DVBCWCS5 ;ALB/RLC CUSHING'S SYNDROME WKS TEXT - 1 ; 12 FEB 2007
;;2.7;AMIE;**164**;Apr 10, 1995;Build 2
;
;
TXT ;
;;A. Review of Medical Records:
;;
;;B. Medical History (Subjective Complaints):
;;
;; Comment on:
;;
;; 1. Date diagnosis established.
;; 2. Current symptoms: bone or muscle weakness, generalized weakness,
;; fatigue, weight gain, vision problems, increased thirst, increased
;; urination, headache, poor wound healing, erectile dysfunction,
;; irregular menstrual periods, fragile skin, acne, mental changes, etc.
;; 3. History of glucose intolerance?
;; 4. Course of condition since onset.
;; 5. Treatments: surgery, medication (including cortisol-inhibiting drugs
;; and post-surgical hormone replacement), etc. Include dose, frequency,
;; response, side effects.
;; 6. History of related hospitalizations or surgery, dates and location, if
;; known, reason or type of surgery.
;; 7. History of neoplasm:
;;
;; a. Date of diagnosis, exact diagnosis, location.
;; b. Benign or malignant.
;; c. Types of treatment and dates.
;; d. Last date of treatment.
;; e. State whether treatment has been completed.
;;
;;C. Physical Examination (Objective Findings):
;;
;; Address each of the following and fully describe current findings:
;;
;; 1. Muscle strength examination.
;; 2. Vascular fragility.
;; 3. Blood Pressure X 3.
;; 4. Skin abnormalities (striae, acne, abnormal thinning, plethora, etc.).
;; 5. Percent weight gain or loss compared to baseline (average weight in 2
;; years preceding onset of disease), presence of obesity.
;; 6. Moonface, buffalo hump, hirsutism (applies to women).
;; 7. Vision abnormalities (signs or symptoms of a vision abnormality)
;; requires an examination by an eye specialist.
;; 8. Gastrointestinal abnormalities.
;; 9. Report evidence of any of the following complications: diabetes
;; mellitus, osteoporosis, kidney stones. Follow appropriate examination
;; worksheets.
;; 10. If Cushing's syndrome has been controlled, describe adrenal
;; insufficiency, cardiovascular, psychiatric, skin, or skeletal
;; complications or residuals. Follow appropriate examination worksheets.
;; 11. If there is or was a related neoplasm, report residuals of the neoplasm
;; and its treatment.
;;
;;D. Diagnostic and Clinical Tests:
;;
;; Provide, as indicated:
;;
;; 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. Imaging study, if osteoporosis is 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? Is it progressive?
;; 2. What is the etiology? Is it iatrogenic?
;; 3. Report enlargement of pituitary or adrenal gland, glucose intolerance.
;; 4. List complications of Cushing's syndrome and follow appropriate
;; examination worksheets.
;; 5. Effects of the condition on occupational functioning and daily
;; activities.
;;
;;
;;Signature: Date:
;;END
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCWCS5 3709 printed Dec 13, 2024@01:50:11 Page 2
DVBCWCS5 ;ALB/RLC CUSHING'S SYNDROME WKS TEXT - 1 ; 12 FEB 2007
+1 ;;2.7;AMIE;**164**;Apr 10, 1995;Build 2
+2 ;
+3 ;
TXT ;
+1 ;;A. Review of Medical Records:
+2 ;;
+3 ;;B. Medical History (Subjective Complaints):
+4 ;;
+5 ;; Comment on:
+6 ;;
+7 ;; 1. Date diagnosis established.
+8 ;; 2. Current symptoms: bone or muscle weakness, generalized weakness,
+9 ;; fatigue, weight gain, vision problems, increased thirst, increased
+10 ;; urination, headache, poor wound healing, erectile dysfunction,
+11 ;; irregular menstrual periods, fragile skin, acne, mental changes, etc.
+12 ;; 3. History of glucose intolerance?
+13 ;; 4. Course of condition since onset.
+14 ;; 5. Treatments: surgery, medication (including cortisol-inhibiting drugs
+15 ;; and post-surgical hormone replacement), etc. Include dose, frequency,
+16 ;; response, side effects.
+17 ;; 6. History of related hospitalizations or surgery, dates and location, if
+18 ;; known, reason or type of surgery.
+19 ;; 7. History of neoplasm:
+20 ;;
+21 ;; a. Date of diagnosis, exact diagnosis, location.
+22 ;; b. Benign or malignant.
+23 ;; c. Types of treatment and dates.
+24 ;; d. Last date of treatment.
+25 ;; e. State whether treatment has been completed.
+26 ;;
+27 ;;C. Physical Examination (Objective Findings):
+28 ;;
+29 ;; Address each of the following and fully describe current findings:
+30 ;;
+31 ;; 1. Muscle strength examination.
+32 ;; 2. Vascular fragility.
+33 ;; 3. Blood Pressure X 3.
+34 ;; 4. Skin abnormalities (striae, acne, abnormal thinning, plethora, etc.).
+35 ;; 5. Percent weight gain or loss compared to baseline (average weight in 2
+36 ;; years preceding onset of disease), presence of obesity.
+37 ;; 6. Moonface, buffalo hump, hirsutism (applies to women).
+38 ;; 7. Vision abnormalities (signs or symptoms of a vision abnormality)
+39 ;; requires an examination by an eye specialist.
+40 ;; 8. Gastrointestinal abnormalities.
+41 ;; 9. Report evidence of any of the following complications: diabetes
+42 ;; mellitus, osteoporosis, kidney stones. Follow appropriate examination
+43 ;; worksheets.
+44 ;; 10. If Cushing's syndrome has been controlled, describe adrenal
+45 ;; insufficiency, cardiovascular, psychiatric, skin, or skeletal
+46 ;; complications or residuals. Follow appropriate examination worksheets.
+47 ;; 11. If there is or was a related neoplasm, report residuals of the neoplasm
+48 ;; and its treatment.
+49 ;;
+50 ;;D. Diagnostic and Clinical Tests:
+51 ;;
+52 ;; Provide, as indicated:
+53 ;;
+54 ;; 1. CT of brain or X-ray of sella turcica, unless of record.
+55 ;; 2. Serum and urine cortisol levels, unless of record.
+56 ;; 3. High and low dose dexamethasone suppression test, unless of record.
+57 ;; 4. Imaging studies for size of adrenals, unless of record.
+58 ;; 5. Glucose tolerance test, if needed, to confirm glucose intolerance.
+59 ;; 6. Imaging study, if osteoporosis is suspected.
+60 ;; 7. Include results of all diagnostic and clinical tests conducted
+61 ;; in the examination report.
+62 ;;
+63 ;;E. Diagnosis:
+64 ;;
+65 ;; Comment on:
+66 ;;
+67 ;; 1. Is the disease active or in remission? Is it progressive?
+68 ;; 2. What is the etiology? Is it iatrogenic?
+69 ;; 3. Report enlargement of pituitary or adrenal gland, glucose intolerance.
+70 ;; 4. List complications of Cushing's syndrome and follow appropriate
+71 ;; examination worksheets.
+72 ;; 5. Effects of the condition on occupational functioning and daily
+73 ;; activities.
+74 ;;
+75 ;;
+76 ;;Signature: Date:
+77 ;;END
