FSR Peer Case Review Submission Form

FSR Sarcoidosis Peer Case Submission Form

Referring Physician(Required)

First Last

Institution(Required)

Email(Required)

Phone(Required)

Case Title

Questions to be discussed

Brief patient history:

ASA Class (on initial presentation)

ASA I: A normal healthy patient

ASA II: A patient with mild systemic disease

ASA III: A patient with severe systemic disease

ASA IV: A patient with severe systemic disease that is a constant threat to life

Diagnosis:

Clinical features:

Radiology:

PFTs:

Biopsy:

Labs:

Treatment history:

Medication

Dose

Duration

Response

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Liability Statement: This session is an academic exercise for discussion purposes only. No advice is intended. By attending this session, you agree to absolve FSR and any participating individuals or institutions from liability associated with recommendations, guidance, or feedback. The information in this presentation is for general informational purposes only and does not constitute official medical advice or recommendation. Any use of information gathered from this session is at your will. 

FSR Sarcoidosis Peer Case Submission Form

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