NEUROMUSCULAR TEST PRESCRIPTION FORM 2

Myasthenia Gravis
      Antibodies
            [ ] Acetylcholine receptor, Binding (Send to Mayo Clinic); [ ] MuSK (Send to Athena)
            Muscle: [ ] Striational
      Systemic: [ ] Thyroid battery and TSH; [ ] Creatine kinase (CK); [ ] Aldolase
      Other: [ ] Vital capacity
      Repetitive nerve stimulation: [ ] 3 per second, Proximal & Facial

Myasthenic Syndrome (Lambert-Eaton)
      [ ] Repetitive nerve stimulation: Rapid
      [ ] Anti-P/Q Calcium channel Antibodies (send to Mayo Clinic)

Polymyositis
      [ ] Creatine kinase (CK);  [ ] Aldolase
      [ ] Myositis specific antibodies: From Oklahoma Medical Research Laboratory
      Connective tissue disease: [ ] ANA battery; [ ] ENA
      [ ] Muscle biopsy_______________; [ ] Nerve biopsy_________________
      EMG, NCV, Imaging: Use separate requisition form

Other Immune
Stiffman syndrome antibodies (send to Mayo Clinic): [ ] Anti-GAD; [ ] Anti-Amphiphysin
Isaac's syndrome antibodies (send to Mayo Clinic): [ ] Anti-Potassium channel

General testing
      [ ] CBC; [ ] Basic metabolic panel; [ ] Comprehensive metabolic panel; [ ] Hemoglobin A1C
      [ ] Creatine kinase;  [ ] Aldolase; [ ] Thyroid panel with TSH
      [ ] Autism/Landau-Kleffner Syndrome variant
      Metabolic myopathy testing: [ ] Lactate; [ ] Pyruvate; [ ] Organic acids; [ ] Acylglycine, Urine;
        [ ] Carnitine panel (Total, Free, Acylcarnitine); [ ] Plasma acylcarnitine profile
      Biopsy testing: [ ] Mitochondrial panel; [ ] Immune myopathy panel; [ ] Glycogen pathway

Genetic testing
    Baylor: SMA 5q & Bulbar; DMD; FA; Myotonic Dystrophy; SCA (1-7)
    Boston University: DMD; FA; HNPP; Myotonic Dyst; NF-1; Paraganglioma; SCA 1-3,6-8; SMA 5q & Bulbar
    Colorado: Lamin A/C
    Iowa: FSH, Carnitine disorders; Also research Congenital MD, CPT II, LGMD
    Mass General: Periodic paralysis; HSN; SOD
    Ohio State: DMD; Mitochondrial; Myotonic Dystrophy; SMA 5q & Bulbar
    Athena: ALD; ALS/SOD1; AMPDA; CMT 1A, 1B, 4E, 4F, X, HNPP; COX; DMD; FSH; Glycogen; Mitochondrial;
        Myotonic Dystrophy 1 & 2; NF2; OPMD; Refsum; SCA 1-3, 6-8, 10, 17; SMA 5q & Bulbar; Transthyretin
    Utah: Dystrophin & Dysferlin gene sequencing

Neuromuscular Division
Washington University
IWJ Room 404
Box 8111, Neurology
660 South Euclid Avenue
St. Louis, MO 63110
Phone: 314-362-6981
Fax: 314-362-3752
Muscle biopsy testing (Washington University)
  Dystrophy-related Muscle proteins
    [ ] Dystrophy panel
    [ ] Dystrophin; [ ] Sarcoglycans: α, β, γ, δ; [ ] Dysferlin; [ ] Desmin;
    [ ] Caveolin; [ ] Emerin; [ ] Laminin α2; [ ] Laminin B; [ ] α-Dystroglycan; [ ] IgM deposition
    [ ] Western blot ____________________________
  Immune panel [ ] (Cells, Complement, Vessels, MHC I, IgM)


DATE:_____________PATIENT NAME:______________________________
ORDERING PHYSICIAN: Pestronk; Al-Lozi; Lopate; Connolly; Ramneantu
          Other__________________________________________
SIGNATURE:_____________________________________________
DOB:______________ DIAGNOSIS:_________________________________

11/7/2006