Pituitary lesion

Chief Complaint

Pituitary lesion

Template

Thank you for referring [name], a [age] year old [gender], who was seen on [date] for assessment of a pituitary lesion. 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.] Headaches: Vision changes: Anosmia: Midline defects: [Symptoms of infiltrative disorders: ] Pituitary Review of Systems: [Vasopressin deficiency: polyuria, polydipsia, weight loss] [Cushing's syndrome: weight gain, skin thinning, easy bruising, abdominal striae, mood changes, osteoporosis/fractures] [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) 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] [Family history of pituitary lesions 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] Occular movements: [ocular_movements] Midline structures: [midline_structures] Cushingnoid features: [cushingnoid_features] Acromegaly features: [acromegaly_features] Thyroid exam: [thyroid_exam] [Testicular exam] Investigations: [investigations] Impression and Plan: [name] is a [age] [gender] presenting with [diagnosis]. The differential diagnosis for a pituitary lesion includes pituitary adenoma (productive or nonproductive), other tumors of the brain (carniopharyngioma, Rathke's cleft cyst, meningioma), empty sella syndrome, lymphoma, metastases, infiltrative diseases (histiocytosis, IgG4-related disease, lymphocytic hypophysitis, hemochromatosis), infectious (TB, sarcoidosis, pituitary abscess), or vascular (apoplexy, aneurysm, Sheehan's). Pituitary carcinoma is extremely rare. 1. Pituitary lesion: [working diagnosis]. Differential also includes [differential diagnosis] (Use first person tone, such as "I have...") - [Full pituitary panel, electrolytes, serum and urine osmolality, eGFR] - [Testing for infiltrative disorders, including ferritin, IgG subtype, hCG, ACE level] - [MR sella] - [I have arranged for a referral for formal visual field testing] - [I have arranged for a fluid deprivation test to assess possible partial vasopressin deficiency] - [I have initiated hormone replacement therapy with the following:] - [I have discussed possible genetic testing for syndromes of pituitary adenoma, including MEN1, FIPA, Carney Complex, McCune-Albright, and DICER1] 2. Follow-up: - [Timing of follow-up] Patient Counseling: I counseled the patient on [medical alert bracelet, sick day management, taking levothyroxine fasting and at least an hour away from other ingestions, water deprivation protocol]. 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]