Amniotic &
amniotic, ascites, overlying skin transport RT bacteria & 3 culdocentesis fluids
bile, joint, with iodine or system, Pericardi weeks for should be
pericardial,periton chlorhexidine sterile screw- al fluid fungal transported in an
eal, pleura, preparation. cap tube, or & fluids anaerobic system &
synovial 2. Obtain blood for need not be
specimen via culture fungal centrifuged prior to
percutaneous bottle for cultures, gram staining.
needle aspiration bacteria. <24hr, Other fluids are
or surgery. Transport 40C best examined by
3. Always submit immediately gram staining of a
as much fluid as to cytocentrifuged
possible; never laboratory. preparation. One
submit a swab Bacteria, >1 aerobic blood
dipped in fluid. ml culture bottle
inoculated at
bedside is highly
recommended.
Gangrenous See abscess Discourage
tissue sampling of surface
or superficial tissue.
Tissue biopsy
samples or
aspirates should be
collected.
Gastric
wash or lavage for Collect in early Sterile, <15 min, RT <24h, AFB smear The specimen must
mycobacteria morning before leakproof or 40C 24h, be processed
patients eat & container neutralize Culture promptly, since
while they are within 1h of 42days, mycobacteria die
still in bed. collection. positive rapidly in gastric
1. Introduce a cultures will washings.
nasogastric tube be sent to Neutralize when
into the stomach. MKAK for ID holding for > 1 h
2. Perform lavage & sensitivity with sodium
with 25-50 ml of testing bicarbonate.
chilled sterile,
distilled water.
3. Recover
sample & place in
a leakproof,
sterile container.
Biopsy sample Collected by Sterile tube <1h,RT <24h, NA
for H.pylori gastroenterologis with 40C
t during transport
endoscopy. medium
191
Genital: female
Amniotic fluid Aspirate via Anaerobic <2h,RT <24hr, 3-5days Swabbing or
amniocentesis, or transport RT aspiration of vaginal
collect during system, > secretion is not
cesarean delivery. 1ml acceptable because
of the potential for
contamination with
commensal
members of the
vaginal biota.
Bartholin gland 1. Disinfect skin Anaerobic <2h,RT <24hr, 3-5days
secretion with iodine transport RT
preparation. system, >
2. Aspirate fluids 1ml
from ducts.
Cervical 1. Visualize the Swab <2h, RT <24hr, 3-5days
secretions. cervix using a transport RT
speculum without
lubricant.
2. Remove mucus
& secretions from
the cervical os
with swab &
discard the swab.
3. Firmly yet
gently sample the
endocervical
canal with a new
sterile swab.
Cul-de-sac fluid Submit aspirate Anaerobic <2h, RT <24hr, 3-5days
or fluid. transport RT
system, >1ml
Endometria tissue 1. Collect Anaerobic <2h, RT <24hr, 3-5days
& secretions transcervical transport RT
aspirate via a system, >1ml
telescoping
catheter.
2. Transfer entire
amount to
anaerobic
transport system.
Products of 1. Submit a Sterile tube <2h, RT <24hr, 3-5days Do not process
conception portion of tissue or anaerobic RT lochia, culture of
in a sterile transport which may give
container. system. misleading results.
2. If obtained by
cesarean delivery,
immediately
transfer to an
anaerobic
transport system.
Urethral Collect at least 1 Swab <2h, RT <24hr, 3-5days
secretions h after patient transport RT
has urinated.
1. Remove old
exudates from
the urethral
orifice.
2. Collect
discharge
material on a
swab by
192
massaging the
urethra against
the pubic
symphysis
through the
vagina.
Vaginal 1. Wipe away old Swab <2h, RT <24hr, 3-5days For IUD, place
secretions secretions/discha transport RT entire device into a
rge. sterile container &
2. Obtain submit at RT.
secretions from Gram stain, not
the mucosal culture, is
membrane of the recommended for
vaginal wall with the diagnosis of BV.
a sterile swab or
pipette.
3. If smear is also
needed, use a
second swab.
Genital
Female or male 1. Clean with Swab <2h, RT <24hr, 3-5days
lesion. sterile saline & transport RT
remove lesions
surface with a
sterile scalpel
blade.
2. Allow
transudate to
accumulate.
3. While pressing
the base of the
lesion, firmly rub
base with a
sterile swab to
collect fluid.
Pilonidal cyst See abscess.
Genital: male
Prostate 1. Cleanse the Swab <2h, RT <24hr, 3-5days Pathogens in
urethral meatus transport or RT prostatic secretions
with soap & sterile tube may be identified
water. for >1ml of by quantitative
2. Masage the specimen. culture of urine
prostate through before & after
the rectum. massage.
3. Collect fluid Ejaculate may also
expressed from be cultured.
the urethra on a
sterile swab.
Urethra Insert a small Swab <2h, RT <24hr, 3-5days
swab 2-4cm into transport RT
the urethral
lumen, rotate
swab, & leave it
in place for at
least 2 sec to
facilitate
absorption.
193
