@extends('layouts.admin')
@section('content')

    <div class="row">
        <h1> Pedido de Laboratorio Paciente: {{$paciente->nombres}} {{$paciente->apellidos}} </h1>
    </div>
    <hr>

    <div class="row">
        <div class="col-md-12">
            <div class="card card-outline card-primary">
                <div class="row">
                    <div class="col-md-12">
                        <div class="col-md-2">
                        </div>
                    </div>
                </div>
                <!-- CUERPO DEL PEDIDO DE LABORATORIO -->

                    <div class="card-body">
                        <form action="{{url('/admin/laboratorio/create')}}" method="POST">
                            @csrf
                            <div class="row">
                                     <div class="col-md-12">
                                        <div class="row">
                                        <div class="col-md-4" style="background-color: #5fb550">
                                            <div class="form-group">
                                                <label for="">Diagnostico</label> <b>*</b>
                                               <input type="hidden" name="diagnostico_cie" value="{{$paciente->diagnostico_cie}}">
                                                <input type="text"  value= "{{$paciente->diagnostico_cie}}" class="form-control" readonly>
                                                @error('nombres')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-4"style="background-color: #5fb550">
                                            <div class="form-group">
                                                <label for="">Paciente</label> <b>*</b>
                                            <input type="hidden" name="paciente_id" value="{{$paciente->id}}">
                                                <input type="text"  value= "{{$paciente->nombres." ".$paciente->apellidos}}" name="nombres" class="form-control" readonly>
                                                @error('nombres')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-1" style="background-color: #5fb550">
                                            <div class="form-group">
                                                <label for="">Edad</label> <b>*</b>
                                                <input type="text" value="{{$paciente->edad}}" name="edad" class="form-control" readonly>
                                                @error('edad')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-3" style="background-color: #5fb550">
                                            <div class="form-group">
                                                <label for="">Fecha </label> <b>*</b>
                                                <input type="date" value="2026-11-13"   name="fecha_visita" class="form-control">
                                                @error('fecha')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                    </div>
                                    <br>
                                </div>

                                         <!-- PRIMERO -->
                                    <div class="col-md-12" style="background-color: #c549e1">
                                        <label><b>LAB. CLINICO HEMATOLOGIA</b></label>
                                    </div>

                                    <div class="col-md-12">
                                        <div class="row">
                                            <div class="col-md-2">
                                                <div class="form-group" style="font-size: small">
                                                    <center> <label for="">Biometria Hematica </label>
                                                    </center>
                                                    <input type="text" value="{{old('biometria')}}" name="biometria" class="form-control" style="text-align: center">
                                                    @error('biometria')
                                                    <small style="color: red">{{$message}}</small>
                                                    @enderror
                                                </div>
                                            </div>

                                            <div class="col-md-2">
                                                <div class="form-group" style="font-size: small">
                                                    <center> <label for="">Hemoglobina </label>
                                                    </center>
                                                    <input type="text" value="{{old('hemoglobina')}}" name="hemoglobina" class="form-control" style="text-align: center" >
                                                    @error('hemoglobina')
                                                    <small style="color: red">{{$message}}</small>
                                                    @enderror
                                                </div>
                                            </div>

                                            <div class="col-md-2">
                                                <div class="form-group" style="font-size: small">
                                                    <center> <label for="">Hematocrito</label>
                                                    </center>
                                                    <input type="text" value="{{old('hemato')}}" name="hemato" class="form-control"  style="text-align: center">
                                                    @error('hemato')
                                                    <small style="color: red">{{$message}}</small>
                                                    @enderror
                                                </div>
                                            </div>

                                            <div class="col-md-2">
                                                <div class="form-group" style="font-size: small">
                                                    <center> <label for="">Hematies</label>
                                                    </center>
                                                    <input type="text" value="{{old('hipertension')}}" name="hipertension" class="form-control" style="text-align: center">
                                                    @error('hipertension')
                                                    <small style="color: red">{{$message}}</small>
                                                    @enderror
                                                </div>
                                            </div>

                                            <div class="col-md-2">
                                                <div class="form-group" style="font-size: small">
                                                    <center> <label for="">Sedimentacion Globular </label>
                                                    </center>
                                                    <input type="text" value="{{old('globular')}}" name="globular" class="form-control" style="text-align: center" >
                                                    @error('globular')
                                                    <small style="color: red">{{$message}}</small>
                                                    @enderror
                                                </div>
                                            </div>

                                            <div class="col-md-2">
                                                <div class="form-group" style="font-size: small">
                                                    <center> <label for="">Leucocitos </label>
                                                    </center>
                                                    <input type="text" value="{{old('leucocitos')}}" name="leucocitos" class="form-control" style="text-align: center" >
                                                    @error('leucocitos')
                                                    <small style="color: red">{{$message}}</small>
                                                    @enderror
                                                </div>
                                            </div>

