source: WorldVistAEHR/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWCS3.m@ 1154

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[613]1DVBCWCS3 ;ALB/RLC CUSHING'S SYNDROME WKS TEXT - 1 ; 12 FEB 2007
2 ;;2.7;AMIE;**121**;Apr 10, 1995;Build 9
3 ;
4 ;
5TXT ;
6 ;;A. Review of Medical Records:
7 ;;
8 ;;B. Medical History (Subjective Complaints):
9 ;;
10 ;; Comment on:
11 ;;
12 ;; 1. Date diagnosis established.
13 ;; 2. Current symptoms: weakness, fatigue, weight change, acne, mental
14 ;; changes, vision problems.
15 ;; 3. History of glucose intolerance?
16 ;; 4. Etiology? Latrogenic?
17 ;; 5. Treatments (surgery, medication, etc.), dose, frequency, response,
18 ;; side effects.
19 ;; 6. Effects of the condition on occupational functioning and daily
20 ;; activities.
21 ;; 7. History of hospitalizations or surgery, dates and location, if known,
22 ;; reason or type of surgery.
23 ;; 8. History of neoplasm:
24 ;;
25 ;; a. Date of diagnosis, diagnosis.
26 ;; b. Benign or malignant.
27 ;; c. Types of treatment and dates.
28 ;; d. Last date of treatment.
29 ;;
30 ;;C. Physical Examination (Objective Findings):
31 ;;
32 ;; Address each of the following and fully describe current findings:
33 ;;
34 ;; 1. Muscle strength.
35 ;; 2. Vascular fragility.
36 ;; 3. Blood Pressure.
37 ;; 4. Striae, skin thinning.
38 ;; 5. Weight gain or loss, presence of obesity.
39 ;; 6. Moonface, buffalo hump.
40 ;; 7. Vision abnormalities, presence of abnormalities requires evaluation
41 ;; by vision specialist.
42 ;; 8. After control, describe adrenal insufficiency, cardiovascular,
43 ;; psychiatric, skin, or skeletal complications or residuals, follow
44 ;; appropriate worksheets.
45 ;;
46 ;;D. Diagnostic and Clinical Tests:
47 ;;
48 ;; Provide:
49 ;;
50 ;; 1. CT of brain or X-ray of sella turcica, unless of record.
51 ;; 2. Serum and urine cortisol levels, unless of record.
52 ;; 3. High and low dose dexamethasone suppression test, unless of record.
53 ;; 4. Imaging studies for size of adrenals, unless of record.
54 ;; 5. Glucose tolerance test, if needed, to confirm glucose intolerance.
55 ;; 6. X-rays if osteoporosis suspected.
56 ;; 7. Include results of all diagnostic and clinical tests conducted
57 ;; in the examination report.
58 ;;
59 ;;E. Diagnosis:
60 ;;
61 ;; Comment on:
62 ;;
63 ;; 1. Is the disease active or in remission?
64 ;;
65 ;;
66 ;;Signature: Date:
67 ;;END
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