Respiratory,
lower
Bronchoalveolar 1. Collect washing sterile <2h, RT <24hr, 3-5days
lavage, fluid, or aspirate in a container, RT
brush sample or sputum trap >1ml of
washing, 2. Place brush in specimen
endotracheal sterile container
aspirate. with 1ml of
saline.
Sputum, 1. Collect sterile <2h, RT <24hr, 3-5days For paediatric
expectorated specimen under container, RT patients unable to
the direct >1ml produce a sputum,
supervision of a a respiratory
nurse or therapist should
physician. collect a specimen
2. Have patient via suction
rinse or gargle
with water to
remove excess
members of the
oral biota.
3. Instruct
patient to cough
deeply to
produce a lower
respiratory
specimen (not
postnasal fluid)
4. Collect in a
sterile container.
Sputum, induced. 1. Have patient sterile <2h, RT <24hr, 3-5days Same as above for
rinse mouth with container, RT sputum,
water after >1ml expectorated.
brushing gums &
tongue.
2. With the aid of
a nebulizer, have
patients inhale
approx 25ml of 3-
10% sterile saline.
3. Collect in a
sterile container.
Respiratory,
upper
Oral 1. Remove oral Swab <2h, RT <24hr, 3-5days Discourage
secretions & transport RT sampling of
debris from the superficial tissue for
surface of the bacterial
lesion with a evaluation. Tissue
swab. Discard this biopsy specimens or
swab. needle aspirates are
2. Using a second the specimens of
swab, vigorously choice.
sample the
lesion, avoiding
any areas of
normal tissue.
Nasal 1. Insert a swab, Swab <2h, RT <24hr, 3-5days Anterior nose
premoistened transport RT cultures are
with sterile reserved for
saline, approx 1-2 identifying
cm into the staphylococcal
194
nares. carriers or for nasal
2. Rotate the lesions.
swab against the
nasal mucosa.
Nasopharynx 1. Gently insert a Swab <2h, RT <24hr, 3-5days
small swab (e.g. transport RT
calcium alginate)
into the posterior
nasopharynx via
the nose.
2. Rotate swab
slowly for 5 sec to
absorb
secretions.
Throat or pharynx 1. Depress Swab <2h, RT <24hr, 3-5days Throat swab
tounge with a transport RT cultures are
tongue contraindicated for
depressor. patients with
2. Sample the epiglottitis.
posterior Swabs for Neisseria
pharynx, tonsils, gonorrhoeae should
& inflamed areas be placed in
with a sterile charcoal-containing
swab. transport medium
& plated < 12 h
after collection.
Tissue Collected during Anaerobic <15 min, RT <24hr, 3-5days Always submit as
surgery or transport RT much tissue as
cutaneous biopsy system or possible.
procedure. sterile, Never submit a
Sample should be screw-cap swab that has been
taken after container. rubbed over the
debridement for Add several surface of a tissue.
dirty/gangreneou drops of
s wound. sterile saline
to keep small
pieces of
tissue moist.
Urine
Female, 1. While holding Sterile Unpreserve <24hr, 3-5days
midstream the labia apart, widemouthe d <2h, RT RT
begin voiding. d Preserved:
2. After several container,>1 <24h,RT
milliliters has ml, or urine
passed, collect a transport
midstream tube with
portion without boric acid
stopping the flow preservative.
of urine.
3. The midstream
portion is used
for bacterial
culture.
Male, midstream 1. While holding Sterile Unpreserve <24hr, 3-5days
the foreskin widemouthe d <2h, RT RT
retracted, begin d Preserved:
voiding. container,>1 <24h,RT
2. After several ml, or urine
milliliters has transport
passed, collect a tube with
midstream boric acid
portion without preservative.
195
stopping the flow
of the urine.
3. The midstream
portion is used
for culture.
Straight catheter 1. Thoroughly Sterile, Unpreserve <24hr, 3-5days Catheterization may
cleanse the leakproof d <2h, RT RT introduce members
urethral opening container or Preserved: of the urethral biota
with soap & urine <24h,RT into the bladder &
water. transport increase the risk of
2. Rinse area with tube with iatrogenic infection.
wet gauze pads. boric acid
Aseptically, insert preservative.
catheter into the
bladder.
4. After allowing
approx 15 ml to
pass, collect urine
to be submitted
in a sterile
container.
Indwelling 1. Disinfect the Sterile Unpreserve <24hr, 3-5days Patients with
catheter catheter leakproof d <2h, RT RT indwelling catheters
collection port container or Preserved: always have
with 70% alcohol. urine <24h,RT bacteria in their
Clamp catheter transport bladders. Do not
below port & tube with collect urine from
allow urine to boric acid these patients
collect in tubing preservative. unless they are
for 10-20 min. symptomatic.
2. Use needle &
syringe to
aseptically collect
5-10ml of urine.
3. Transfer to a
sterile tube or
container.
Wound See Abscess.
4.3 Specimen collection for Mycology
4.3.1 Skin, nails and hair