                                            <div class="col-md-2">
                                                <div class="form-group" style="font-size: small">
                                                    <center> <label for="">Formula Leucocitaria </label>
                                                    </center>
                                                    <input type="text" value="{{old('formula')}}" name="formula" class="form-control" style="text-align: center" >
                                                    @error('formula')
                                                    <small style="color: red">{{$message}}</small>
                                                    @enderror
                                                </div>
                                            </div>

                                            <div class="col-md-2">
                                                <div class="form-group" style="font-size: small">
                                                    <center> <label for="">Morfologia de enritrocitos </label>
                                                    </center>
                                                    <input type="text" value="{{old('morfologia')}}" name="morfologia" class="form-control" style="text-align: center" >
                                                    @error('morfologia')
                                                    <small style="color: red">{{$message}}</small>
                                                    @enderror
                                                </div>
                                            </div>

                                            <div class="col-md-2">
                                                <div class="form-group" style="font-size: small">
                                                    <center> <label for="">Plaquetas </label>
                                                    </center>
                                                    <input type="text" value="{{old('plaquetas')}}" name="plaquetas" class="form-control" style="text-align: center" >
                                                    @error('plaquetas')
                                                    <small style="color: red">{{$message}}</small>
                                                    @enderror
                                                </div>
                                            </div>

                                            <div class="col-md-2">
                                                <div class="form-group" style="font-size: small">
                                                    <center> <label for="">Reticulocitos </label>
                                                    </center>
                                                    <input type="text" value="{{old('reticulocitos')}}" name="reticulocitos" class="form-control" style="text-align: center" >
                                                    @error('reticulocitos')
                                                    <small style="color: red">{{$message}}</small>
                                                    @enderror
                                                </div>
                                            </div>

                                            <div class="col-md-2">
                                                <div class="form-group" style="font-size: small">
                                                    <center> <label for="">Hematozoario </label>
                                                    </center>
                                                    <input type="text" value="{{old('hematozoario')}}" name="hematozoario" class="form-control" style="text-align: center" >
                                                    @error('hematozoario')
                                                    <small style="color: red">{{$message}}</small>
                                                    @enderror
                                                </div>
                                            </div>

                                            <div class="col-md-2">
                                                <div class="form-group" style="font-size: small">
                                                    <center> <label for="">Tp </label>
                                                    </center>
                                                    <input type="text" value="{{old('tp')}}" name="tp" class="form-control" style="text-align: center" >
                                                    @error('tp')
                                                    <small style="color: red">{{$message}}</small>
                                                    @enderror
                                                </div>
                                            </div>


                                            <div class="col-md-2">
                                                <div class="form-group" style="font-size: small">
                                                    <center> <label for="">TTP </label>
                                                    </center>
                                                    <input type="text" value="{{old('ttp')}}" name="ttp" class="form-control" style="text-align: center" >
                                                    @error('ttp')
                                                    <small style="color: red">{{$message}}</small>
                                                    @enderror
                                                </div>
                                            </div>

                                            <div class="col-md-2">
                                                <div class="form-group" style="font-size: small">
                                                    <center> <label for="">Fibrinogeno </label>
                                                    </center>
                                                    <input type="text" value="{{old('fibrinogeno')}}" name="fibrinogeno" class="form-control" style="text-align: center" >
                                                    @error('fibrinogeno')
                                                    <small style="color: red">{{$message}}</small>
                                                    @enderror
                                                </div>
                                            </div>

                                            <div class="col-md-2">
                                                <div class="form-group" style="font-size: small">
                                                    <center> <label for="">Factores Coagulacion II </label>
                                                    </center>
                                                    <input type="text" value="{{old('factores')}}" name="factores" class="form-control" style="text-align: center" >
                                                    @error('factores')
                                                    <small style="color: red">{{$message}}</small>
                                                    @enderror
                                                </div>
                                            </div>










                                        </div>
                                    </div>

                                        <!-- SEGUNDO -->
                                <div class="col-md-12" style="background-color: #c549e1">
                                            <label><b>LAB. QUIMICA SANGUINEA</b></label>
                                </div>

                                <div class="col-md-12">
                                            <div class="row">
                                              
                                                <div class="col-md-2">
                                                    <div class="form-group" style="font-size: small">
                                                        <center> <label for="">Glucosa </label>
                                                        </center>
                                                        <input type="text" value="{{old('glucosa')}}" name="glucosa" class="form-control" style="text-align: center">
                                                        @error('glucosa')
                                                        <small style="color: red">{{$message}}</small>
                                                        @enderror
                                                    </div>
                                                </div>

                                                <div class="col-md-2">
                                                    <div class="form-group" style="font-size: small">
                                                        <center> <label for="">Glucosa Post Prandial </label>
                                                        </center>
                                                        <input type="text" value="{{old('glucosapost')}}" name="glucosapost" class="form-control" style="text-align: center" >
                                                        @error('glucosapost')
                                                        <small style="color: red">{{$message}}</small>
                                                        @enderror
                                                    </div>
                                                </div>

