source: FOIAVistA/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWCS1.m@ 1757

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1DVBCWCS1 ;ALB/CMM CUSHING'S SYNDROME WKS TEXT - 1 ; 5 MARCH 1997
2 ;;2.7;AMIE;**12**;Apr 10, 1995
3 ;
4 ;
5TXT ;
6 ;;A. Review of Medical Records:
7 ;;
8 ;;
9 ;;
10 ;;B. Medical History (Subjective Complaints):
11 ;;
12 ;; Comment on:
13 ;; 1. Date diagnosis established.
14 ;;
15 ;;
16 ;; 2. Weakness or fatigability.
17 ;;
18 ;;
19 ;; 3. Etiology ? Iatrogenic?
20 ;;
21 ;;
22 ;; 4. Treatments (surgery, medication, etc.), dose, frequency,
23 ;; response, side effects.
24 ;;
25 ;;
26 ;;C. Physical Examination (Objective Findings):
27 ;;
28 ;; Address each of the following and fully describe current findings:
29 ;; 1. Muscle strength.
30 ;;
31 ;;
32 ;; 2. Vascular fragility.
33 ;;
34 ;;
35 ;; 3. Gastrointestinal.
36 ;;
37 ;;
38 ;; 4. Blood Pressure.
39 ;;
40 ;;
41 ;; 5. Striae.
42 ;;
43 ;;
44 ;; 6. Weight gain or loss (weigh patient).
45 ;;
46 ;;
47 ;; 7. Moonface.
48 ;;
49 ;;
50 ;; 8. Glucose metabolism.
51 ;;
52 ;;
53 ;; 9. After control, describe adrenal insufficiency, cardiovascular,
54 ;; psychiatric, skin, or skeletal complications or residuals.
55 ;;
56 ;;
57 ;;D. Diagnostic and Clinical Tests:
58 ;;
59 ;; Provide:
60 ;; 1. CT of brain or X-ray of sella turcica.
61 ;; 2. Serum and urine cortisol levels.
62 ;; 3. High and low dose dexamethasone suppression test.
63 ;; 4. X-rays if osteoporosis suspected.
64 ;; 5. Include results of all diagnostic and clinical tests conducted
65 ;; in the examination report.
66 ;;
67 ;;
68 ;;E. Diagnosis:
69 ;;
70 ;; Comment on:
71 ;; 1. Is the disease active or in remission?
72 ;;
73 ;;
74 ;;Signature: Date:
75 ;;END
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