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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): _____________ U □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# _______________ U □Followup Date of visit: _ _|_ _|_ _ _ _ Diagnosis, plan, signature on page 7 START HERE U 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. U 1. U 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) U Approximate weight: Normal U _______________________________________ 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: U U 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: U U 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 U U Findings: C. Sensation : Findings: □ Light touch, vibratory sense and temperature: normal D. Motor : Findings: □ Muscle bulk: U U U U 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 : U U U U U U H. Other findings : U U 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: U 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 U 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 U NAME: MRN: DOB: DATE: Contact : extension □2-6867 or □2-0263 Physician name and signature:____________________________________ U U 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 U 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