                                                <div class="col-md-2">
                                                    <div class="form-group" style="font-size: small">
                                                        <center> <label for="">Urea</label>
                                                        </center>
                                                        <input type="text" value="{{old('Urea')}}" name="urea" class="form-control"  style="text-align: center">
                                                        @error('urea')
                                                        <small style="color: red">{{$message}}</small>
                                                        @enderror
                                                    </div>
                                                </div>

                                                <div class="col-md-2">
                                                    <div class="form-group" style="font-size: small">
                                                        <center> <label for="">Creatina</label>
                                                        </center>
                                                        <input type="text" value="{{old('creatina')}}" name="creatina" class="form-control" style="text-align: center">
                                                        @error('creatina')
                                                        <small style="color: red">{{$message}}</small>
                                                        @enderror
                                                    </div>
                                                </div>

                                                <div class="col-md-2">
                                                    <div class="form-group" style="font-size: small">
                                                        <center> <label for="">Acido Urico </label>
                                                        </center>
                                                        <input type="text" value="{{old('acidourico')}}" name="acidourico" class="form-control" style="text-align: center" >
                                                        @error('acidourico')
                                                        <small style="color: red">{{$message}}</small>
                                                        @enderror
                                                    </div>
                                                </div>

                                                <div class="col-md-2">
                                                    <div class="form-group" style="font-size: small">
                                                        <center> <label for="">Bilirrubina total </label>
                                                        </center>
                                                        <input type="text" value="{{old('bilirrubina')}}" name="bilirrubina" class="form-control" style="text-align: center" >
                                                        @error('bilirrubina')
                                                        <small style="color: red">{{$message}}</small>
                                                        @enderror
                                                    </div>
                                                </div>

                                                <div class="col-md-2">
                                                    <div class="form-group" style="font-size: small">
                                                        <center> <label for="">Bilirrubina Directa</label>
                                                        </center>
                                                        <input type="text" value="{{old('bilirrubinad')}}" name="bilirrubinad" class="form-control" style="text-align: center" >
                                                        @error('bilirrubinad')
                                                        <small style="color: red">{{$message}}</small>
                                                        @enderror
                                                    </div>
                                                </div>

                                                <div class="col-md-2">
                                                    <div class="form-group" style="font-size: small">
                                                        <center> <label for="">Proteina Totales </label>
                                                        </center>
                                                        <input type="text" value="{{old('proteinas')}}" name="proteinas" class="form-control" style="text-align: center" >
                                                        @error('proteinas')
                                                        <small style="color: red">{{$message}}</small>
                                                        @enderror
                                                    </div>
                                                </div>

                                                <div class="col-md-2">
                                                    <div class="form-group" style="font-size: small">
                                                        <center> <label for="">Alburnina </label>
                                                        </center>
                                                        <input type="text" value="{{old('alburnina')}}" name="alburnina" class="form-control" style="text-align: center" >
                                                        @error('alburnina')
                                                        <small style="color: red">{{$message}}</small>
                                                        @enderror
                                                    </div>
                                                </div>

                                                <div class="col-md-2">
                                                    <div class="form-group" style="font-size: small">
                                                        <center> <label for="">GOT</label>
                                                        </center>
                                                        <input type="text" value="{{old('got')}}" name="got" class="form-control" style="text-align: center" >
                                                        @error('got')
                                                        <small style="color: red">{{$message}}</small>
                                                        @enderror
                                                    </div>
                                                </div>

                                                <div class="col-md-2">
                                                    <div class="form-group" style="font-size: small">
                                                        <center> <label for="">GPT</label>
                                                        </center>
                                                        <input type="text" value="{{old('gpt')}}" name="gpt" class="form-control" style="text-align: center" >
                                                        @error('gpt')
                                                        <small style="color: red">{{$message}}</small>
                                                        @enderror
                                                    </div>
                                                </div>

                                                <div class="col-md-2">
                                                    <div class="form-group" style="font-size: small">
                                                        <center> <label for="">LDH</label>
                                                        </center>
                                                        <input type="text" value="{{old('ldh')}}" name="ldh" class="form-control" style="text-align: center" >
                                                        @error('ldh')
                                                        <small style="color: red">{{$message}}</small>
                                                        @enderror
                                                    </div>
                                                </div>

                                                <div class="col-md-2">
                                                    <div class="form-group" style="font-size: small">
                                                        <center> <label for="">CKNAC</label>
                                                        </center>
                                                        <input type="text" value="{{old('cknac')}}" name="cknac" class="form-control" style="text-align: center" >
                                                        @error('cknac')
                                                        <small style="color: red">{{$message}}</small>
                                                        @enderror
                                                    </div>
                                                </div>

