Download Neurological consultation - (SMA) Clinical Research Center

Pediatric Neuromuscular Center
The Neurological Institute of New York
Children’s Hospital of New York
Columbia Muscular Dystrophy Association (MDA) Clinic
Columbia Spinal Muscular Atrophy (SMA) Center
Neuromuscular and Neurological Consultation
Darryl C. De Vivo, MD, Director
Petra Kaufmann, MD, MSc, Associate Director
Juan M. Pascual, MD, PhD, Attending Physician
Maryam Oskoui, MD, Pediatric Neuromuscular Fellow
Leslie Disla, BA, Center Coordinator
Tel (212) 342-0263
Fax (212) 342-2893
[email protected]
www.columbiasma.org
F O R
O F F I C E
NAME:
Marc C. Patterson, MD, FRACP, Divisional Director
U S E O N L Y
Physician(s) (initials): _____________
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□First visit
MRN: __ __ __ __ __ __ __
Date of birth: _ _|_ _|_ _ _ _
Dictation
5-4373 or 800.694.8704
Your physician ID (eg 1/2 0842#)
Work type 5
Dictated by: _______________
Dictated on: _______________
Job#
_______________
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□Followup
Date of visit: _ _|_ _|_ _ _ _
Diagnosis, plan, signature on page 7
START
HERE
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Patient and Family Provided Information
INSTRUCTIONS: Please complete all fifteen (15) sections of this form (PAGES 1 to 3 ONLY). If you are unsure of
an answer, please write ‘unsure’. If a condition is not present or did not occur, please write ‘No’ or ‘None’. You must
call the office at a later time to give any missing information. Thank you.
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1.
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MAIN REASON for this visit using your own words; for example ‘speech impairment and weak eyelids’:
_______________________________________________________________________________________________________________________________________________________________________________________________
2.
GENERAL INFORMATION
Name of the patient
Date of Birth (Month/day/year)
Patient’s occupation or school grade
AGE:
Contact information:
Name of parent(s) or guardian(s)
Street address and apartment number
City, State and Zip code
Telephone and fax number(s) (home and cell)
e-mail
Father’s name, occupation, work phone number
Mother’s name, occupation, work phone number
HOME: (
)
CELL: (
)
Referring physician:
Name (First and Last)
Street address (including office/suite number)
City, State and Zip code
Telephone and fax number (s)
e-mail
First:
TEL:(
Last:
)
FAX:(
)
3.
ALLERGIES or adverse effects from medicines. Write ‘None’ if there is no history of such events
Name of drug or substance
Effect (e.g. rash, asthma)
Date of event(s)
4.
MEDICATIONS (Past and Present) List all prescribed medications, including dose and times; also list all
vitamin, herbal and dietary supplements and other substances including caffeine and alcohol
Name
Dose
Started
Ended (note if current)
Continue here if needed:
Division of Pediatric Neurology  Columbia University Medical Center
180 Fort Washington Avenue, 5th Floor  New York, NY 10032
© 2004-2005
Chart page 1 of 11
NAME:
MRN:
DOB:
□Up-to-date
□Not up-to-date; reason:
DATE:
5.
6.
IMMUNIZATIONS
7.
REVIEW OF SYSTEMS
(Place a check mark in the ‘Normal’ column if there the patient has no symptoms referable to that system; circle
any symptoms that are present and add comments or additional symptoms in ‘Comments’. Use extra space
below table, if needed)
________________________________________________________________________________________
SOCIAL HISTORY (Who does the child live with? Please describe your family’s circumstances (all individuals
living in the household and their relationships to the patient and each other)
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Approximate weight:
Normal
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_______________________________________
System
Constitutional
Eyes
Ears, nose and
throat
Respiratory
Cardiovascular
Gastrointestinal
Approximate height:
_______________________________________
Symptoms
Fever, weight loss, fatigue, recurrent infection, unusual odors of body fluids
Double vision, loss of visual acuity, blurring, cataracts, strabismus, need for
glasses
Hearing loss, ringing in the ears, vertigo, aural (ear) discharge, infections,
congestion, hoarse voice, difficulty swallowing, dental symptoms
Shortness of breath, wheeze, cough, coughing up blood, blue discoloration,
altered pattern or breathing.
