Gender Affirming Care Follow-Up

Appointment date: 1 November 2024 Diagnosis: Gender Dysphoria Preferred name: Alex Height: 170 cm Weight: 65 kg BMI: 22.5 Vitals: BP: 120/80 mmHg Heart rate: 72 bpm Current Medications: - Estradiol 2 mg daily - Spironolactone 100 mg daily Labs: Testosterone = 0.5 ng/mL Testosterone – Free = 0.1 ng/mL Estradiol = 200 pg/mL Cholesterol = 180 mg/dL Total triglyceride = 150 mg/dL LDL cholesterol = 100 mg/dL HDL cholesterol = 60 mg/dL Liver Enzymes: ALT = 25 U/L ALP = 70 U/L AST = 20 U/L GGT = 30 U/L Renal Function: eGFR = 90 mL/min/1.73 m² Serum creatinine = 0.8 mg/dL BUN = 14 mg/dL Electrolytes: Sodium = 140 mmol/L Potassium = 4.2 mmol/L Calcium = 9.5 mg/dL Vitamin D = 30 ng/mL Required bloodwork on follow-up: - Repeat hormone levels - Lipid panel Gender Affirming Changes: - Mental health: Improved mood, no signs of depression - Energy levels: Stable - Libido: Increased - Bodily changes: Noticeable breast development, softer skin, reduced body hair - Urination: Normal - Appetite: Increased Side Effects and Red Flags: - No significant side effects reported Physical Assessment: General State of Health: Skin: Clear, no rashes HEENT: Normal Respiratory: Clear breath sounds Cardiovascular: Regular heart rate and rhythm GI: No abdominal tenderness GU: Normal MSK: Normal muscle tone Lifestyle: - Physical activity: Regular exercise, 3 times a week - Food habits: Balanced diet - Smoking: Non-smoker - Alcohol use: Occasional - Recreational substance use: None Plan: - Continue current medication regimen - Monitor hormone levels and adjust doses as needed - Schedule follow-up appointment in 3 months