[613] | 1 | DVBCWTD1 ;ALB/CMM THYROID DISEASES WKS TEXT - 1 ; 5 MARCH 1997
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| 2 | ;;2.7;AMIE;**12**;Apr 10, 1995
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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 | ;;
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| 9 | ;;
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| 10 | ;;B. Medical History (Subjective Complaints):
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| 11 | ;;
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| 12 | ;; Comment on:
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| 13 | ;; 1. Date diagnosis established.
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| 14 | ;;
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| 15 | ;;
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| 16 | ;; 2. Fatigability.
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| 17 | ;;
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| 18 | ;;
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| 19 | ;; 3. Mental assessment.
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| 20 | ;;
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| 21 | ;;
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| 22 | ;; 4. Neurologic, cardiovascular, or gastrointestinal symptoms.
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| 23 | ;;
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| 24 | ;;
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| 25 | ;; 5. Treatments (surgery, medications, hormones), including dose,
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| 26 | ;; frequency, response, side effects. For C-cell hyperplasia,
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| 27 | ;; provide date of completion of any treatment for malignancy.
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| 28 | ;;
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| 29 | ;;
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| 30 | ;; 6. Symptoms due to pressure (on larynx, esophagus, etc.).
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| 31 | ;;
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| 32 | ;;
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| 33 | ;; 7. Cold or heat intolerance.
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| 34 | ;;
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| 35 | ;;
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| 36 | ;; 8. Constipation.
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| 37 | ;;
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| 38 | ;;
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| 39 | ;; 9. Weight gain or loss.
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| 40 | ;;
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| 41 | ;;
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| 42 | ;;C. Physical Examination (Objective Findings):
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| 43 | ;;
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| 44 | ;; Address each of the following and fully describe current findings:
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| 45 | ;; 1. Thyroid size.
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| 46 | ;;
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| 47 | ;;
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| 48 | ;; 2. Pulse and blood pressure.
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| 49 | ;;
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| 50 | ;;
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| 51 | ;; 3. Eye and vision abnormalities.
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| 52 | ;;
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| 53 | ;;
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| 54 | ;; 4. Muscle strength.
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| 55 | ;;
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| 56 | ;;
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| 57 | ;; 5. Tremor.
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| 58 | ;;
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| 59 | ;;
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| 60 | ;; 6. Myxedema.
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| 61 | ;;
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| 62 | ;;
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| 63 | ;; 7. All other residuals of thyroid disease or its treatment.
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| 64 | ;;
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| 65 | ;;
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| 66 | ;;D. Diagnostic and Clinical Tests:
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| 67 | ;;
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| 68 | ;; Provide:
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| 69 | ;; 1. T4, T3, TSH, and/or other thyroid function tests, if needed.
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| 70 | ;; 2. If thyroidectomy scar is disfiguring, order color photograph.
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| 71 | ;; 3. Thyroid scan, if indicated.
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| 72 | ;; 4. Include results of all diagnostic and clinical tests conducted
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| 73 | ;; in the examination report.
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| 74 | ;;
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| 75 | ;;
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| 76 | ;;E. Diagnosis:
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| 77 | ;;
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| 78 | ;; Comment on:
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| 79 | ;; 1. Is the disease active or in remission?
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| 80 | ;;
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| 81 | ;;
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| 82 | ;;Signature: Date:
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| 83 | ;;END
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