Clean cutaneous and scalp lesions with 70% alcohol prior to sampling as this
will improve the chances of detecting fungus on microscopic examination, as
well as reducing the likehood of bacterial contamination of cultures. Prior
cleaning is essential if oitments, creams or powders have been applied to the
lesion.
Skin, nails and hairs specimens should be collected into folded squares of
paper or directly onto agar plate.
4.3.1.1. Skin
i. Material should be collected from cutaneous lesions by scraping outwards

from the margin of the lesions with edge of glass microscope slide or a
blunt scalpel.
196
4.3.1.2. Nail
i. Nail specimens should be taken from any discoloured, dystrophic or brittle

parts of the nail.
ii. Specimen should be cut as far back as possible from the edge of the nail
and should include the full thickness of the nail.
4.3.1.3 Hair
i. Specimens from the scalp should include hair roots, the contents of
plugged follicles and skin scales.
ii. Hairs should be plucked from the scalp with forceps or the scalp is brushed
with a plastic hairbrush and collected onto an agar plate.
4.4 Medicolegal cases

Specific guidelines:
i. Specimens should be sealed and send directly to the microbiology laboratory.

ii. Specimens should be sent to the laboratory by designated personnel.
iii. Chain of custody should be maintained at all times and record book should
accompany the samples.
iv. Sample collection of various tests should follow the guidelines as of normal
microbiological requirements and the specific headings are referred.
4.5 Smear preparation for BFMP

1. Clean new glass slides with alcohol.
2. Sample can be obtained from finger prick or venous blood.
3. For finger prick, select the third finger from the thumb (big toe can be used for
infants). Clean the finger with cotton wool soak in 70% alcohol. Dry the finger
with cotton towel.
4. With sterile lancet, puncture the ball of the finger using quick rolling action.
5. By applying gentle pressure to the finger, express the first drop of blood and wipe it
away with dry cotton wool.
4.5.1 How to prepare thick blood film

1. Collect a single drop of blood on the surface of clean slide.
2. Using the corner of another glass slide as a spreader quickly spread the blood to
make an even, thick film. The blood is spread in a circular motion with 3-6
movements, and spread over 20mm diameter or 10 cent size.
3. Label the slide with patients registration number and date on the frosted end.
4. Allow the slide to air dry. Place the blood film in slide holder and sent to the
laboratory with a complete request form.
197
4.5.2 How to prepare thin blood film.
1. Collect another one small drop of blood on to a new slide about 5 mm away from
the edge of the slide.
2. Rest the blood slide on a firm, flat surface. Use another slide as a spreader. Touch
the drop of blood with a spreader and allow the blood to run along its edge.
Keep the spreader at an angle of 30-45 and in steady movement, firmly
push the spreader forward to prepare a thin smear.
3. Label the slide with patients registration number and date of collection on the
frosted end.
4. Allow the slide to air dry. Place the blood film in slide holder and sent to the
laboratory with a complete request form.
4.6 Specimen Collection For Filariasis
4.6.1Timing:
i. Whenever possible, specimens should be collected before treatment is initiated.

When malaria and babesiosis are suspected, blood smears should be obtained and
examined without delay. Since the parasitemia may fluctuate, multiple smears might
be needed.These can be taken at 8 to 12 hour intervals for 2 to 3 days.
ii. Microfilariae exhibit a marked periodicity depending on the species involved,

therefore the time of specimen collection is critical. If a filarial infection is suspected,
the optimal collection time for demonstrating microfilariae is:
Loa loamidday (10 AM to 2 PM)

Brugia or Wuchereriaat night, after 8 PM
Mansonellaany time
Onchocercaany time
4.6.2 Type of Sample:
Capillary blood obtained by fingerstick:
1. Label pre-cleaned slides (preferably frosted-end) with the patient's name (or other
identifier) and date and time of collection.
2. Clean the site well with alcohol; allow to dry.
3. Prick the side of the pulp of the 3rd or 4th finger (alternate sites include ear lobe, or in
infants large toe or heel).
4. Wipe away the first drop of blood with clean gauze.
198
4.7 Table 3: SEROLOGICAL EXAMINATION
These comprise of tests in bacteriology, virology and immunology.
Test Type of LTAT