Chest pain, abnormal rate or rhythm, abnormal blood pressure, shortness of
breath, swelling of ankles.
Diarrhea, constipation, nausea, vomiting, rectal bleeding, black, tarry bowel
motions, weight loss or gain, jaundice, specific food intolerance or aversion
Genitourinary
Integumentary
Musculoskeletal
Psychiatric
Endocrine
Hematological
and lymphatic
Allergic
Blood in the urine, pain on urination, loin pain, impotence
Dark or light patches on the skin, rash, changes in hair or nails
Joint pain or swelling, small lumps under the skin, skeletal deformities
Mood changes, delusions, hallucinations
Symptoms of thyroid, adrenal, islet cell, parathyroid disease
Pale appearance, loss of energy, enlargement of lymph nodes, abnormal
bleeding or clotting
Running nose, eyes, or skin redness or swelling
Neurological
Abnormalities of higher function (including speech and language), strength,
coordination, sensation, development; seizures or other spells; headaches
Comments
Other symptoms not listed above:
8.
*
PRENATAL AND BIRTH HISTORY. Check ‘normal’ or ‘N/A’ or record details, except for items marked with ,
which require an answer. Use extra space at the end of table if needed.
Normal
Details (if abnormal or present)
Pregnancy and delivery:
or N/A
* Length of pregnancy (weeks)?
* Folic acid before conception?
Infections
X-rays, radiation exposure or therapy
* Use of antenatal vitamins and iron?
Prescribed medications
Alcohol, Tobacco, Other drugs
Diabetes or blood sugar
Blood pressure
* Length of labor (hours)
Did the child move normally during the
entire pregnancy?
* Delivery method (vaginal, vacuum
extraction, forceps, Caesarian section)
* Place of delivery (Hospital, City)
* Birth weight
Apgar scores (if known)
Any other difficulties? Please explain:
Division of Pediatric Neurology  Columbia University Medical Center
180 Fort Washington Avenue, 5th Floor  New York, NY 10032
Chart page 2 of 11
NAME:
MRN:
DOB:
9.
DATE:
DEVELOPMENT: Please check ‘normal’ if he or she attained the milestones in the range indicated; otherwise
record the time the milestone was attained with any comments
Milestones [usual range for term infants]
Normal Time achieved otherwise
Regards (looks at) toy
Transfers hand to hand
Knows own name, babbles – ‘ba, ma, ga’
Reaches with one hand
Pincer grasp
Sits alone at least 10-30 seconds
Points to nose on request, says ‘mama, dada’
Walks alone
List any concerns:
[newborn]
[5 –6 months]
[5-7 months]
[4-7 months]
[7-12 months]
[5-8 months]
[8-12 months]
[9-17 months]
10. SCHOOL PERFORMANCE. Record current and past grades, indicating areas of strength and weakness
11. BEHAVIOR, MOOD AND SOCIAL INTERACTIONS (describe any concerns)
12. HOSPITALIZATIONS AND MAJOR illnesses/ injuries/ surgery/ procedures/ biopsies
Date/ age
Hospitalization/ illness/ injury/ surgery/ procedure
Treating physician/hospital
13. FAMILY HISTORY. Include illnesses, including neurologic, learning, mental, psychiatric or behavioral
problems. Please include deceased members of the family, with age and cause of death where known
Name (s)
Age (s)
Illnesses
Relationship
Brothers and sisters
Mother
Father
Mother’s father
Mother’s mother
Father’s father
Father’s mother
Others
14. USE OF ASSISTIVE DEVICES AND THERAPIES (please, complete only if currently used) □Not used
Underline or write all the devices that are used at the present time:
Stander
Walker
Wheelchair
BiPAP
Suction
Braces
Home care
Physical therapy
Other:
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Mechanical ventilation
Occupational therapy
Please specify if any of the above needs refitting or adjustment and where it was done last time:
15. PLEASE READ AND SIGN:
I hereby authorize direct payment of medical benefits to physician(s) affiliated with the Pediatric MDA/SMA
Neuromuscular Center for medical services rendered. I understand that I am financially responsible for any
balance not covered by insurance. I hereby authorize the Pediatric MDA/SMA Neuromuscular Center to
release any medical or incidental information that may be necessary for either medical care or in processing
applications for financial benefits.
