Adrenal Surgery Consultation Worksheet:
Information your doctor will ask you:
Please make sure to bring copies of your blood tests and reports of X-rays (CAT scan, MRI, MIBG scan ultrasound, etc.) as well as copies of the pictures of the X-rays.
How old are you? ______
How was your adrenal problem diagnosed? ______
How long ago was your adrenal problem diagnosed? ______
Do you have a family history of adrenal disease? O Yes O No
If so, what disease and which family member had it? ______
______
Do you have any of the following symptoms: O Yes O No
O palpitations (fluttering heart beat) O arrhythmia (irregular heart rate)
O headaches O sweating
O flushing O high blood pressure
O spikes of high blood pressure O stroke
O heart attack O enlarged heart
O low potassium levels O muscle weakness
O muscle aches O fatigue
O high sodium levels O urinating more frequently
O waking up in the middle of the night to urinate O Diabetes (high blood sugar)
O purple stripes on the abdomen or arms/legs O swollen face
O weight gain in abdomen with skinny arms and legs O weight gain
O weight loss O easy bruising
O thin skin O increased body hair
O depression O abdominal pain
O tumor that is growing quickly O fever
O chills O night sweats
O irregular periods O no periods
O difficulty getting pregnant O acne
O male-pattern baldness O impotence
O loss of libido O testicular atrophy
Questions you should ask your surgeon:
1) How many adrenal operations do you do each year? ______
2) Can we do this laparoscopically? ______
3) How often do you need to convert from laparoscopic to an open operation?
______
4) What is your cure rate? ______
5) How long do I need to be out of work? ______
6) How long will I be in the hospital? ______
7) How often do your patients have the following problems after the operation?
a. Bleeding: ______
b. Infections: ______
c. Injury to surrounding organs: ______
8) What is the follow-up? ______
9) Other questions:
______