specimens and Type of (working
amount container day)
required
IMMUNOLOGY Anti nuclear antibody ( Blood , 3-5ml Plain/Gel tube 7 days
ANA )
Anti Streptolysin O Test Blood , 3-5ml Plain/Gel tube 2 days
dsDNA antibody Blood , 3-5ml Plain/Gel tube 14 days
Rheumatoid factor Blood , 3-5ml Plain/Gel tube 2 days
smear on slide
Chlamydia trachomatis -IF Genital using special 3 days
discharge collection kits
Indirect Immunoperoxidase
test ( IIP ) for Typhus Blood , 3-5ml Plain/Gel tube 14 days
Leptospira lgM (Rapid test) Blood , 3-5ml Plain/Gel tube 2 days
BACTERIOLOGY M. pneumoniae PA Blood , 3-5ml Plain/Gel tube 3 days
Particle agglutination test
for T. palladium ( TPPA ) Blood , 3-5ml Plain/Gel tube 3 days
Reagin test for syphilis Blood , 3-5ml 2 days
Plain/Gel tube
(RPR )
Typhidot for Salmonella Blood , 3-5ml Plain/Gel tube 2 days
Legionella antigen Urine Sterile container 2 days
PARASITOLOGY Sputum, BAL,
Pneumocystis jiroveci (IF) tracheal Sterile container 7 days
aspirate, NPA
Toxoplasma lgG / lgM Blood , 3-5ml Plain/Gel tube 7 days
(CMIA)
VIROLOGY Anti-HAV lgM Blood , 3-5ml Plain/Gel tube 7 days
Cytomegalovirus (CMV) Blood , 3-5ml Plain/Gel tube 7 days
IgG / IgM (CMIA)
Dengue lgM ELISA Blood , 3-5ml Plain/Gel tube 3 days
Dengue IgG (Rapid test) on Blood , 3-5ml Plain/Gel tube 2 days
request
Dengue NS 1 ELISA Blood , 3-5ml Plain/Gel tube 3 days
Hbe Ag and Hbe Ab Blood , 3-5ml Plain/Gel tube 7 days
(CMIA)
HBs Ag (Negative) and Blood , 3-5ml Plain/Gel tube 2 days
HBs Ab (CMIA)
HBs Ag (Positive) (CMIA) Blood , 3-5ml Plain/Gel tube 7 days
HBcTotal (CMIA) Blood , 3-5ml Plain/Gel tube 7 days
HBcIgM (CMIA) Blood , 3-5ml Plain/Gel tube 7 days
Blood , 3-5ml Plain/Gel tube 2 days
HCV Antibody (CMIA) (Negative)
3 days
(Positive)
HCV Antigen (CMIA) Blood , 3-5ml Plain/Gel tube 7 days
Blood , 3-5ml Plain/Gel tube 2 days
(Negative)
HIV Antibody (CMIA)
4 days
(Positive)
smear on slide 3 days
HSV type 1 & 2 IF Lesion
199
Rotavirus antigen Stool ( fresh Sterile container 2 days
stool )
Rubella lgG / lgM (CMIA) Blood , 3-5ml Plain/Gel tube 7 days
MOLECULAR PCR H1N1 Real time PCR Throat swab,
(All molecular test Influenza A Real time PCR nasal swab, VTM (swab), 7 days
should consulted Influenza B Real time PCR NPA Sterile container
Clinical MERS-COV Real time Sputum, BAL, VTM (swab), 1 day
Microbiologists on PCR tracheal Sterile container
duty) aspirate, NPA,
Throat swab,
nasal swab
Zika Virus Real time PCR Blood , 3-5ml Plain/Gel tube, 7 days
EDTA tube
Urine, 10ml Sterile container
CSF, >1ml Sterile container
Tissue samples Sterile container
5. SPECIMEN CONTAINERS COMMONLY USED IN MICROBIOLOGY
Container Test volume specimen Note

Blood culture (paediatrics) Blood culture for 1-3ml or 1% Blood Do not refrigerate
paediatric patients of blood Do not stick
volume patients sticker
on the bottles
barcode
Anaerobic blood bottle Anaerobic blood culture 8-10ml Blood Do not refrigerate
Do not stick
patients sticker
on the bottles
barcode
Aerobic blood bottle Aerobic blood culture 8-10ml Blood Do not refrigerate
Do not stick
patients sticker
on the bottles
barcode
200
Myco F / lytic Blood culture for fungal 1-5ml Blood Do not refrigerate
Blood culture for Do not stick
Mycobacterium patients sticker
on the bottles
barcode
stool container Stool culture > 2g Stool

Stool FEME
Stool for Rotavirus
Stool for C.difficile
Universal sterile container Sterile fluid for culture, >1ml for each CSF, pleural
PCR, FEME, etc test fluid,
requested peritoneal
fluid, etc.
EDTA Malaria PCR 2.0 ml Blood /

Leptospiral PCR plasma
Viral load
Etc.
Plain / gel separator tube Routine serology & 3.5ml Blood / serum
virology tests
Amies transport medium 1. Plain swab for any NA Ear swab, For suspected
without / with charcoal swab sample for FEME eye swab, Bordetella to use
or culture & sensitivity genital swab, special per nasal
throat swab, swab specimen
2. Amies with charcoal per nasal collection
for Neisseria swab(Bordete
gonorrhoeae or lla)
Bordetella pertussis
201
Dacron swab and viral 1. Viral culture NA Throat swab, Always
transport medium ( VTM ) 2. Molecular testing for rectal swab, refrigerated.
virus etc
Agar media For direct inoculation NA Corneal