Signature: ____________________ Your name: ______________________ Relationship: __________________ Date:____________
END of Patient and Family Provided Information
Please do not write on any other sections of this form. Thank you.
Physician review and signature:
_________________
Division of Pediatric Neurology  Columbia University Medical Center
180 Fort Washington Avenue, 5th Floor  New York, NY 10032
Chart page 3 of 11
Present today: □Patient □Father □Mother
Chief complaint or reason for consultation:
□Other:
History of present illness: □ No hand preference
NAME:
MRN:
DOB:
DATE:
□ Right-handed □ Left-handed □ Ambidextrous
Family structure, descent and additional history: Consanguinity?: □None known
□Other:
Division of Pediatric Neurology  Columbia University Medical Center
180 Fort Washington Avenue, 5th Floor  New York, NY 10032
Chart page 4 of 11
NAME:
MRN:
DOB:
DATE:
Review of data, documents and communications §NOTE: All items checked have also been summarized in detail in the HPI
□ CUMC medical records,
pages.
□Outside medical records/ notes/ reports,
pages. Type:
□E-mail,
pages. To/from and regarding:
□Telephone calls,
(number). To/from and regarding:
□Imaging reports, type(s) and findings:
□Personal review of images, type(s) and findings:
□Analytes, total number of results reviewed: _____, and selected relevant values:
□Muscle biopsy report:
□EEG:
□EMG/NCV:
□Other:
Physical examination
□ Well formed □ Well-appearing
□ Other:
Head circumference: _______ cm §NOTE: Averages: Birth: 35cm|3m: 40cm|9m:45cm|3y:50cm|9y:55cm
W: ________ (
%) L: ________ (
%) HR: _____ bpm RR: _____ bpm BP: ________mmHg
§ Check boxes if examined and normal. Leave unchecked and specify if abnormal
Skin:
HEENT:
Respiratory:
Cardiovascular:
Gastrointestinal:
Endocrine:
Hematopoietic:
Genitourinary:
Musculoskeletal:
Other:
□ Limbs, trunk, head and neck: normal
□ Hair and nails: normal
□ Head: normal
□ Nose, ears and throat: normal
□ Shape and expansion: normal
□ Air entry: normal
□ Trachea: normal
□ Apex beat: normal
□ Heart sounds: normal
□ JVP: normal
□ Abdomen: normal
□ Peripheral signs: normal
□ Thyroid gland: normal
□ Pigmentation: normal
□ Secondary sexual characteristics: normal
□ Lymph nodes: normal
□ Liver and Spleen: normal
□ Coagulation: normal
□ External genitalia
□ Skeleton: normal
□ Joints: normal
Division of Pediatric Neurology  Columbia University Medical Center
180 Fort Washington Avenue, 5th Floor  New York, NY 10032
Chart page 5 of 11
NAME:
MRN:
DOB:
Neurological examination
§ Check boxes if examined and normal. Leave unchecked and specify if abnormal
A. Higher Functions :
□Behavior
□Awareness of surroundings
□Comprehension □Fund of knowledge
Findings:
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DATE:
□Fluency
B. Cranial nerves :
□ I (Olfactory): normal.