                                                <div class="col-md-2">
                                                    <div class="form-group" style="font-size: small">
                                                        <center> <label for="">CKMB</label>
                                                        </center>
                                                        <input type="text" value="{{old('ckmb')}}" name="ckmb" class="form-control" style="text-align: center" >
                                                        @error('ckmb')
                                                        <small style="color: red">{{$message}}</small>
                                                        @enderror
                                                    </div>
                                                </div>

                                                <div class="col-md-2">
                                                    <div class="form-group" style="font-size: small">
                                                        <center> <label for="">Curva Tolerancia</label>
                                                        </center>
                                                        <input type="text" value="{{old('curva')}}" name="curva" class="form-control" style="text-align: center" >
                                                        @error('curva')
                                                        <small style="color: red">{{$message}}</small>
                                                        @enderror
                                                    </div>
                                                </div>

                                                <div class="col-md-2">
                                                    <div class="form-group" style="font-size: small">
                                                        <center> <label for="">GAMMA GT</label>
                                                        </center>
                                                        <input type="text" value="{{old('gamma')}}" name="gamma" class="form-control" style="text-align: center" >
                                                        @error('gamma')
                                                        <small style="color: red">{{$message}}</small>
                                                        @enderror
                                                    </div>
                                                </div>
                                                <div class="col-md-2">
                                                    <div class="form-group" style="font-size: small">
                                                        <center> <label for="">Fosfatasa Alcalina</label>
                                                        </center>
                                                        <input type="text" value="{{old('fosfatasa')}}" name="fosfatasa" class="form-control" style="text-align: center" >
                                                        @error('fosfatasa')
                                                        <small style="color: red">{{$message}}</small>
                                                        @enderror
                                                    </div>
                                                </div>

                                                <div class="col-md-2">
                                                    <div class="form-group" style="font-size: small">
                                                        <center> <label for="">Fosfatasa Acida</label>
                                                        </center>
                                                        <input type="text" value="{{old('fosfatasaacida')}}" name="fosfatasaacida" class="form-control" style="text-align: center" >
                                                        @error('fosfatasaacida')
                                                        <small style="color: red">{{$message}}</small>
                                                        @enderror
                                                    </div>
                                                </div>

                                                <div class="col-md-2">
                                                    <div class="form-group" style="font-size: small">
                                                        <center> <label for="">Fosfatasa Acida Prostatica</label>
                                                        </center>
                                                        <input type="text" value="{{old('fosfatasapros')}}" name="fosfatasapro" class="form-control" style="text-align: center" >
                                                        @error('fosfatasapro')
                                                        <small style="color: red">{{$message}}</small>
                                                        @enderror
                                                    </div>
                                                </div>
                                                <div class="col-md-2">
                                                    <div class="form-group" style="font-size: small">
                                                        <center> <label for="">Amilasa</label>
                                                        </center>
                                                       <input type="text" value="{{old('amilasa')}}" name="amilasa" class="form-control" style="text-align: center" >
                                                        @error('amilasa')
                                                        <small style="color: red">{{$message}}</small>
                                                        @enderror
                                                    </div>
                                                </div>

                                                <div class="col-md-2">
                                                    <div class="form-group" style="font-size: small">
                                                        <center> <label for="">Lipasa</label>
                                                        </center>
                                                        <input type="text" value="{{old('lipasa')}}" name="lipasa" class="form-control" style="text-align: center" >
                                                        @error('lipasa')
                                                        <small style="color: red">{{$message}}</small>
                                                        @enderror
                                                    </div>
                                                </div>
                                                <div class="col-md-2">
                                                    <div class="form-group" style="font-size: small">
                                                        <center> <label for="">BUN</label>
                                                        </center>
                                                        <input type="text" value="{{old('bun')}}" name="bun" class="form-control" style="text-align: center" >
                                                        @error('bun')
                                                        <small style="color: red">{{$message}}</small>
                                                        @enderror
                                                    </div>
                                                </div>

                                                <div class="col-md-2">
                                                    <div class="form-group" style="font-size: small">
                                                        <center> <label for="">Trigliseridos</label>
                                                        </center>
                                                        <input type="text" value="{{old('trigliseridos')}}" name="trigliseridos" class="form-control" style="text-align: center" >
                                                        @error('trigliseridos')
                                                        <small style="color: red">{{$message}}</small>
                                                        @enderror
                                                    </div>
                                                </div>

                                                <div class="col-md-2">
                                                    <div class="form-group" style="font-size: small">
                                                        <center> <label for="">Colesterol</label>
                                                        </center>
                                                        <input type="text" value="{{old('colesterol')}}" name="colesterol" class="form-control" style="text-align: center" >
                                                        @error('colesterol')
                                                        <small style="color: red">{{$message}}</small>
                                                        @enderror
                                                    </div>
                                                </div>

