Endocrinology Consult

Subjective: - [reason for consultation, including specific endocrine concerns or symptoms such as fatigue, unexplained weight gain or loss, cold or heat intolerance, hair thinning or loss, menstrual irregularities, delayed or precocious puberty, gynecomastia, excessive sweating, growth abnormalities, or polydipsia/polyuria] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentences.) - [detailed history of presenting complaints including onset, duration, progression, severity, pattern, associated symptoms, previous evaluations, treatments received, and patient response] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph form.) - [past medical and surgical history including any previous endocrine diagnoses (e.g., diabetes, thyroid disease, adrenal insufficiency, pituitary tumours), surgeries, hospitalisations (both public and private sector), and complications] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.) - [current medications including hormone replacement therapy, anti-thyroid medications, corticosteroids, insulin, oral hypoglycaemics, bisphosphonates, and nutritional supplements including doses and frequency] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.) - [social history including typical diet (including traditional or staple foods), physical activity level, alcohol use, tobacco use, employment or income status, housing conditions, psychosocial stressors, family planning concerns, cultural health beliefs, and environmental exposures common to the South African context] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph form.) - [known allergies including medications, iodine, radiologic contrast agents, or other relevant substances] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.) Objective: - [vital signs including blood pressure, heart rate, temperature, weight, height, BMI, and relevant growth chart parameters for paediatric patients] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Use metric units — mmHg, bpm, °C, kg, cm, etc. Write as list.) - [physical examination findings including thyroid gland palpation, signs of goitre, tremor, skin changes (e.g., acanthosis nigricans, vitiligo), hirsutism, gynecomastia, galactorrhoea, testicular size, breast development, or Tanner staging] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) - [investigation results including blood tests (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] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list. Ensure local lab units and reference ranges are used if relevant.) Assessment & Plan: [1. Endocrine Issue or Condition] - [assessment including diagnosis or working diagnosis and justification based on symptoms, examination, and investigations] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as paragraph.) - [differential diagnosis with ICD-10 codes (aligned with South African ICD-10 coding standards)] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.) - [investigations planned such as confirmatory hormone testing, imaging, or functional tests available in the South African public or private sector] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.) - [medical treatment plan including medications prescribed (state generic name), changes made to existing therapy, dosing regimen, therapeutic targets, monitoring requirements, potential side effects, and availability through local pharmacy or public hospital] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) - [lifestyle modifications advised including locally relevant dietary guidance (e.g., reduce refined carbs, increase calcium-rich foods), stress management, home-based exercise options, or weight reduction plans suited to resource availability] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) - [follow-up plan including time frame for review, follow-up testing, telephonic vs in-person review (e.g., clinic vs district hospital), and anticipated next steps] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.) - [referrals made to specialists such as public or private endocrinology services, reproductive endocrinology, bariatric clinics, state dietitians, diabetes educators, psychology, or allied health within the local district] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.) [2. Additional Endocrine Issues or Conditions] - [follow same structure as above for each additional issue or condition identified] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Repeat format.) [Additional Notes:] - [patient education provided regarding condition-specific education, health system navigation (e.g., referral pathways or where to collect medication), treatment adherence, and recognition of warning signs or complications] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentences.) - [instructions for symptom monitoring such as home glucose monitoring, blood pressure recordings (e.g., at local clinic), weight tracking, or medication diaries] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) - [any patient or family concerns addressed including fertility, sexual health, body image, psychological wellbeing, cultural beliefs, or long-term health expectations] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph form.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, or continuing care – use only the transcript, contextual notes, or clinical note as a reference. If any information related to a placeholder has not been explicitly mentioned, do not state that it has not been mentioned – simply leave the relevant placeholder or section blank.)