Acromegaly Consult

Chief Complaint

Acromegaly

Template

Thank you for referring [name], a [age] year old [gender], who was seen on [date] for assessment of possible acromegaly. Consent: I obtained consent from the patient for use of an AI scribe software. I explained that [software_name] saves a copy of our conversation on their website for the purpose of generating a note, and that this software is FDA approved. History of Presenting Illness: [Initial symptoms and initial workup.] [Progression of symptoms and further workup.] Symptom's of acromegaly: Coarse facial features: Interdental separation Enlarging tongue: Enlarging hands or feet: Skin tags: Joint pain: Carpal tunnel: Heart failure: Oily skin: Excessive sweating: GI symptoms: Headaches: Vision changes: Pituitary Review of Systems: [Hyperthyroidism symptoms: heat intolerance, excess sweating, weight loss, fatigue, palpitations, tremors, anxiety, hyperdefecation, menstrual irregularities] [Hypothyroidism symptoms: cold intolerance, weight gain, fatigue, bradycardia, dry oily skin, coarse hairs, constipation] [Hyperprolactinemia symptoms: galactorrhea, gynecomastia, menstrual irregularities, secondary hypogonadism] [Hypogonadism: menstrual irregularities, vaginal dryness, hot flushes, mood changes, dyspareunia, reduced libido, erectile dysfunction, loss of morning erections, muscle weakness, loss of body hair] [Cushing's syndrome: weight gain, skin thinning, easy bruising, abdominal striae, mood changes] [Adrenal insufficiency symptoms: orthostatic lightheadedness, fatigue, abdominal discomfort, skin darkening] Medical history: [medical_history] (List numerically with each having its own line) Medications: [drug_name] (List numerically with each having its own line) [Exogenous growth hormone use.] Allergies: [allergies] (List numerically with each having its own line) Social history: Exercise: [exercise] Work: [work] Extended coverage: [coverage] Alcohol: [alcohol] Cigarettes: [cigarettes] Drugs: [drugs] Family history: [family_history] Exam: [general exam, weight, height, vitals, cardiac exam, pulmonary exam] Weight: [weight] Height: [height] Blood pressure: [blood_pressure] Heart rate: [heart_rate] Visual field: [visual_field] [Evidence/no evidence of coarse features, oily skin, frontal bossing, large nose, deep nasolabial folds, prognathism, increased interdental separation, macroglossia, cutis verticis gyrata, soft tissue swelling, clubbing] Thyroid [normal size/enlarged] Investigations: [investigations] (List each lab value in its own line, do not list numerically). Impression and Plan: [name] is a [age] [gender] presenting with [diagnosis]. Essentially all cases of acromegaly is caused by a pituitary adenoma, and there are very few cases of excess GHRH production or ectopic growth hormone production. Physiologic causes of elevated growth hormone include puberty, pregnancy, stress, CKD, cirrhosis, opioid use, significant stress, critical illness, and diabetes. I counselled the patient on potential complications of acromegaly, including hypertension, impaired glucose tolerance/diabetes, OSA, colon cancer, heart disease, stroke, CHF, hypercalcemia due to increased turnover of 25OH vitamin D to 1,25OH vitamin D, osteoporosis/fractures, and increased thrombosis risk. Overall there is increased mortality in patients with acromegaly and treatment will help minimize this. I informed the patient that headaches, hyperhydrosis, joint pain, and soft tissue swelling usually improve, but fatigue, depression, snoring/OSA, and arthropathy may not improve. First line treatment for acromegaly is through surgery, though patients who are not surgical candidates can consider medical therapy. [Medication options include somatostatin analogues, dopamine agonists, and GH antagonist (pegvisomant).] 1. Acromegaly: [working diagnosis]. Differential also includes [differential diagnosis] (Use first person tone, such as "I have...") - [Repeat IGF-1 with full pituitary panel. Often adenomas will cosecrete prolactin.] - [Calcium level, A1c, lipid panel, TTE, OSA screen] - [Confirmatory testing with 75g oral glucose tolerance test] - [MR sella] - [I have made a referral to neurosurgery for consideration of pituitary surgery] - [I have arranged for a referral for formal visual field testing] - [I have arranged for a BMD, as this is indicated in patients over 40 years old with acromegaly] - [I kindly ask that his family physician arrange for a baseline colonoscopy, and to repeat this at least every 10 years] - [I have provided the patient with the AcroQOL questionnaire] - [I recommended that the patient consider genetic testing for acromegaly, such as MEN1, Carney Complex, McCune-Albright Syndrome, and familial isolated pituitary adenoma. Options include geneticist referral, or through private companies such as Blueprint Genetics.] 2. Follow-up: - [Timing of follow-up, with repeat bloodwork and imaging] Patient Counseling: I counseled the patient on causes of elevated prolactin and advised minimal nipple stimulation or trying to express galactorrhea, as this can trigger prolactin secretion. Thank you for involving me in the care of this pleasant patient. Please do not hesitate to contact me with any questions or concerns. Dr. [name], MD, FRCPC [hospital/clinic]