□ II (Optic: VA: normal; Fields: normal to confrontation; Fundi: normal without dilatation)
□ III, IV, VI (ocular motor): external ocular movements: full; saccades: normal; pursuit: normal
□ Pupils: equal, round, react directly and consensually to light.
□ V (Trigeminal): sensation: normal; corneals: normal; Motor: normal; Jaw jerk: normal.
□ VII (Facial): normal strength and symmetry of facial expression
□ VIII (Auditory): auditory acuity: normal
□ IX, X (Glossopharyngeal, Vagus): pharyngeal sensation: normal; pharyngeal gag: normal
□ XI (Accessory): sternomastoids: normal; trapezii: normal
□ XII (Hypoglossal): tongue bulk, movement and strength: normal
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Findings:
C. Sensation :
Findings:
□ Light touch, vibratory sense and temperature: normal
D. Motor :
Findings:
□ Muscle bulk:
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normal; Tone: normal; Power: normal; Gowers sign absent
□ normal
or
findings (if abnormal):
F. Plantar responses : □ flexor
G. Gait and stance : □ normal
or
or
Babinski sign (R | L)
findings (if abnormal):
E. Reflexes :
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H. Other findings :
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SYNDROMIC DIAGNOSIS (§ Summarize findings here regardless of etiology. For example: “progressive ataxia with cardiomyopathy
and optic atrophy” or “severe weakness sparing the face with onset at 4 months and normal intelligence” )
Division of Pediatric Neurology  Columbia University Medical Center
180 Fort Washington Avenue, 5th Floor  New York, NY 10032
Chart page 6 of 11
NAME:
MRN:
DOB:
DATE:
Physician (name) ___________________(signature)_________________________
Impression:
Supported (§ check all that apply):
□By muscle biopsy
□Other:
Additional diagnoses:
□Clinically
□Genetically
□Resident □Fellow □Attending
□By imaging
At risk for:
□Respiratory failure
□Ambulatory disability
□Joint contractures
Other:
Plan:
1. To be seen again: □after tests completed
□in
month(s)
2. NEURORADIOLOGY MRI REQUISITION: fill in all fields:
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Test(s) Ordered:
Analysis of:
Biopsy of:
10.□ EEG
11.□
□ if and when needed
DOB:
Contact:
Signature:
Diagnosis with ICD9
What are you ruling
out?
Previous Studies here
Relevant Medications
Sedation Required
Anesthesia Required
Reason for
Anesthesia
□Scoliosis
□Cardiopathy
□Pneumonia
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Patient Name:
Requesting Physician:
Brain MRI
Cervical MRI
Thoracic MRI
L/S MRI
Brain MRS 76390
Brain MRV
Brain MRA
Neck MRA
Face, Orbit & Neck
Other (please detail)
yes
□Analytically
Extension 2-0263
Without Contrast
MRN:
Extension 2-6867
With and Without
Contrast
70551
72141
72146
72148
70553
72156
72157
72158
70544
70544
70547
70540
70546
70546
70549
70543
no
yes
no
yes
no
Unable to cooperate due to
immature physiology
Other (please describe)
3.□ Blood
4.□ Urine
5.□ Cerebrospinal fluid (CSF)
6.□ Muscle 7.□ Nerve
8.□ Skin
9.□ Rectum
Echocardiogram 12.□ EKG 13.□ Spine X-rays 14.□ Pulmonary function
15.□Other tests:
16. Referrals: □Social work □PT □OT □ST □Orthopedic surgery □Neurosurgery □Ophthalmology
□Cardiology □Rehabilitation □Pulmonology □Dietician □Psychiatry □Genetics □Other:
17. Medications: □No change; refills made available.
□Changes or new medications:
I discussed with caretakers and patient: □Diagnoses □Cause(s) □Inheritance □Severity □Prognosis □Degree of
□
□
□
□
□
□
certainty for all of these.| Lifestile Treatment Alternative(s) Side effects.| Followup plans Reason for each of the Plan
items. | QUESTIONS ENCOURAGED AND ANSWERED.| ALL OF THESE WERE EXPLICITLY UNDERSTOOD AND AGREED ON.
