Congenital Adrenal Hyperplasia Follow-Up Note

Date: [Date]

Patient: [Patient name / MRN]

Clinician: [Clinician name, credentials]

Visit Type: [in-person / telehealth]

Reason for Visit

[One-line visit purpose; may include brief patient/caregiver quote if helpful]

CAH Background

(Persist across visits; update only when information changes. For safety-critical items, document "Not yet assessed" if unknown rather than omitting.)

• Diagnosis: [CAH type, phenotype (salt-wasting / simple virilizing / nonclassic), age at diagnosis]
• Key history: [Prior adrenal crises with number/dates, relevant surgeries, significant complications]
• Emergency preparedness: [Medical alert ID status, injectable hydrocortisone availability, training status]

Interval History

[Narrative summary since last endocrine visit: intercurrent illnesses, ER visits, hospitalizations; stress dosing use and response; adherence patterns and barriers; signs of overtreatment or undertreatment; developmental milestones and pubertal progression for pediatrics; mood, energy, and psychosocial concerns as age-appropriate]

Sick-day rules and emergency injection technique reviewed today: [yes / no / deferred: reason] (Safety-critical element; do not omit silently.)

Current Medications

(Include both prescribed regimen and actual use if they differ.)

• Glucocorticoid: [Name, dose, schedule; for pediatrics include mg/m²/day with BSA used]
• Mineralocorticoid: [Name, dose, schedule]
• Emergency supplies: [Injectable hydrocortisone dose, expiration if known]
• Other relevant medications: [As applicable]
• Allergies: [List or verified NKDA]

Objective

• Vitals: [BP with percentile/category, other vitals as relevant]
• Growth: [Height, weight, BMI with percentiles/z-scores for pediatrics; growth velocity in cm/year with measurement interval]
• Exam: [Pertinent findings: general appearance, cushingoid features, skin changes, virilization signs, pubertal staging as relevant]
• Trends: [Brief summary of growth velocity trajectory, BP pattern, and dose changes across recent visits]

(For telehealth: document limitations and any home measurements used.)

Labs/Data Reviewed

[Lab collection date/time and relationship to medication timing (e.g., pre-morning dose, 2 hours post-AM dose); relevant hormone levels (17-OHP, androstenedione, testosterone), electrolytes, renin; bone age if obtained] (Timing context is essential for interpretation. Emphasize trends across measurements rather than single values.)

(If no new labs: "No new labs since [date]" and note planned monitoring in Plan.)

Assessment & Plan

(Organize by clinical problem, prioritizing highest-risk issues. Integrate clinical indicators with biochemical trends.)

CAH Control

[Assessment integrating growth velocity, BP, weight, virilization findings, and lab trends: overtreatment risk / undertreatment risk / adequate control]

• Glucocorticoid: [Continue / adjust to new dose] (For pediatrics: mg/m²/day with BSA.) [Rationale]
• Mineralocorticoid: [Continue / adjust to new dose] [Rationale]
• Monitoring: [Labs to obtain with timing instructions, interval, and target ranges if applicable]

Adrenal Crisis Prevention

• Stress-dose instructions provided: [Oral adjustments for mild illness; injectable hydrocortisone and ED evaluation for vomiting/inability to take oral meds]
• Emergency supplies: [Confirmed current / refill needed; prescription actions taken]
• Written instructions: [Provided via print / portal / not provided]

Additional Problems

[Other issues addressed today as applicable: growth/puberty concerns, BP management, fertility/reproductive health, psychosocial needs, transition planning] (Include only problems actively addressed this visit.)

Follow-Up

• Labs ordered: [Tests with timing instructions relative to dosing]
• Referrals: [If any]
• Prescriptions: [Including emergency supplies if refilled]
• Return: [Interval and precautions for earlier return]

After-visit instructions provided: [yes / no] (Including sick-day rules and emergency action plan.)