                                                <div class="col-md-2">
                                                    <div class="form-group" style="font-size: small">
                                                        <center> <label for="">HDL</label>
                                                        </center>
                                                        <input type="text" value="{{old('hdl')}}" name="hdl" class="form-control" style="text-align: center" >
                                                        @error('hdl')
                                                        <small style="color: red">{{$message}}</small>
                                                        @enderror
                                                    </div>
                                                </div>

                                                <div class="col-md-2">
                                                    <div class="form-group" style="font-size: small">
                                                        <center> <label for="">Depuracion de Creatinina</label>
                                                        </center>
                                                        <input type="text" value="{{old('depuracion')}}" name="depuracion" class="form-control" style="text-align: center" >
                                                        @error('depuracion')
                                                        <small style="color: red">{{$message}}</small>
                                                        @enderror
                                                    </div>
                                                </div>
                                            <div class="col-md-2">
                                                    <div class="form-group" style="font-size: small">
                                                        <center> <label for="">Citoquimico de LCR</label>
                                                        </center>
                                                        <input type="text" value="{{old('citoquimico')}}" name="citoquimico" class="form-control" style="text-align: center" >
                                                        @error('citoquimico')
                                                        <small style="color: red">{{$message}}</small>
                                                        @enderror
                                                    </div>
                                                </div>
                                                <div class="col-md-2">
                                                    <div class="form-group" style="font-size: small">
                                                        <center> <label for="">Glucosa Capilar</label>
                                                        </center>
                                                        <input type="text" value="{{old('glucosacapilar')}}" name="glucosacapilar" class="form-control" style="text-align: center" >
                                                        @error('glucosacapilar')
                                                        <small style="color: red">{{$message}}</small>
                                                        @enderror
                                                    </div>
                                                </div>
                                                <div class="col-md-2">
                                                    <div class="form-group" style="font-size: small">
                                                        <center> <label for="">Electrolitos K,NA CL</label>
                                                        </center>
                                                        <input type="text" value="{{old('electrolitos')}}" name="electrolitos" class="form-control" style="text-align: center" >
                                                        @error('electrolitos')
                                                        <small style="color: red">{{$message}}</small>
                                                        @enderror
                                                    </div>
                                                </div>







                                            </div>
                                        </div>

                                <!-- TERCERO -->
                                <div class="col-md-12" style="background-color: #c549e1">
                                        <label><b>LAB. CLINICO AEREOLOGIA E INMUN</b></label>
                                    </div>

                                <div class="col-md-12">
                                        <div class="row">

                                            <div class="col-md-2">
                                                <div class="form-group" style="font-size: small">
                                                    <center> <label for="">Eosinofilos Nasal </label>
                                                    </center>
                                                    <input type="text" value="{{old('nasal')}}" name="nasal" class="form-control" style="text-align: center" >
                                                    @error('nasal')
                                                    <small style="color: red">{{$message}}</small>
                                                    @enderror
                                                </div>
                                            </div>

                                            <div class="col-md-2">
                                                <div class="form-group" style="font-size: small">
                                                    <center> <label for="">Eosinofilos Salival </label>
                                                    </center>
                                                    <input type="text" value="{{old('salival')}}" name="salival" class="form-control" style="text-align: center" >
                                                    @error('salival')
                                                    <small style="color: red">{{$message}}</small>
                                                    @enderror
                                                </div>
                                            </div>

                                            <div class="col-md-2">
                                                <div class="form-group" style="font-size: small">
                                                    <center> <label for="">Eosinofilos Lagrimal </label>
                                                    </center>
                                                    <input type="text" value="{{old('lagrimal')}}" name="lagrimal" class="form-control" style="text-align: center" >
                                                    @error('lagrimal')
                                                    <small style="color: red">{{$message}}</small>
                                                    @enderror
                                                </div>
                                            </div>

                                            <div class="col-md-2">
                                                <div class="form-group" style="font-size: small">
                                                    <center> <label for="">Eosinofilos Faringuea </label>
                                                    </center>
                                                    <input type="text" value="{{old('faringuea')}}" name="faringuea" class="form-control" style="text-align: center" >
                                                    @error('faringuea')
                                                    <small style="color: red">{{$message}}</small>
                                                    @enderror
                                                </div>
                                            </div>

                                            <div class="col-md-2">
                                                <div class="form-group" style="font-size: small">
                                                    <center> <label for="">Anticuerpo Dengue </label>
                                                    </center>
                                                    <input type="text" value="{{old('anticuerpo')}}" name="anticuerpo" class="form-control" style="text-align: center" >
                                                    @error('anticuerpo')
                                                    <small style="color: red">{{$message}}</small>
                                                    @enderror
                                                </div>
                                            </div>

                                            <div class="col-md-2">
                                                <div class="form-group" style="font-size: small">
                                                    <center> <label for="">Leishmaniasis</label>
                                                    </center>
                                                    <input type="text" value="{{old('leishma')}}" name="leishma" class="form-control" style="text-align: center" >
                                                    @error('leishma')
                                                    <small style="color: red">{{$message}}</small>
                                                    @enderror
                                                </div>
                                            </div>


