©2011-2018 Open Source Electronic Health Record Alliance
This work is licensed under a Creative Commons Attribution 3.0 Unported License
This work is licensed under a Creative Commons Attribution 3.0 Unported License
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:
;;
;;
;;
;;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