EDM Adrenal Consult Note

OVERALL_INSTRUCTIONS

Chief Complaint

Evaluation of adrenal adenoma or adrenal insufficiency

Template

Date: [Insert Date] Referring Physician: [insert physician name] Dear Dr. [referring physician name], Thank you for asking me to see your patient. HISTORY OF PRESENT ILLNESS: [Patient name] presents for evaluation of [adrenal adenoma|adrenal insufficiency| ] - Patient was found to have incidental adrenal adenoma on imaging done for [Insert indication] - Denies abdominal pain, diarrhea, nausea, vomiting, fevers - Denies any excessive weight gain, bruising, violaceous striae, development of diabetes - No episodes of palpitations, headache, panic attacks - No history of hypertension, low potassium levels - No family history of adrenal tumors REVIEW OF SYSTEMS: [insert any positive, significant findings. If none state "No headaches, dyspnea, symptoms of ischemic heart disease, abdominal pain, urinary or bowel complaints"] LABORATORY RESULTS: Recent Labs: [Insert laboratory results] IMAGING: [Insert imaging findings] LIFESTYLE NOTES: [Insert any notes related to lifestyle such as smoking, substance use, etc.] FAMILY HISTORY: [insert any relevant family history] PHYSICAL EXAMINATION: The head and neck exam was unremarkable with no cervical adenopathy. Acanthosis nigricans and skin tags were [absent|noted]. Cushing's features were [noted|absent]. The patient was euthyroid to physical exam. The thyroid was normal and non-tender with no nodularity. The chest was clear to auscultation. Cardiovascular examination showed normal heart sounds, with no audible murmurs or bruits. There was no peripheral edema. The abdomen was soft with no palpable organomegaly. ASSESSMENT AND PLAN: 1. Adrenal adenoma: Accuro - Patient has an incidental finding of adrenal adenoma on CT scan. Patient does not have signs or symptoms of any hormonal excess. I will check for any hormonal abnormalities: - Serum aldosterone and renin activity - 1 mg overnight dexamethasone suppression test - Plasma metanephrines and normetanephrines - I will review results in 6 weeks. - As per 2016 European Society of Endocrinology guidelines for evaluation and management of adrenal incidentalomas: If lab testing is normal, patient does not require routine hormonal evaluation and can be followed clinically for signs of adrenal hormonal excess. Routine imaging for monitoring of benign appearing adrenal lesions < 4 cm not usually required. FOLLOW-UP: [Follow up: Appointment planned in 1 week|Follow up: Appointment planned in 2 weeks|Follow up: Appointment planned in 3 weeks|Follow up: Appointment planned in 4 weeks|Follow up: Appointment planned in 5 weeks|Follow up: Appointment planned in 6 weeks|Follow up: Appointment planned in 8 weeks|Follow up: Appointment planned in 3 months|Follow up: Appointment planned in 4 months|Follow up: Appointment planned in 5 months|Follow up: Appointment planned in 6 months|Follow up: Appointment planned in 1 year|Follow up: Appointment planned in 2 years|Follow up: Patient is being discharged to your continuing care. I remain available for future reassessment at your discretion.|Follow up: Appointment planned in [Insert interval]|Follow up: Brief appointment planned in [Insert interval]|Follow up: Per your request, we haven’t booked a follow-up visit but I would be happy to see your patient again, for continuing support, at your discretion.|Follow up: With your permission, I would like to schedule 1-2 further follow up visits to assess the outcomes of the above steps. I’ll then remain available for future reassessment at your discretion.|Follow up: Patient will be contacted for follow-up] Thank you very much for the opportunity to see your patient and share in their care. Sincerely, [Insert Consulting Physician Name] [Insert Contact Information]