Endocrinology New Patient Consultation

(Always write in a fluent, easy to read and concise manner with a narrative tone.) [date of review] (Write in YYMMDD format. Only include if explicitly mentioned in transcript, context or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank.) Dear Dr [recipient's name], (Only include if explicitly mentioned in transcript, context or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank.) <u>Endocrinology New Patient</u> [patient's name] (Only include if explicitly mentioned in transcript, context or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank.) was referred by [referrer's name and title] (Their GP or specialist referrer, and General Practitioner's name. Only include if explicitly mentioned in transcript, context or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank.) for [reason for consultation] (Specific endocrine concerns or symptoms such as growth disorder, short stature, deranged thyroid function, fatigue, unexplained weight gain or loss, cold or heat intolerance, hair thinning or loss, menstrual irregularities, delayed or precocious puberty, gynaecomastia, excessive sweating, growth abnormalities, or polydipsia/polyuria. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.). [patient's name] was [patient's age] (Write as YY and MM format. Only include if explicitly mentioned in transcript, context or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank.) and attended with [accompanying persons] (First names of the patient's parents or guardians, or who accompanied the patient, e.g. both parents, guardian, other family members. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) [presenting complaint history] (Describe the primary reason for the endocrinology referral, such as concerns about growth, thyroid issues, or suspected hormone imbalances as indicated by the referring provider or family. Include history of presenting complaints including onset, duration, progression, severity, pattern, associated symptoms, previous evaluations, treatments received, and patient response. Write in paragraph form. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) **Past Medical History:** - Pregnancy and birth: [pregnancy and birth details] (Include details of the pregnancy and birth, such as complications during pregnancy, birth weight, and gestational age at birth. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) - Developmental: [developmental milestones] (Summarise key developmental milestones, noting any concerns in areas such as motor skills, language, or social development. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) - [other relevant history] (Summarise any other key symptoms or medical history related to endocrine issues. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) **Family History:** [family history] (Record family medical history of endocrine or related conditions, including the onset of puberty, diabetes, thyroid disorders, or other genetic conditions in immediate family members. Include other significant health issues. Include both parent heights, details of age at puberty onset, and occupations if mentioned. Use bullet points. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) **Examination** **Height** [height] (Record the patient's height in centimetres along with the corresponding growth centile for age and sex. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.), **Weight** [weight] (Record the patient's weight in kilograms along with the corresponding growth centile for age and sex. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.), **BMI** [BMI] (Calculate BMI based on height and weight and include the BMI centile based on age and sex, include Z-score if explicitly mentioned. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.). Blood pressure [BP] (Record the patient's BP expressed as mmHg. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.). "Cardiovascular, respiratory, abdominal, thyroid, spine examinations were normal." [additional examination findings] (Thyroid gland palpation, signs of goitre, tremor, skin changes (e.g. acanthosis nigricans, vitiligo), hirsutism, gynaecomastia, galactorrhoea, testicular size, breast development, or Tanner staging. Write as bullet points. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) Pubertal assessment: [Tanner staging] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) [other examination findings] (Document additional examination findings explicitly mentioned, such as skin pigmentation or lesions, muscle tone, or specific signs associated with endocrine disorders, or a Beighton score of joint hypermobility. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) **Investigations available:** [investigations] (List any prior relevant investigations, such as blood tests, imaging studies (e.g. TSH, T3/T4, cortisol, ACTH, LH, FSH, prolactin, insulin, glucose, HbA1c, calcium, vitamin D), urine studies, imaging (e.g. thyroid ultrasound, adrenal CT/MRI, pituitary MRI), or bone mineral density scans, along with findings if available. Use bullet points. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) <u>Impression</u> [impression] (Initial or suspected diagnosis based on examination and history, such as hypothyroidism or growth hormone deficiency. List other possible diagnoses that are being considered based on the patient's presentation. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) Discussions with child/family: [discussions] (Summarise the key points discussed with the family, including explanations of the diagnosis, treatment options, lifestyle recommendations, and any family questions or concerns raised. Document the family's understanding and agreement with the plan. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) **PLAN** - [investigations ordered] (Specify any additional tests ordered, such as hormone levels, imaging, or other diagnostic studies relevant to the suspected condition. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) - Treatment: [treatment] (Outline any treatments started, including medications, dietary advice, or referrals to other specialists. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) - Follow up: [follow-up] (Summarise any follow-up appointments, instructions for home care, or next steps. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) Kind Regards, [clinician's name] [practice name and address] [qualifications and title] [provider number] "Heidi Medical AI Scribe used with patient/guardian consent during the consultation to assist in the preparation of this record. This record/document has been reviewed and finalised by the author."