Cushing's Syndrome

Name:	SSN:
Date of Exam:	C-number:
Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Date diagnosis established.
2. Current symptoms: weakness, fatigue, weight change, acne, mental changes, vision problems
3. History of glucose intolerance?
4. Etiology? Iatrogenic?
5. Treatments (surgery, medication, etc.), dose, frequency, response, side effects.
6. Effects of the condition on occupational functioning and daily activities.
7. History of hospitalizations or surgery, dates and location, if known, reason or type of surgery.
8. History of neoplasm:

1. Date of diagnosis, diagnosis.
2. Benign or malignant.
3. Types of treatment and dates.
4. Last date of treatment.

C. Physical Examination (Objective Findings):

Address each of the following and fully describe current findings:

1. Muscle strength.
2. Vascular fragility.
3. Blood Pressure.
4. Striae, skin thinning.
5. Weight gain or loss, presence of obesity.
6. Moonface, buffalo hump.
7. Vision abnormalities, presence of abnormalities requires evaluation by vision specialist.
8. After control, describe adrenal insufficiency, cardiovascular, psychiatric, skin, or skeletal complications or residuals, follow appropriate worksheets.

D. Diagnostic and Clinical Tests:

Provide:

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. X-rays if osteoporosis 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?

Signature:

Date: