source: FOIAVistA/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWCS1.m@ 804

DVBCWCS1 ;ALB/CMM CUSHING'S SYNDROME WKS TEXT - 1 ; 5 MARCH 1997
 ;;2.7;AMIE;**12**;Apr 10, 1995
 ;
 ;
TXT ;
 ;;A.  Review of Medical Records:
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 ;;
 ;;
 ;;B.  Medical History (Subjective Complaints):
 ;;
 ;;    Comment on:
 ;;    1.  Date diagnosis established.
 ;;
 ;;
 ;;    2.  Weakness or fatigability.
 ;;
 ;;
 ;;    3.  Etiology ?  Iatrogenic?
 ;;
 ;;
 ;;    4.  Treatments (surgery, medication, etc.), dose, frequency, 
 ;;        response, side effects.
 ;;
 ;;
 ;;C.  Physical Examination (Objective Findings):
 ;;
 ;;    Address each of the following and fully describe current findings:
 ;;    1.  Muscle strength.
 ;;
 ;;
 ;;    2.  Vascular fragility.
 ;;
 ;;
 ;;    3.  Gastrointestinal.
 ;;
 ;;
 ;;    4.  Blood Pressure.
 ;;
 ;;
 ;;    5.  Striae.
 ;;
 ;;
 ;;    6.  Weight gain or loss (weigh patient).
 ;;
 ;;
 ;;    7.  Moonface.
 ;;
 ;;
 ;;    8.  Glucose metabolism.
 ;;
 ;;
 ;;    9.  After control, describe adrenal insufficiency, cardiovascular,
 ;;        psychiatric, skin, or skeletal complications or residuals.
 ;;
 ;;
 ;;D.  Diagnostic and Clinical Tests:
 ;;
 ;;    Provide:
 ;;    1.  CT of brain or X-ray of sella turcica.
 ;;    2.  Serum and urine cortisol levels.
 ;;    3.  High and low dose dexamethasone suppression test.
 ;;    4.  X-rays if osteoporosis suspected.
 ;;    5.  Include results of all diagnostic and clinical tests conducted
 ;;        in the examination report.
 ;;
 ;;
 ;;E.  Diagnosis:
 ;;
 ;;    Comment on:
 ;;    1.  Is the disease active or in remission?
 ;;
 ;;
 ;;Signature:                             Date:
 ;;END