Fondazione FONAMA fonama@fonama.org Telefono 335250742

Neuromuscular  Traduzione di Natale Marzari

Home, Ricerca, Indice alfabetico, Collegamenti, Patologia, Molecole, Sindromi, Muscoli,

Giunzioni neuromuscolari, Nervi, Spinale, Atassia, Anticorpi e Biopsia, Informazioni per i pazienti

 

LABORATORIO della CLINICA NEUROMUSCOLARE
    Neuromuscolare Malattia Center
    Department of Neurology
    Washington University School of Medicine 		Campus Box 8111, Room IWJ 404
660 South Euclid Avenue; St. Louis, MO 63110
Phone: 314-362-6981; Fax: 314-362-2826

paziente Name (Last, First, Initials):___________________________________________
Diagnosi clinica: _____________________________________________________
Esami medici richiesti: _____________________________ UPIN# ____________
Referring hospital: _____________________________________________________
Name e indirizzo per il referto e/o charges ______________________________________________________
                                                                      ___________________________________________________________
Vedi: Istruzioni; Stampabile form ||   ___________________________________________________________
 ===========================================================================
ESAMI DEGLI ANTICORPI e INTERPRETAZIONI RICHIESTE

Sindrome Panels Individual anticorpi
[ ] Neuropatia motoria
        IgM vs. Co-GM1, asialo-GM1; NP-9;   IgG vs. GM1; GalNAc-GD1a
 [ ] Motorio: Co-GM1; GM1 (IgM e IgG); NP-9 (IgM)
???????????????? GalNAc-GD1a (IgG)
  Neuropatia
[ ] MAG (IgM)                          [ ] SGPG (IgM)
[ ] GALOP Antigen (IgM)
[ ] Solfatidici (IgM e IgG)
[ ] GD1b (IgM)                        [ ] GQ1b (IgG)
[ ] β-Tubulina (IgM e IgG)      [ ] GT1a (IgG)
[ ]?Heparan Sulfate (IgM)
[ ]?Trisulfated Heparin Disaccharide (TS-HDS)
[ ] Sensoria (e#177; Motorio) Neuropatia
        IgM vs. MAG, GalNAc-GD1a e Solfatidici;   IgG vs. Solfatidici
 
[ ] Neuropatia periferica
        Motorio e Neuropatia sensoria Panels
 
[ ] Sensoria Neuropatia/Neuropatia
        IgM vs. Solfatidici, GD1b, GalNAc-GD1a; IgG?vs. Solfatidici, Hu
 Paraneoplastico (IgG)
    [ ] Hu; [ ] Yo;? [ ] Ri; [ ] Tr
    [ ] Cerebellare immunoColorazioneing
 
[ ] Neuropatia demielinizzante
        IgM vs. MAG, GM1, GalNAc-GD1a, β-Tubulina;   IgG? vs. β-Tubulina
 Altro IgM:? [ ] GM2;? [ ] GD1a; [ ] asialo-GM1;
    [ ] Z-MAG; ?[ ] Decorin; [ ] Chondroitin solfato;
    [ ] Histone H3;? [ ] AHS; [ ] GalNAc-GD1a
 
[ ] Acuta Neuropatia:? IgM vs. GM1, β-Tubulina, Heparan solfato
        IgG vs. GM1, GQ1b, GD1a, GalNAc-GD1a; β-Tubulina
 Altro IgG:? [ ] GalNAc-GD1a; [ ]?Heparan Sulfate;
                    [ ] Lysoganglioside-GM1
  [ ] Autism/Landau-Kleffner Sindrome variante
[ ] Miopatia: IgM vs. Decorin
 Altro: [ ] _________________________
 
NOTA: Please send 3 a 5 cc di siero dal clotted blood
========================================================================================
paziente Informazioni
paziente Signature: __________________________________________(For rilascio of information)
Età? ____? | Sex? ____ | Nascita Date ______________ | Sample Date_______________ | Specimen #____________
=======================================================================================
Address: ________________________________________________________
City/State/ZIP: ____________________________________________________
Telephone numero: ________________________| Social Security #: _____________________________
========================================================================================
Medicare # e Suffix:? _________________________________| In name of: _____________________________
Missouri Medicaid Recipient # (8 digits): _________________________ | In name of: _________________________
========================================================================================
Subscriber name:_________________________________________________
Commercial insurance company: __________________________________________________________
Mailing indirizzo: _______________________________________ City/State/ZIP: _________________________
Employer: __________________________________________________ Employer phone: ____________________
Certificate/ID/SS #: _________________________?Gruppo #:? ________________
Subscriber signature: __________________________________ (For assignment of benefits)             (Rev 10/03 AP)


Va a Acronimi e sigle

Va a Mitolario in italiano

Va a Mitolario italiano - inglese

Va a Mitolario inglese - italiano

Ritorno a Fonama.org Home Page