Transcription of The Children's Hospital of Philadelphia
1 Division of Anatomic PathologyPierre Russo, , ChiefPaul Miller, ManagerPhone: 215-590-1728 Fax: 215-590-1736 Glomerulonephritis: YES NODiabetes: YES NOOther (specify): YES NOClinical Manifestations Diarrhea: YES NOYES NOHematchezia: YES NO Vomiting: YES NO YES NOFailure to thrive: YES NOPeripheral Edema: YES NO YES NORecurrent Infections (specify): YES NO YES NOAthralgias/Arthritis: YES NO YES NOBiopsy Results: (enclose copy please)Esphoagus:Stomach:Duodenum/Small Bowel:Colon:Other (kidney, skin, etc):TreatmentDose/KGResponseCorticoster oidsCyclosporineTacrolimusOther (Specify) The Children's Hospital of Philadelphia Department of Pathology and Laboratory MedicineDivision of Anatomic PathologyAnti-Enterocyte Antibody Clinical FormDepartment of Pathology and Laboratory MedicineJeffrey Golden, , Pathologist-in-ChiefPatient Name: _____DOB: _____Age at AEA Testing: _____Recurrent Infections (specify): DurationSkin Rash (specify):Family History (specify):Age at onset of symptoms: _____Other (specify):Chronic cough/Asthma (specify):Associated auto-immune disorders