(bedside). scrapping, air
sampling
Sample collection kit for urethral, cervical, NA Please refer Please refer to
Chlamydia trachomatis conjunctival, rectal or to insert insert available in
nasopharyngeal available in each kit for
samples each kit for specimen
type of collection & slide
specimen . preparation.
Slide with frosted end, & 1. BFMP NA blood

slide holder 2. Blood film for
microfilaria
3. Corneal scraping
FEME
Selenite F Stool for suspected container Stool

Salmonella / Shigella volume
202
Sterile container Culture & sensitivity, Atleast 5ml of Urine, tissue,
AFB direct smear & fluid or 1cm pus, sterile
culture, FEME, NPAIF, of tissue. fluids, stool,
PCP, sputum, body
fluids
6. LIST OF TESTS TO BE SENT TO OTHER INSTITUTIONS/ OUTSOURCING;
NO TEST SPECIMEN CONTAINER LOCATION
BACTERIOLOGY
IMR,
1 Culture for Difficult Identification Bacteria Culture plate/slope Bacteriology
IMR,
2 Mellioidosis Blood Plain Tube Bacteriology
3 Legionella antibody Blood Plain Tube *HSB, Serology
Multiplex PCR
4 H.influenza,S.pneumo and
N.meningitidis Blood Plain tube HSB, Molecular
IMR,
5 Serum for Leptospirosis (MAT) Blood Plain Tube Bacteriology
EDTA /sterile IMR,

6 Leptospira PCR Blood/tissue/sterile sample container Bacteriology
IMR,
7 Urine for Chlamydia Urine Sterile container Bacteriology
Chlamydia
8 *HSB, Serology
trachomatis/pneumoniae/psittaci
Swab, NPA Sterile container
(IF )
9 Chlamydia trachomatis serology Blood Plain/Gel tube *HSB, Serology
10 Chlamydia pneumoniae serology Blood Plain/Gel tube *HSB, Serology
203
11 Chlamydia psittaci serology Blood Plain/Gel tube *HSB, Serology
12 TB Sensitivity Test Culture TB culture media MKAK Sg Buloh
Sterile
container/Dacron
13
Bordetella pertusis PCR Nasopharyngeal swab in charcoal IMR,
aspirate/swab media Bacteriology
14 Coxiella serology Blood Plain/Gel tube *HSB, Serology
15 Brucella serology Blood Plain/Gel tube *HSB, Serology
IMR,
Brucella PCR EDTA tube
16 Whole blood or serum/1 ml Bacteriology
17 Borrelia serology Blood Plain/Gel tube *HSB, Serology
18 CSF VDRL CSF Sterile container *HSB, Serology
Mycobacterium Tuberculosis
19 PCR Tissue bx/sterile sample/csf Sterile container IMR,Bacteriology
PARASITOLOGY
IMR,
1 Toxocara Blood Plain Tube Parasitology
IMR,
2 Ascaris Serology Blood Plain Tube Parasitology
IMR,
3 Serum Leishmania Antibody Blood Plain Tube Parasitology
IMR,
4 Malaria PCR Blood Plain Tube Parasitology
IMR,
5 Filariasis Serology Blood Plain Tube Parasitology
IMR,
6 Serum Ameobasis Blood Plain Tube Parasitology
IMR,
7 Serum Teaniasis Blood Plain Tube Parasitology
MYCOLOGY
1 Culture for Difficult Identification Fungus Culture plate/slope IMR, Mycology
2 Fungal for Serology Test Blood Plain Tube *HSB, Mycology
3 Yeast isolate SDA Agar plate *HSB, Mycology

Fungal(yeast) for antifungal
204
susceptibility Test
4 Fungal PCR Blood EDTA IMR, Mycology
Sterile
5 Fungal PCR sample(CSF,BAL,aspirates) Sterile container IMR, Mycology
Fresh/formalin/paraffin
6
Fungal PCR embeded Sterile container IMR, Mycology
IMMUNOLOGY
IMR,
1 Anti-CCP Blood Plain Tube Immunology
IMR,
2 Anti-RNP Blood Plain Tube Immunology
IMR,
3 Anti Smooth Muscle Antibody Blood Plain Tube Immunology
IMR,
4 Anti Mitochondrial Antibody Blood Plain Tube Immunology
IMR,
5 Anti-Phospholipid Antibody Blood Plain Tube Immunology
IMR,
6 LKM Antigen Blood Plain Tube Immunology
IMR,
7 T & B Cell Function Blood Plain Tube Immunology
IMR,
8 Phagocytic Function Test Blood Plain Tube Immunology
IMR,
9 Anti Ro Blood Plain Tube Immunology
IMR,
10 Anti La Blood Plain Tube Immunology
IMR,
11 Anticardiolipin Antibody Blood Plain Tube Immunology
IMR,
12 ENA Blood Plain Tube Immunology
IMR,
13 pANCA ,cANCA Blood Plain Tube Immunology
205
IMR,
14 Immunoglobulin (IgA,IgG,IgM) Blood Plain Tube Immunology
IMR,
15 Anti-histone Blood Plain Tube Immunology
16 Plain Tube H.Putrajaya

