Endocrine system

{Endocrine system}

[+] yes, present, positive
[-] no, absent, negative
[~] equivocal
[\] not applicable, not performed
[?] unknown, unsure, unavailable
{ } annotation, comment

PRESENTING COMPLAINTS OR ISSUES
Reasons for visit:
[-] new problem/issue
[-] review/follow-up

Hyperthyroidism symptoms: 
[-] heat intolerance 
[-] weight loss 
[-] increased appetite 
[-] palpitation 
[-] hyperhydrosis 
[-] nervousness/increased arousal 
[-] diarrhoa

Hypothyroidism symptoms: 
[-] goitre 
[-] cold intolerance 
[-] low energy 
[-] periorbital oedema 
[-] hoarse voice 
[-] coarse skin 
[-] constipation

Diabetes mellitus symptoms: 
[-] polyuria 
[-] polydipsia 
[-] abnormal thirst 
[-] skin infections

Adrenal symptoms: 
[-] resistant hypertension 
[-] hypotension 
[-] orthostatic symptoms 
[-] skin pigmentation

Female reproductive symptoms: 
[-] cycle abnormality 
[-] abnormal pv bleeding 
[-] altered libido

Male reproductive symptoms: 
[-] erectile dysfunction 
[-] reduced stamina/energy 
[-] altered libido

History of presenting complaint:
-

Management to date:
[-] iodine supplements 
[-] antithyroid drugs 
[-] iodine-131 
[-] thyroxine 
[-] insulin and other glucose-lowering medication 
[-] corticosteroids 
[-] mineralocorticoids 
[-] sex steroids 
Details: 
-

Diagnostic investigation results:
[+] 
[~] 
[-] 
[?]

PAST MEDICAL HISTORY
Relevant past medical history:
[-] neck surgery or irradiation (around the thyroid gland) 
[-] delivery of large babies 
[-] gestational diabetes 
[-] hypertension 
[-] pheochromocytoma 
[-] Cushing syndrome 
[-] Cohn syndrome (hyperaldosteronism) 
[-] infertility

FAMILY HISTORY
Relevant family history:
[-] goitre 
[-] diabetes mellitus 
[-] multiple adenomas (autosomal dominant)

[Vital signs]

Skin colour: 
Temp (deg.C): 
HR (bpm): 
Heart rhythm: 
BP seated (mmHg): 
BP standing (mmHg): 
BP lying (mmHg): 
Respiratory rate (/min): 
SpO2 (%):

PHYSICAL EXAMINATION
Relevant examination findings:
[-] goitre
[-] exophthalmos
[-] pretibial myxoedema
[-] lid lag
[-] central obesity

ASSESSMENT
Clinical summary:
[+] 
[~] 
[-]

Diagnosis/es:
1. 
2.

Differential diagnosis:
-

MANAGEMENT PLAN
Procedures performed:
-

Diagnostic investigations requested:
-

Referrals:
-

Information and advice given:
-

Medication:
-

FOLLOW-UP
Outstanding issues:
-

Next appointment:
-

[dqref.com 260131]

Endocrine system

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