| SECTION 1: SOCIO-DEMOGRAPHIC DATA | ||||||
| 1 | SEX: M = Male, F = Female | |_| | ||||
| 2 | Age (in years) |
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| 3 | Marital status: S = single, M = married, D = Divorced | |_| | ||||
| 4 | Residence | |||||
| 5 | Region of origin: EN = Extreme North, N = North, A = Adamawa, C = Centre, W = west, NW = North west, SW = South west, E = East, L = Littoral | |_| | ||||
| 6 | Profession | |||||
| SECTION 2: PAST MEDICAL AND FAMILY HISTORY | ||||||
| 7 | Chronic pathologies: Y = Yes, N = No | |_| | ||||
| 8 | If yes, what type; HTN, diabetes = D, Nephropathy = N, Endocrinopathy = Endoc to precise, Neoplasia = precise, Others (precise) | |_| | ||||
| 9 | Use of Medications Y = Yes, N = No | |_| | ||||
| 10 | Past surgery Y = Yes, N = No | |_| | ||||
| 11 | If yes, precise | |_| | ||||
| 12 | Smoking Active = A, passive = P, Non = N | |_| | ||||
| 13 | Alcohol comsuption Y = Yes, N = No | |_| | ||||
| 14 | If yes, IE = number × volume × % × alcohol density/day | |_| | ||||
| 15 | Sedentary life style Y = Yes, N = No | |_| | ||||
| 16 | Socio-professional stress Y = Yes, N = No | |_| | ||||
| 17 | Similar cas in family, Y = Yes, N = No | |_| | ||||
| 18 | Phaeochromocytoma, Y = Yes, N = No | |_| | ||||
| 19 | Thyroid medullary carcinoma, Y = Yes, N = No | |_| | ||||
| 20 | MEN type I Y = Yes, N = No | |_| | ||||
| 21 | Von Hipple—Lindau disease Y = Yes, N = No | |_| | ||||
| 22 | Neurofibromatosis Y = Yes, N = No | |_| | ||||
| 23 | Other tumor Y = Yes, N = No | |_| | ||||
| 24 | If yes precise | |_| | ||||
| SECTION 3: CLINICAL EXAMINATION | ||||||
| A-Functional Signs | ||||||
| 25 | Presenting complaint or circumstance of diagnosis | |||||
| 26 | Duration of evolution since presentation of first symptom |
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| 27 | Weight gain Yes |_|, No |_| | |_| | ||||
| 28 | Secondary ammenorrhoea Yes |_|, No |_| | |_| | ||||
| 29 | Decrease libido Yes |_|, No |_| | |_| | ||||
| 30 | Bone signs (non mechanical lumbar or pelvic pains) Yes |_|, No |_| | |_| | ||||
| 31 | Immunity disorders Yes |_|, No |_| | |_| | ||||
| 32 | Psychiatric disorders/problems Yes |_|, No |_| | |_| | ||||
| 33 | HTN Yes |_|, No |_| | |_| | ||||
| 34 | Neuromuscular signs Yes |_|, No |_| | |_| | ||||
| 35 | Constipation Yes |_|, No |_| | |_| | ||||
| 36 | PUPD syndrome Yes |_|, No |_| | |_| | ||||
| 37 | Cramps and paresthesia of extremeties Yes |_|, No |_| | |_| | ||||
| 38 | Dyspnea on effort Yes |_|, No |_| | |_| | ||||
| 39 | Intense pulsatile headache Yes |_|, No |_| | |_| | ||||
| 40 | Palpitations Yes |_|, No |_| | |_| | ||||
| 41 | Profuse sweating Yes |_|, No |_| | |_| | ||||
| 42 | Orthostatique hypotension | |_| | ||||
| 43 | Ascending constrictive pains:abdomen and thorax Yes |_|, No |_| | |_| | ||||
| B-Physical Signs | ||||||
| 44 | General state: performance status index (WHO) | ……… | ||||
| 45 | Blood pressure | ……mm/Hg | ||||
| 46 | Pulse | ……….Bpm | ||||
| 47 | Respiratory rate | ………cpm | ||||
| 48 | Temperature | ……..˚C | ||||
| 49 | BMI: weight………(Kg)/Height…….(m) | |_| |_|kg/m2 | ||||
| 50 | Waist circumference | …..cm | ||||
| 51 | Facial and trunkal obesity Yes |_|, No |_| | |_| | ||||
| 52 | Easy bruising Yes |_|, No |_| | |_| | ||||
| 53 | Cutaneous eruptions (pupural at pertechies) Yes |_|, No |_| | |_| | ||||
| 54 | Signs of virilism Yes |_|, No |_| | |_| | ||||
| 55 | Amyotrophie of lower limbs Yes |_|, No |_| | |_| | ||||
| 56 | Pseudoparalytic crises Yes |_|, No |_| | |_| | ||||
| 57 | Cardiac arrhythmias Yes |_|, No |_| | |_| | ||||
| 58 | Gynaecomastia Yes |_|, No |_| | |_| | ||||
| 59 | Palpable tumour at the level of the abdomen | |_| | ||||
| 60 | Presence of goiter, exolpthalmos and signes of thyroid dysfunction Yes |_|, No |_| | |_| | ||||
| 61 | Gallactorrhoea Yes |_|, No |_| | |_| | ||||
| 62 | Presence of breast nodule Yes |_|, No |_| | |_| | ||||
| 63 | Peculiarities of rest of physical examination …………………………………………………………………………………… …………………………………………………………………………………… …………………………………………………………………………………… | |||||
| SECTION 4: BIOLOGICAL INVESTIGATIONS | ||||||
| Investigation | Results | Normal value | ||||
| Aldosterone |
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| Plasma renin activity |
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| 24 hrs CLU |
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| Freinage minute test |
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| ● Midnight cortisol |
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| ● 8 h cortisol |
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| ACTH |
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| DHEAS |
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| Testosterone |
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| 17OHP |
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| Plasma metanephrines |