Anti-thyroglobulin Blood
VIROLOGY
Hosp. Sg Buloh,
1 HIV Viral Load Blood EDTA Virology
IMR/ MKAK
2 Enteroviral Screening Blood Plain Tube Virology
3 Stool For Acute Flaccid Paralysis Stool Sterile container IMR, Virology
Plain sterile
tube/sterile bijoux Hosp. Sg Buloh,
4 CMV DNA PCR Blood/ CSF/tissue/BAL bottle Virology
Hosp. Sg Buloh,
5 HSV 1/2 DNA PCR Blood/ CSF/tissue/BAL Plain sterile tube Virology
Hosp. Sg Buloh,
6 EBV DNA PCR Blood/ CSF Plain sterile tube Virology
7 Varicella Serology Blood Plain Tube HSB, Virology
8 Measles Serology Blood Plain Tube MKAK Virology
Dacron swab In
9 Measles Virus isolation Throat swab VTM MKAK Virology
10 Measles Genotyping Urine Plain Tube MKAK Virology
11 Viral Culture/Isolation Blood Plain Tube IMR, Virology
12 Mumps Serology Blood Plain Tube HSB, Virology
13 HIV LIA Blood EDTA IMR, Virology
14 HBV Viral load Blood Plain tube HKL, Virology
15 HBV DNA PCR Blood Plain Tube HKL, Virology
16 HCV viral load Blood Plain Tube HKL, Virology
17 HCV RNA PCR (viral load) Blood Plain Tube HKL, Virology
206
18 HCV Line immunoassay Blood Plain Tube HSB, Virology
19 Hep B Core Antigen Blood Plain Tube HKL, Virology
20 EBV Serology Blood Plain Tube HKL, Virology
21 HIV DNA PCR(paeds) Blood EDTA IMR, Virology
Plain tube/sterile
22 JE Serology Blood/CSF container MKAK Sg Buloh
23 Parvovirus Serology Blood Plain Tube HKL, Virology
24 Dengue PCR Blood Plain Tube MKAK Sg Buloh
aspirate/blood
25 Viral culture /tissue/swab According to sample MKAK, Sg Buloh
Note:
1. All request form for outside test must be completed.

2. For HIV viral load:
i. Particular in the request form:
- Whether patient on HAART therapy
- Date and time specimen taken
ii. request form must be 3 copies
3. For any test not stated above, please call microbiology laboratory for further
information.
207
7.SPECIMEN REJECTION MICROBIOLOGY UNIT
Specimens will be rejected according to these criteria.
SAMPLE REQUEST FORMS OTHERS
Request form Test not available/ not

Wrong specimen. incomplete. offered.
Bad smear for BFMP. To send request in Test done by

duplicate forms. appointment only.
Broken slide.
No original request Requested test was
form received. cancelled by Clinician.
Empty container
received.
Required test not Test suspended until
written. further notice.
Unsatisfactory
collection of sputum
sample. Clinical history not Test requested not
fulfils the case specific.
definition criteria for
Unsatisfactory the particular test
collection of stool. Please specify the
requested
correct test required.
Specimen consists
mainly of saliva Test previously done.
indicate by <25 pus
cells per lpf; >10
epithelial cells per lpf. Diagnostic result
Unsuitable for culture. known.
Dry swab received. Request rejected. Last

request less than 3
months.
Specimen received in
non-sterile container.
Specimen received in
formalin.
*Please refer to the Departments Rejection Criteria for general rejection.
208
APPENDICES : REQUEST FORMS
REQUEST FORMS APPENDIX PAGE