                                        </div>
                                    </div>


                                <!-- CUARTO -->
                                <div class="col-md-12" style="background-color: #c549e1">
                                    <label><b>LAB. CLINICO SEROLOGIA</b></label>
                                </div>

                                <div class="col-md-12">
                                    <div class="row">

                                        <div class="col-md-2">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">VDRL</label>
                                                </center>
                                                <input type="text" value="{{old('vdrl')}}" name="vdrl" class="form-control" style="text-align: center">
                                                @error('vdrl')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-2">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">Reaccion Vidal y Well </label>
                                                </center>
                                                <input type="text" value="{{old('reaccion')}}" name="reaccion" class="form-control" style="text-align: center" >
                                                @error('reaccion')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-2">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">Factor Reumatico (Latex) </label>
                                                </center>
                                                <input type="text" value="{{old('reumatico')}}" name="reumatico" class="form-control" style="text-align: center" >
                                                @error('reumatico')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-2">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">PCR </label>
                                                </center>
                                                <input type="text" value="{{old('pcr')}}" name="pcr" class="form-control" style="text-align: center" >
                                                @error('pcr')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-2">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">ASTO</label>
                                                </center>
                                                <input type="text" value="{{old('asto')}}" name="asto" class="form-control" style="text-align: center" >
                                                @error('asto')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-2">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">Dengue </label>
                                                </center>
                                                <input type="text" value="{{old('dengue')}}" name="dengue" class="form-control" style="text-align: center" >
                                                @error('dengue')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>


                                    </div>
                                </div>

                                <!-- QUINTO -->
                                <div class="col-md-12" style="background-color: #c549e1">
                                    <label><b>LAB. CLINICO UROANALISIS</b></label>
                                </div>

                                <div class="col-md-12">
                                    <div class="row">
                                        <div class="col-md-1">
                                        </div>

                                        <div class="col-md-2">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">EMO Glucosuria y Glucoset </label>
                                                </center>
                                                <input type="text" value="{{old('emogluco')}}" name="emogluco" class="form-control" style="text-align: center" >
                                                @error('emogluco')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-2">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">Proteina en 24H </label>
                                                </center>
                                                <input type="text" value="{{old('proteina')}}" name="proteina" class="form-control" style="text-align: center" >
                                                @error('proteina')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-2">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">Prueba Embarazo Orina </label>
                                                </center>
                                                <input type="text" value="{{old('embarazo')}}" name="embarazo" class="form-control" style="text-align: center" >
                                                @error('embarazo')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-2">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">Microalbuminuria</label>
                                                </center>
                                                <input type="text" value="{{old('microal')}}" name="microal" class="form-control" style="text-align: center" >
                                                @error('microal')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-2">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">Gota fresca GRAM </label>
                                                </center>
                                                <input type="text" value="{{old('gotafresca')}}" name="gotafresca" class="form-control" style="text-align: center" >
                                                @error('gotafresca')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>


                                    </div>
                                </div>


                                <!-- SEXTO -->
                                <div class="col-md-12" style="background-color: #c549e1">
                                    <label><b>LAB. CLINICO COPROLOGIA</b></label>
                                </div>

                                <div class="col-md-12">
                                    <div class="row">
                                        <div class="col-md-1">
                                        </div>

                                        <div class="col-md-2">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">Examen de Heces </label>
                                                </center>
                                                <input type="text" value="{{old('heces')}}" name="heces" class="form-control" style="text-align: center" >
                                                @error('heces')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-2">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">Sangre Oculta Heces </label>
                                                </center>
                                                <input type="text" value="{{old('sangreoculta')}}" name="sangreoculta" class="form-control" style="text-align: center" >
                                                @error('sangreoculta')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-2">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">Poliformonucleares </label>
                                                </center>
                                                <input type="text" value="{{old('poliformo')}}" name="poliformo" class="form-control" style="text-align: center" >
                                                @error('poliformo')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-2">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">Rotavirus </label>
                                                </center>
                                                <input type="text" value="{{old('rotavirus')}}" name="rotavirus" class="form-control" style="text-align: center" >
                                                @error('rotavirus')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-2">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">Helicobacter Pilory Heces </label>
                                                </center>
                                                <input type="text" value="{{old('pilory')}}" name="pilory" class="form-control" style="text-align: center" >
                                                @error('pilory')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>


                                    </div>
                                </div>

                                <!-- SEPTIMO -->
                                <div class="col-md-12" style="background-color: #c549e1">
                                    <label><b>LAB. CLINICO MICROBIOLOGIA</b></label>
                                </div>

