- 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 Feb 18, 2025@23:16:38 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