source: FOIAVistA/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWCS3.m@ 1582

DVBCWCS3 ;ALB/RLC CUSHING'S SYNDROME WKS TEXT - 1 ; 12 FEB 2007
 ;;2.7;AMIE;**121**;Apr 10, 1995;Build 9
 ;
 ;
TXT ;
 ;;A.  Review of Medical Records:
 ;;
 ;;B.  Medical History (Subjective Complaints):
 ;;
 ;;    Comment on:
 ;;
 ;;    1.  Date diagnosis established.
 ;;    2.  Current symptoms:  weakness, fatigue, weight change, acne, mental
 ;;        changes, vision problems.
 ;;    3.  History of glucose intolerance?
 ;;    4.  Etiology?  Latrogenic?
 ;;    5.  Treatments (surgery, medication, etc.), dose, frequency, response,
 ;;        side effects.
 ;;    6.  Effects of the condition on occupational functioning and daily
 ;;        activities.
 ;;    7.  History of hospitalizations or surgery, dates and location, if known,
 ;;        reason or type of surgery.
 ;;    8.  History of neoplasm:
 ;;        
 ;;        a.  Date of diagnosis, diagnosis.
 ;;        b.  Benign or malignant.
 ;;        c.  Types of treatment and dates.
 ;;        d.  Last date of treatment.
 ;;
 ;;C.  Physical Examination (Objective Findings):
 ;;
 ;;    Address each of the following and fully describe current findings:
 ;;
 ;;    1.  Muscle strength.
 ;;    2.  Vascular fragility.
 ;;    3.  Blood Pressure.
 ;;    4.  Striae, skin thinning.
 ;;    5.  Weight gain or loss, presence of obesity.
 ;;    6.  Moonface, buffalo hump.
 ;;    7.  Vision abnormalities, presence of abnormalities requires evaluation
 ;;        by vision specialist.
 ;;    8.  After control, describe adrenal insufficiency, cardiovascular,
 ;;        psychiatric, skin, or skeletal complications or residuals, follow
 ;;        appropriate worksheets.
 ;;
 ;;D.  Diagnostic and Clinical Tests:
 ;;
 ;;    Provide:
 ;;
 ;;    1.  CT of brain or X-ray of sella turcica, unless of record.
 ;;    2.  Serum and urine cortisol levels, unless of record.
 ;;    3.  High and low dose dexamethasone suppression test, unless of record.
 ;;    4.  Imaging studies for size of adrenals, unless of record.
 ;;    5.  Glucose tolerance test, if needed, to confirm glucose intolerance.
 ;;    6.  X-rays if osteoporosis suspected.
 ;;    7.  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