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| 24 hrs urinary metanephrines |
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| Creatinnuria |
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| Creatinine (mg/l) |
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| Urea (g/l) |
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| FBS |
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| Na+/K+/Cl− (meq/l) |
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| Ca2+/PO4/Mg2+ |
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| Albuminemia (g/l) |
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| EPPS |
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| TSH (IU/l) |
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| Free T4 pmol/L |
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| CT/HDL/LDL/TG (g/l) |
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| FBC, WBC |
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| Hb |
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| Platelets |
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| CRP |
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| ASAT/ALAT/GGT |
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| Abdominal ultrasound………………………………………………………………………. ………………………………………………………………………………………………… ………………………………………………………………………………………………… Abdominal CT scan: ● Tumour location: left |_|, right |_| ● Size of tumour: ……….cm ● Content: homogenous |_|, heterogeneous|_| ● Spontaneous density: <10 HU |_|, >10 HU |_| ● Wash out: absolute……..%, Relative…………….% ● Limits: Regular irregular ● Necrosis: Yes |_|, No |_| ● Calcifications: Yes |_|, No |_| ● Infiltration of pararenal fats: Yes |_|, No |_| ● Hemorrhagic Yes |_|, No |_| ● Metastasis Yes |_|, No |_| Chest X-Ray:…………………………………………………………………………………. Others: ……………………………………………………………………………………….. | ||||||
| SECTION 6: SURGICAL MANAGEMENT | ||||||
| A-Pre-surgical preparation | ||||||
| Pre-anesthetic consultation: ASA………………, Altemier | ||||||
| Pre-surgical investigations: | ||||||
| FBC, WBC | ||||||
| Hb | ||||||
| Platelets, TP TCK | ||||||
| Urea creatinine | ||||||
| 64 | Multidispinary consertations (RCP) Yes |_|, No |_| |
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| 65 | Medications Yes |_|, No |_| |
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| 66 | If yes which type of medications? |
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| 67 | Blood transfusion Yes |_|, No |_| |
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| B-Per operative | ||||||
| Day of surgical intervention…………………………………………………… Duration with respect to onset of symptoms Type of Anesthesia:…………………………………………… Installation of patient:…………………………………………. | ||||||
| 68 | Indications: | |||||
| 69 | Type of surgical intervention: Laparoscopic open surgery | |||||
| 70 | Surgical technic: 1-Total adrenalectomy, 2-Partial adrenalectomy, | |||||
| 71 | Surgical approach: 1-anterior midline, 2-Anterior Subcostal, 3-Anterior bisubcostal 4-thoracoabdominal | |||||
| 72 | Surgical attitude: 1 = transperitoneal, 2 = extraperitoneal | |||||
| 73 | Intraoperative findings: | |||||
| 74 | Per-operative complications: HTN: Yes |_|, No |_| Hypotension Yes |_|, No |_| Bleeding Yes |_|, No |_| Cardiac arrest Yes |_|, No |_| Peritoneal breech Yes |_|, No |_| Pleural effraction Yes |_|, No |_| IVC injury Yes |_|, No |_| Adjacent organ injury Yes |_|, No |_| | |||||
| 75 | Duration of surgery: |
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| 76 | Specimen size………(cm) and weight……..(g) |
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| C-Post surgery | ||||||
| 77 | Immediate ………………………………………………………………………………………… ………………………………………………………………………………………… | |||||
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| 78 | Complications: Hemorrhage: Yes |_|, No |_| Anemia: Yes |_|, No |_| Surgical site infection: Yes |_|, No |_| | |||||
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| Acute adrenal insufficiency: Yes |_|, No |_| Paralytic ileus: Yes |_|, No |_| Fistulas: Yes |_|, No |_| Death: Yes |_|, No |_| Others | |||||
| 79 | hospital stay duration |
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| SECTION 7: DIAGNOSIS (Anatomopathological diagnosis) | ||||||
| 80 | Anatomopathological results:………………………………………………………… …………………………………………………………………………………………. | |||||
| SECTION 8: ADJUVANT TREATMENT | ||||||
| Hydrocortisone supplementation Yes |_|, No |_| Chemotherapy Yes |_|, No |_| | ||||||
| SECTION 9: SURVEILLANCE | ||||||
| 81 | CLINICAL: Resolution of initial clinical signs Yes |_|, No |_| Appearance of new signs: Yes |_|, No |_| ………………………………………………………………. ………………………………………………………………………………………… Relapse | |||||
| 82 | Paraclinical: ● Cortisol 8 h ● Cortisol 1 H after synacthene test | Base 0 - 3 months 3 - 6 months >6 m | ||||
| 83 | Control abdominal CT scan |
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