Borang PER.PAT 301 1 211
Cytology Pap Smear(PS1/98 PINDAAN 2007) 2 212
Borang Permohonan Tranfusi Darah (PPDK 5-PIN 1/97) 3 213
IEM Request Form 4 214
Request Form For Multiple Myeloma and other Related 5 216
Disorders
Request Form For Specific Protein 6 217
Request Form For Molecular Diagnostics Services 7 218
Bone Marrow Cytogenetic Request Form, Institute Medical 8 219
Research
PDN/HA/QP-01/01, Pusat Darah Negara 9 220
HLA Typing, IMR 10 221
HLA CB27/B5 , IMR 11 222
Bone Marrow/ Peripheral Blood For Cytogenetic or Molecular 12 223
Testing, Hospital Ampang
Cytogenetic Request Form for Congenital Abnormality , 13 224
Hospital Kuala Lumpur
Dengue Serotype Surveillance 14 225
National Enterovirus Surveillance Diagnostic Request Form 15 226
Ujian Polymerase Chain Reaction(PCR) UntukHuman Deficiency 16 227
Virus (HIV) di kalangan bayi
Laboratory Request Form- MKAK-BPU-U01 17 228
MEASLES-borang permohonan dan keputusan ujian makmal 18 229
(MSLF:01/2004)
Laboratory Request Form For MERS-CoV Investigation 19 230
Surveillance Of Streptoccus Pneumoniae Isolate in Malaysia 20 231
Laboratory-Base Surveillance Notifications Form 21 232
Borang Permohonan Ujian TIBI TBIS 20C 22 233
TORCHES Program 23 234
HIV Genotyping Resistance Testing 24 235
Primary Immunology Research Centre(AIRC) 25 236
Acute Flaccid Paralysis Case Investigation Form 26 237
Sample collection check list for AFP cases 26.1 238
209
Appendix 1
Type of form: PER.PAT 301
210
Appendix 2
211
Appendix 3
212
Appendix 4
BIOCHEMISTRY UNIT, SPECIALISED DIAGNOSTIC CENTRE
INSTITUTE FOR MEDICAL RESEARCH
Jalan Pahang, 50588 Kuala Lumpur, Phone: 26162794, Fax: 26938210
IEM REQUEST FORM
IMPORTANT NOTICE: To ensure correct, reliable result and interpretation given, the following must be followed:
1. Please fill up the entire form.

2. At least 1ml plasma and 5ml urine are needed. Heparinised plasma is preferred.
3. Separate plasma from RBC immediately. Haemolysed samples will be rejected.
4. ALL processed samples (plasma and urine) must be frozen immediately and transport in DRY ICE to IMR.
Name:____________________________Age:________Sex: M / F / U Race: M / C / I / O__________
RN:_________________M I/C:____________________Hospital:___________ Wad:_____________
House Address:__________________________________________________Tel:________________
1. Symptoms/signs of current illness:

Fever Poor sucking/feeding
Pallor Respiratory problem
Jaundice Difficulty in breathing
Hypothermia Mental retardation
Hypotonia/floppy Developmental delay
Cyanosed Failure to thrive
Lethargy Feeding intolerance
Easily irritable Septicaemic-like illness
Seizures or h/o seizures Headache
Drowsy Smelly urine
Coma Coloured urine
Abnormal behaviour Skin lesions
Frequent vomiting Eye lesions
Other symptoms/signs:_______________________________________________________________
2. Feeding history: Type of milk: Breast/ Formula/ Mixed/ Solid diet:________________________
3. Family history: Consanguinity: Yes / No. If Yes please specify:___________________________
Occurrence of Stillbirth neonatal neonatal metabolic disease

in death seizures
Siblings
Maternal side
Paternal side
4.Physical Examination:
Respiratory distress Hyperreflexia

Dysmorphic features Nystagmus
Hypothermia Optical atrophy
Cardiomyopathy Ptosis
Drowsy Abnormal odour
Coma Abnormal hair
Opisthotonus Hepatomegaly
Dystonia Splenomegaly
Choreoathetoid movement Eczema/ Other rashes
Hyptonia Others (specify)
213
5. Treatment given (specimen should be taken before any form of treatment given or stop for 2-3 days)
Drug therapy: Antibiotic: No/Yes__________________ Anticonvulsant: No/Yes________________
Steroid: No/Yes____________________ Other drug:____________________________
Fluid infusion: Saline / Dextrose / Mannitol / Parenteral feeding / Others:________________________
6. Lab Result (before treatment is given)
LFT: ALT:_______________mmol/l Blood Glucose:____________mmol/l
AST:_______________mmol/l Blood Ammonia___________
ALP:_______________mmol/ l Blood Lactate:_____________pyruvate:__________
Blood Gases: Normal / Met. Acidosis / Met.alkalosis / Resp.acidosis / Resp.alkalosis
Anion Gap:_________________________Other relevant test ( specify)_______________________
CTscan/MRI:________________________________________________________________
Urine Analysis: pH___________Ketones: Pos/ Neg Reducing Sugar: Pos/Neg
Provisional Diagnosis:_____________________________________________________________
7. Test required: (Please tick appropriate test/s required)

