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Routine: DVBCWCS5

DVBCWCS5.m

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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