Male Hypogonadism

Chief Complaint

Male Hypogonadism

specialty

Endocrinology

tags

Template

Thank you for referring [name], a [age] year old man, who was seen on [date] for assessment of hypogonadism. Consent: I obtained consent from the patient for use of an AI scribe software. I explained that Empathia 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: [Brief description of initial symptoms, how long ago they started, and initial work up.] Erectile dysfunction: [present or absent] Fatigue: [present or absent] Galactorrhea: [present or absent] Gynecomastia: [present or absent] Headaches: [present or absent] Visual disturbances: [present or absent] Anosmia: [present or absent] Infertility: [present or absent] Weakness: [present or absent] Weight changes: [present or absent] Hot flashes: [present or absent] Depression: [present or absent] Prior chemotherapy: [present or absent] Developmental abnormality: [present or absent] Mumps or orchitis: [present or absent] Testicular trauma: [present or absent] Steroid use: [present or absent] Medical history: [medical_history] (List numerically with each having its own line) Medications: [drug_name] (List numerically with each having its own line) 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] Abnormalities of the pituitary or puberty: Hypogonadism or infertility: Hemochromatosis: 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] Testicular exam: [testicular_exam] Investigations: [investigations] (Group labs by date and list each lab value in it's own line) Impression and Plan: [name] is a [age] year old man with [symptoms] who [possibly/likely] has [diagnosis]. The differential includes [diagnoses] and I will provide him with further investigations to clarify the diagnosis. 1. Low testosterone: [unlikely or possible or definite] hypogonadism (Use first person tone, such as "I have...") - I will pursue further workup with a repeat AM total testosterone, bioavailable testosterone, and free testosterone - [LH, FSH, prolactin, CBC, liver panel, ferritin, PSA, TSH, fT4, AM cortisol, ACTH, DHEAS, A1c, IGF-1, HCG, calcium, 25OH vitamin D, B12] - [Screening for OSA] - [Testicular ultrasound] - [MR sella] - [Treatment] - [Follow-up] Patient Counseling: I counseled the patient on causes of risks and benefits of testosterone supplementation, including polycythemia, potentially increased risk of heart attacks and stroke, and increased growth of an existing prostate cancer. 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