                                <div class="col-md-12">
                                    <div class="row">

                                        <div class="col-md-2">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">Fresco Suero </label>
                                                </center>
                                                <input type="text" value="{{old('cologran')}}" name="cologran" class="form-control" style="text-align: center">
                                                @error('cologran')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>
                                        <div class="col-md-2">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">Fresco KOH</label>
                                                </center>
                                                <input type="text" value="{{old('cologran')}}" name="cologran" class="form-control" style="text-align: center">
                                                @error('cologran')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-2">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">Fresco tinta/China</label>
                                                </center>
                                                <input type="text" value="{{old('cologran')}}" name="cologran" class="form-control" style="text-align: center">
                                                @error('cologran')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>


                                        <div class="col-md-2">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">Coloracion Gran</label>
                                                </center>
                                                <input type="text" value="{{old('cologran')}}" name="cologran" class="form-control" style="text-align: center">
                                                @error('cologran')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-2">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">Coloracion Bk</label>
                                                </center>
                                                <input type="text" value="{{old('colobk')}}" name="colobk" class="form-control" style="text-align: center" >
                                                @error('colobk')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-2">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">Coloracion Brigth</label>
                                                </center>
                                                <input type="text" value="{{old('coloracion')}}" name="coloracion" class="form-control"  style="text-align: center">
                                                @error('coloracion')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-2">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">Cultivo Bacterias</label>
                                                </center>
                                                <input type="text" value="{{old('culbacterias')}}" name="culbacterias" class="form-control" style="text-align: center">
                                                @error('culbacterias')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-2">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">Cultivo Hongos </label>
                                                </center>
                                                <input type="text" value="{{old('culhongos')}}" name="culhongos" class="form-control" style="text-align: center" >
                                                @error('culhongos')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-2" >
                                            <div class="form-group"  style="font-size: small">
                                                <center> <label for="">Antibiograma y Cultivo</label>
                                                </center>
                                                <input type="text" value="{{old('tuberulosis')}}" name="tuberculosis" class="form-control" style="text-align: center" >
                                                @error('tuberculosis')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-2">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">Espermatograma </label>
                                                </center>
                                                <input type="text" value="{{old('espermatograma')}}" name="espermatograma" class="form-control" style="text-align: center" >
                                                @error('espermatograma')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-2">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">Serologia Helicobacter </label>
                                                </center>
                                                <input type="text" value="{{old('helicobacter')}}" name="helicobacter" class="form-control" style="text-align: center" >
                                                @error('helicobacter')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-2">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">Hemocultivo </label>
                                                </center>
                                                <input type="text" value="{{old('hemocultivo')}}" name="hemocultivo" class="form-control" style="text-align: center" >
                                                @error('hemocultivo')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-2">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">Serologia Tb </label>
                                                </center>
                                                <input type="text" value="{{old('serologia')}}" name="serologia" class="form-control" style="text-align: center" >
                                                @error('serologia')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>


                                    </div>
                                </div>

                                <!-- OCTAVO -->
                                <div class="col-md-12" style="background-color: #c549e1">
                                    <label><b>LAB. HORMONAL ENDOCRINOLOGIA</b></label>
                                </div>

                                <div class="col-md-12">
                                    <div class="row">

                                        <div class="col-md-2">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for=""> HCG Cuali </label>
                                                </center>
                                                <input type="text" value="{{old('hcg')}}" name="hcg" class="form-control" style="text-align: center">
                                                @error('hcg')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-2">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">B-HCG Cuant </label>
                                                </center>
                                                <input type="text" value="{{old('bhcg')}}" name="bhcg" class="form-control" style="text-align: center" >
                                                @error('bhcg')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-2">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">PCA RAPIDO  </label>
                                                </center>
                                                <input type="text" value="{{old('pcarapido')}}" name="pcarapido" class="form-control"  style="text-align: center">
                                                @error('pcarapido')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-2">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">Antigeno Prostatico  </label>
                                                </center>
                                                <input type="text" value="{{old('antigeno')}}" name="antigeno" class="form-control"  style="text-align: center">
                                                @error('antigeno')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-2" >
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">Fructosamina  </label>
                                                </center>
                                                <input type="text" value="{{old('fructosamina')}}" name="fructosamina" class="form-control"  style="text-align: center">
                                                @error('fructosamina')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-2">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">Hemoglobina Glico </label>
                                                </center>
                                                <input type="text" value="{{old('glicosilada')}}" name="glicosilada" class="form-control"  style="text-align: center">
                                                @error('glicosilada')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                    </div>
                                </div>

                                <!-- NOVENO -->
                                <div class="col-md-12" style="background-color: #c549e1">
                                    <label><b>LAB. BANCO DE SANGRE</b></label>
                                </div>

                                <div class="col-md-12">
                                    <div class="row">

                                        <div class="col-md-2">
                                            <div class="form-group">
                                                <center> <label for=""> HIV (SIDA) </label>
                                                </center>
                                                <input type="text" value="{{old('sida')}}" name="sida" class="form-control" style="text-align: center">
                                                @error('sida')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-2.5">
                                            <div class="form-group">
                                                <center> <label for="">HBSAg (Hepatitis A-B-C) </label>
                                                </center>
                                                <input type="text" value="{{old('hbsag')}}" name="hbsag" class="form-control" style="text-align: center" >
                                                @error('hbsag')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-2">
                                            <div class="form-group">
                                                <center> <label for="">ABO + RH </label>
                                                </center>
                                                <input type="text" value="{{old('aborh')}}" name="aborh" class="form-control"  style="text-align: center">
                                                @error('aborh')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>
                                    </div>
                                </div>

