Prolactin

Chief Complaint

Assessment of elevated prolactin

Template

Dear Dr. [name], Thank you for referring [name], a [age] year old [gender], who was seen on [date] for assessment of elevated prolactin. The patient was seen [in person or via telemedicine]. We spoke in [English or Mandarin]. 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: [Initial symptoms and initial workup.] [Progression of symptoms and further workup.] Galactorrhea: Menstruations: Headaches: Vision changes: Hypogonadism symptoms: Significant stress, eating disorder, strenuous exercise, or excess nipple stimulation: No medications associated with hyperprolactinemia 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] [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] [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) [Use of dopamine antagonists] [Use of marijuanna] 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] The patient [does/does not] have a family history of pituitary disorders, elevated prolactin, galactorrhea, infertility, or menstrual irregularities. EXAM: [general exam, weight, height, vitals, cardiac exam, pulmonary exam] Weight: Height: Blood pressure: Heart rate: Visual field: INVESTIGATIONS: [investigations] (List each lab value in its own line, do not list numerically). IMPRESSION AND PLAN: [name] is a [age] [gender] with elevated prolactin likely secondary to [diagnosis]. Other possible etiologies include [differential diagnosis]. 1. Elevated prolactin: (Use first person tone, such as "I have...") - [Macroprolactin] - [MR sella] - [I have initiated treatment with cabergoline 0.25mg PO twice weekly] - [Follow-up] - [I have arranged for a referral for formal visual field testing] 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. I discussed the side effects of dopamine agonists, such as GI upset and symptoms of disinhibition (behavioral change, excess spending, gambling, or inappropriate sexual acts). I encouraged the patient to inform his close friends and family of possible disinhibition and to point it out if they notice these changes. 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. Leo Hu, MD, FRCPC Elida Medical Centre