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