                                <!-- DECIMO -->
                                <div class="col-md-12" style="background-color: #c549e1">
                                    <label><b>OTROS </b></label>
                                </div>

                                <div class="col-md-12">
                                    <div class="row">

                                        <div class="col-md-1">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for=""> Progesterona </label>
                                                </center>
                                                <input type="text" value="{{old('progesterona')}}" name="progesterona" class="form-control" style="text-align: center">
                                                @error('progesterona')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-1">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">Prolactina </label>
                                                </center>
                                                <input type="text" value="{{old('prolactina')}}" name="prolactina" class="form-control" style="text-align: center" >
                                                @error('prolactina')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-1">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">LH  </label>
                                                </center>
                                                <input type="text" value="{{old('lh')}}" name="lh" class="form-control"  style="text-align: center">
                                                @error('lh')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-1">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">FSH  </label>
                                                </center>
                                                <input type="text" value="{{old('fsh')}}" name="fsh" class="form-control"  style="text-align: center">
                                                @error('fsh')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>
                                        <div class="col-md-1" >
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">Cortisol  </label>
                                                </center>
                                                <input type="text" value="{{old('cortisol')}}" name="cortisol" class="form-control"  style="text-align: center">
                                                @error('cortisol')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-1">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">TSH  </label>
                                                </center>
                                                <input type="text" value="{{old('tsh')}}" name="tsh" class="form-control"  style="text-align: center">
                                                @error('tsh')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>
                                        <div class="col-md-1">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">T3  </label>
                                                </center>
                                                <input type="text" value="{{old('t3')}}" name="t3" class="form-control"  style="text-align: center">
                                                @error('t3')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-1">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">T4  </label>
                                                </center>
                                                <input type="text" value="{{old('t4')}}" name="t4" class="form-control"  style="text-align: center">
                                                @error('t4')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-1">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">Testesterona  </label>
                                                </center>
                                                <input type="text" value="{{old('testosterona')}}" name="testosterona" class="form-control"  style="text-align: center">
                                                @error('testosterona')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-1">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">Troponina I</label>
                                                </center>
                                                <input type="text" value="{{old('troponina')}}" name="troponina" class="form-control"  style="text-align: center">
                                                @error('troponina')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-1">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">Procalcitonina  </label>
                                                </center>
                                                <input type="text" value="{{old('procalcitonina')}}" name="procalcitonina" class="form-control"  style="text-align: center">
                                                @error('procalcitonina')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-1">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">Ferritina  </label>
                                                </center>
                                                <input type="text" value="{{old('ferritina')}}" name="ferritina" class="form-control"  style="text-align: center">
                                                @error('ferritina')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-1">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">Alfa-Fetroproteina</label>
                                                </center>
                                                <input type="text" value="{{old('alfa')}}" name="alfa" class="form-control"  style="text-align: center">
                                                @error('alfa')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-1">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">CEA  </label>
                                                </center>
                                                <input type="text" value="{{old('cea')}}" name="cea" class="form-control"  style="text-align: center">
                                                @error('cea')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-1">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">CK-MB  </label>
                                                </center>
                                                <input type="text" value="{{old('ckmb')}}" name="ckmb" class="form-control"  style="text-align: center">
                                                @error('ckmb')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-1">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">PCR alta Sensibilidad  </label>
                                                </center>
                                                <input type="text" value="{{old('pcr')}}" name="pcr" class="form-control"  style="text-align: center">
                                                @error('pcr')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>

                                        <div class="col-md-1">
                                            <div class="form-group" style="font-size: small">
                                                <center> <label for="">Ige en Sangre  </label>
                                                </center>
                                                <input type="text" value="{{old('igsangre')}}" name="igsangre" class="form-control"  style="text-align: center">
                                                @error('igsangre')
                                                <small style="color: red">{{$message}}</small>
                                                @enderror
                                            </div>
                                        </div>


                                    </div>
                                </div>

                                <!-- BOTONES-->
                                    <div class="col-md-12">
                                        <div class="row">
                                            <br>
                                                <div class="col-md-8">
                                                    <div class="form-group">
                                                        <a href="{{url('admin/pacientes')}}" class="btn btn-secondary">Cancelar</a>
                                                        <button type="submit" class="btn btn-primary">Guardar Pedido Lab</button>
                                                    </div>
                                                </div>
                                        </div>
                                    </div>
                            </div>

                        </form>
                    </div>
            </div>
        </div>
    </div>
@endsection