□
□
Division of Pediatric Neurology  Columbia University Medical Center
180 Fort Washington Avenue, 5th Floor  New York, NY 10032
Chart page 7 of 11
Birth to 36 months NAME:
Weight, length, OFC MRN:
DOB:
Division of Pediatric Neurology  Columbia University Medical Center
180 Fort Washington Avenue, 5th Floor  New York, NY 10032
Chart page 8 of 11
DIVISION OF PEDIATRIC NEUROLOGY
COLUMBIA UNIVERSITY MEDICAL CENTER
LABORATORY REQUISITION FORM
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NAME:
MRN:
DOB:
DATE:
Contact : extension □2-6867 or □2-0263 Physician name and signature:____________________________________
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THIS IS FORM PAGE 1 OF 2. PLEASE CHECK PAGE 2 FOR ADDITIONAL TESTS NOT LISTED ON THIS PAGE
Order Code
Blood Tests
AMMON
LACV
PYRV
HEXD
BMET
□
□
□
□
□
LIFP
□
MG
UA
AAF
VLCFA
CARNTF
FATTY
BIOTN
CDTRAN
□
□
□
□
□
□
□
□
ATIII
TBGL
GLIADN
CK
no code
COPR
CERU
ACHRB
ACHRBL
ACHRM
AYO
AHU
ANN2
SPE
QI
IGGSUB
AFP
TOXOG
HSVG
RUBG
RPR
LIPID
RBCFL
VITB12
VTE
7DH
T4C
TSH
need new code
BLOOD,OTHER:
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
Test Name
Specimen Requirements
Ammonia
Lactate
Pyruvate
CBC with Diff
BMET (Na,K,Cl,CO2,BUN,
Glucose, Creatinine, Ca)
Hepatic Function Panel
(TP,Alb,TBili,DBili,AST,ALT,AlkP)
Magnesium
Uric Acid
Amino Acids, Quant.
Very Long Chain Fatty Acids
Total and Free Carnitine
Free Fatty Acids
Biotinidase
Carbohydrate Deficient
Transferrin
Anti-Thrombin III
TBG
Gliadin Ab
CK
Lead, Pediatric
Copper
Ceruloplasmin
ACHR AB, BINDING
ACHR AB, BLOCKING
ACHR AB, MODULATING
Anti-Purkingie
Anti-Neuronal Ab, Type 1
Anti-Neuronal Ab, Type 2
PROTEIN ELECTROPHORESIS
IMMUNOGLOBULINS, (G,A,M)
IGG SUBCLASSES
ALPHA-FETOPROTEIN
Toxo IgG Abs
HSV Abs
Rubella Abs
RPR
Lipid Panel
RBC Folate
B12
Vitamin E
7-Dehydrocholesterol
T4
TSH
TPO Antibodies
Li Heparin (Green on Ice)
Li Heparin (Green on Ice)
Li Heparin (Green on Ice)
EDTA Whole Blood
Serum (Gold Top)
Comments
Serum (Gold Top)
Serum (Gold Top)
Serum (Gold Top)
Li Heparin (Green on Ice)
EDTA Plasma
Red on Ice, Freeze Serum
Red on Ice, Freeze Serum
Red on Ice, Freeze Serum
Serum (Gold Top), Freeze
Serum
Na Citrate (Blue Top)
Serum (Gold Top)
Serum (Gold Top)
Serum (Gold Top)
EDTA Whole Blood
Royal Blue, Metal Free
Serum (Gold Top)
Serum
Serum
Serum
Serum
Serum
Serum
Serum
Serum
Serum
Serum
Serum (Gold Top)
Serum (Gold Top)
Serum (Gold Top)
Serum (Gold Top)
Serum (Gold Top)
EDTA Whole Blood
Serum (Gold Top)
Serum (Gold Top)
EDTA, Freeze Plasma
Serum (Gold Top)