1. Plasma amino acid Specimen No:
2. CSF amino acid
3. Urine Amino acid (HPLC-by appt) Collected by:
4. Urine Orotic acid Date specimen collected
5. Urine Organic Acid
6. Urine GAG / MPS (DMB & HRE) Collected by:
7. Plasma Total and Free Carnitine (Operator ID)
8. Plasma Total homocysteine
9. Blood spot: Total Galactose Date specimen send
10. Blood spot: GALT / G1PUT
11. Blood spot: AA & Acylcarnitines (IEM screening) Paediatrician In-Charge:
12. Blood spot for biotinidase assay
13. Blood spot for Fabry
14. Blood spot for Pompe
15. Plasma VLCFA Sign. And chop:
16. Plasma Phytanic acid
17. Urine Succinylacetone
18. Urine S-sulphocysteine :
19. Urine Oligosaccharide/Tetraglucoside
20. Urine Delta ALA
21. Urine Phorphyrin & Phorphobilinogen
22. Urine Cystine
23. Urine Homocystine
24. Urine Sialic Acid (Neuraminic acid)
25. Others (Please specify):
214
Appendix 5
215
Appendix 6
216
Appendix 7
217
Appendix 8
Type of form: Bone Marrow Cytogenetic Request Form, Institute medical Research
218
Appendix 9
Type of form: PDN/HA/QP-01/01, PusatDarah Negara
219
Appendix 10
Type of form: HLA Typing, IMR
220
Appendix 11
Type of form: HLA CB27/B5 , IMR
221
Appendix 12
Type of form: Bone Marrow / Peripheral Blood For Cytogenetic or Molecular Testing,
Hospital Ampang
222
Appendix 13
Type of form: Cytogenetic Request Form for Congenital Abnormality ,
Hospital Kuala Lumpur.
223
Appendix 14
224
Appendix 15
225
Appendix 16
226
Appendix 17
227
Appendix 18
228
Appendix 19
229
Appendix 20
230
Appendix 21
231
Appendix 22
232
Appendix 23
233
Appendix 24
234
Appendix 25
235
Appendix 26
236
Appendix 26.1
237
Acknowledgements:
1. Y Bhg Dato Dr. Zailan bt Dato Adnan, Pengarah Kesihatan, JKNS.
2. Dr. Ariffin bin Mohamad, Timbalan Pengarah Kesihatan, JKNS.
3. Dr. Jaafar bin Che Mat, Pengarah HTJS.
4. Dr. Azizon binti Othman, Ketua Jabatan Patologi, HTJS.
5. Committee Members of Laboratory User Manual, Pathology Department, HTJS.
6. Unit Heads, Pathology Department, HTJS.
7. All staff of Pathology Department, HTJS involved in the preparation of the manual.
238
ALL RESULT ARE CONFIDENTIAL
239

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Laboratory User Manual

Dr Azizon binti Othman : Head of Department of Pathology

Dr. Nazlinda Sulaiman : Anatomic Pathologist

Puan Murniza Ahmad Najimudin : Science Officer Microbiology Unit

Dr Suryani binti Mohd Yusoff : Head of Cytopathology Unit

Dr Nik Faizah binti Hik Hussein : Head of Chemical Pathology Unit

Dr Noor Hasni binti Shamsudin : Head of Histopathology Unit

Dr Nik Hafidzah binti Nik Mustapha : Head of Haematology Unit

Dr Idaleswati binti Nor Mohamad : Head of Transfusion Medicine

Dr Marlindawati binti Mohd Ali : Head of Medical Microbiology Unit

Puan Norhazwati Mokhtar : Science Officer Chemical Pathology Unit

Puan Maimiza Zahari : Science Officer Transfusion Medicine

Puan Ierdawateey binti Ibrahim : Science Officer Histopathology Unit

Cik Teh Lay Kuan : Science Officer Cytology Unit

1. Every customer will be treated with quality service and care.

Department telephone directory 7

Scope of services, specimen collection and transportation 8

Request form and specimen rejection 9

Cytology Unit 11-15

Histopathology Unit 16-21

Blood Transfusion Service 22-35

Chemical Pathology Unit 36 - 156

Haematology Unit 157 - 183

Microbiology Unit 184 - 209

Appendices 210 - 238

I take great pleasure in expressing my appreciation to the Head of Department of

The issue contains information on pathology services available in HTJS as well as

Dr Azizon binti Othman

Senior Consultant Pathologist (Haematologist)

Head of Pathology Department

Hospital Tuanku Jaafar Seremban

LOCATION EXTENSION LOCATION EXTENSION

Main Receiving Counter 4304 Dr. Azizon Othman 4301

the following fields:

The laboratory occupies an area on the ground floor of the hospital.

D: SPECIMEN COLLECTION AND TRANSPORT

Test offered, specimen types and containers are variable.

positive patient identification cannot be overemphasized. The requirement of specimen labelling

Specimens should be sent to the laboratory as soon as possible.

2. Forms must be signed by requesting doctor with official stamp.

3. Relevant information and history must be included.

Specimens Request forms

Lipaemic sample Required test not written

LOCATION TEST OPERATING HOUR

Main Receiving Counter Chemical Pathology tests 24 Hours

H1N1, Mers-CoV, Influenza A &

Histopathology and HPE Office hours only

Blood Transfusion Lab Group Crossmatch 24 hours

Group Screen and Hold

Request for blood product

i. Gynaecological Pap smear

(C) REQUEST FORM

1. Gynaecological Pap smear: Method of cervical screening used to detect

(i) Specimen to be collected prior to bimanual examination.

Sample Container Fixative Form TAT Result

Specimen Container Fixative Form TAT Result

Sample Container Sample Collection Form TAT Result

Day Time Location TAT Result

REJECTIONS CRITERIAS ACTIONS