Imipram/Desipramine
| PATIENT INFO |
| Patient Name: |
| Medical Record #: |
| BD: / / Sex: F M |
| PHYSICIAN INFO |
| Physician Name : |
| Address: |
| Ph: ( ) - Fax: ( ) - |
| Additional Report to: |
| Ph: ( ) - Fax: ( ) - |
| TESTS REQUESTED | |
| Test Name: | ICD9 Code: (required) |
| 1. Imipram/Desipramine | |
| 2. | |
| 3. | |
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| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
IMIDP
Test Workstation :
MAYO
Specimen Type:
Blood
Tube Type:
Red top (no anticoagulant) tube
Collection Volume:
2.5 mL
Minimum Volume:
0.75 mL
Storage:
Refrigerated
Availability:
Sent to reference lab
Methodology:
Liquid Chromatography-Tandem Mass Spectrometry (LC-MS/MS)
Special Instructions:
Collect immediately prior to next dose. Serum must be separated from cells within 2 hours of collection.
For Outpatients, test should only be drawn in outpatient locations within a Hospital (Akron or Mahoning Valley)
Lab/Phone:
330-543-8418
TAT:
3-5 days
Additional Info:
Reference range:
Desipramine Critical Value: greater than 400 ng/mL
Desipramine (Therapeutic Concentration): 100-300 ng/mL
Total Therapeutic Concentration Imip/Desipramine: 175-300 ng/mL
CPT Code:
80335, G0480 (if appropriate)
Panel Includes:
Imipramine; Desipramine; Total Imipramine/Desipramine
