Cushing's Consult

Chief Complaint

Excess Cortisol

Template

Thank you for referring [name], a [age] year old [gender], who was seen on [date] for assessment of possible Cushing's syndrome. 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 excess cortisol: Weight gain: Weight redistribution: Proximal muscle weakness: Skin thinning: Easy bruising: Facial plethora: Hirsutism: Abdominal striae: Mood changes: VTE: Hypertension: Hyperglycemia: Osteoporosis/fractures: Headaches: Vision changes: The patient [does/does not] endorse causes of pseudocushing's, such as PCOS, severe depression, obesity, eating disorder, or alcohol use. 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] [Acromegaly symptoms: coarse facial features, interdental separation, enlarging tongue, enlarging hands or feet, skin tags, joint pain, carpal tunnel, heart failure, oily skin, excessive sweating] [Growth hormone deficiency symptoms: fatigue, weight gain, low mood] [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] [Obstructive sleep apnea symptoms: snoring, breathing cessation, excessive daytime somnolence, morning headaches] Medical history: [medical_history] (List numerically with each having its own line) Medications: [drug_name] (List numerically with each having its own line) [Exogenous cortisol 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] There [is/is no] family history of [adrenal tumors, pituitary tumors, pancreatic tumors, medullary thyroid cancer, or other malignancies]. Exam: [general exam, weight, height, vitals, cardiac exam, pulmonary exam] Weight: Height: Blood pressure: Heart rate: Visual field: Investigations: [investigations] [Stigmata of Cushing's: the patient had/did not have abdominal striae, facial plethora, dorsocervical fat pad, supraclavicular fullness, skin thinning, hirsutism] [Proximal muscle strength] [Stigmata of hyperandrogenism: the patient had/did not have increased musculature, male pattern baldness, hirsutism] Impression and Plan: [name] is a [age] [gender] presenting with [diagnosis]. The differential for excess cortisol includes: exogenous cortisol use, pituitary adenoma (Cushing's disease), ectopic ACTH production, adrenal adenoma, adrenal carcinoma, adrenal nodular disease, cyclical Cushing's, and pseudocushing's. [The best test to differentiate pseudocushing's is the late night salivary cortisol, as these patients tend to retain their diurnal pattern of cortisol secretion, unlike patients with Cushing's syndrome.] [Patients with Cushing's syndrome will require prophylaxis for infection depending on their degree of cortisol excess] 1. Elevated cortisol: [working diagnosis]. Differential also includes [differential diagnosis] (Use first person tone, such as "I have...") - [Repeat AM cortisol, ACTH, 24 hour urine free cortisol, late night salivary cortisol, 1mg dexamethasone suppression test] - [Full pituitary panel, though hypercortisolism may suppress the thyroid, gonadal, and growth hormone axes] - [High dose dexamethasone suppression test to differentiate pituitary versus ectopic ACTH production] - [MR sella] - [Inferior petrosal sinus sampling] - [Prophylaxis for PJP and VTE] - [Treatment for pituitary Cushing's is typically through surgery] - [I have arranged for a referral for formal visual field testing] 2. Follow-up: - [Timing of follow-up] 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, [credentials] [hospital/clinic]