Serum (Gold Top)
Serum (Gold Top)
Division of Pediatric Neurology  Columbia University Medical Center
180 Fort Washington Avenue, 5th Floor  New York, NY 10032
Chart page 9 of 11
DIVISION OF PEDIATRIC NEUROLOGY
COLUMBIA UNIVERSITY MEDICAL CENTER
LABORATORY REQUISITION FORM
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NAME:
MRN:
DOB:
DATE:
T HIS I S FO R M P AG E 2 O F 2 . S EE P AG E 1 FO R CO NT ACT INFO RM AT IO N
Order Code
GENETIC TESTS
Cytogenetic Req
□
□
Test Name
Specimen Requirements
Comments
Na Heparin (Tan Top)
6 ml EDTA Room Temp--sent Baylor in Houston, Tx + Baylor Requisition +
Baylor Genetics Form
Na Heparin (Tan Top) , Freeze Plasma--send to Dr. Shanske's Lab (5-1663)
No Code
Cytogenetic Req
Cytogenetic Req
□
□
□
Cytogenetic Req
Cytogenetic Req
□
□
□
Karyotype
MECP2 Genotype (Rett's
Syndrome)
Dystrophin
Williams Syndrome
Prader-Willie-Angelman
Syndrome
Smith-Magenis Syndrome
FISH for Subtelomeric Regions
FRAGILE X (FMR)
□
SCA PANEL
□
SMA (SMN GENE)
□
□
□
□
□
□
Cell Count
Glucose/Total Protein
IgG Index
Oligoclonal Bands
Amino Acids
Biogenic Amines
□
Lactate
CSF
CSF
CSF + 1 ml Serum
2 ml CSF, Frozen
1 ml CSF Frozen
CSF in Special Collection Kit to Baylor, Dallas, Texas + Baylor Requisition +
Baylor Consent Form
CSF
□
□
□
□
□
□
□
□
□
□
Sulfites
Organic Acids
Oligosaccharides
Gycoaminoglycans
Heavy Metals
Uric Acid
Catecholamines
VMA
HVA
PURINE AND PYRIMIDINE
PANEL
Dipstick test on fresh urine
10 ML Random Urine
10 ML Random Urine
10 ML Random Urine
24 Hour Urine, 50 ML Aliquot
24 Hour Urine, 50 ML Aliquot
24 Hour Urine, 10 ML Aliquot
24 Hour Urine, 10 ML Aliquot
10 ML Random Urine
3 ml Random Urine FROZEN
Mayo 81420
□
□
□
□
□
□
□
□
CARBAMAZEPINE
FELBAMATE
PHENYTOIN
PHENOBARBITAL
PRIMIDONE
VALPROIC ACID
FREE VALPROIC ACID
LAMOTRIGINE
LiHeparin (Green)
Serum
LiHeparin (Green)
LiHeparin (Green)
Red/ Serum
Serum
Red/ Serum
EDTA
CSF Tests
HCSF
GLTP
CSFIN
OLIGOC
AACSF
BIOAM
2 ACD Room Temp
Mayo 9569
2 ACD Room Temp
Mayo 80941
10 ml EDTA Room Temp
Mayo to Athena
Plus Mayo Req and GENETICS
FORM
Plus Mayo Req and GENETICS
FORM
Urine Tests
OAU
OLIGOU
GAGS
HMP24
UUA24
CATE24
UVMA24
HVA
URINE, OTHER:
Antiepileptic
drugs
CRBM
FEL
PYTN
PHEN
PRIM
VALP
VALF
LAM
OTHER TESTS:
Division of Pediatric Neurology  Columbia University Medical Center
180 Fort Washington Avenue, 5th Floor  New York, NY 10032
Chart page 10 of 11
Division of Pediatric Neurology  Columbia University Medical Center
180 Fort Washington Avenue, 5th Floor  New York, NY 10032
Chart page 11 of 11