Endocrinology New Patient Consultation Note

Patient: [Name] | [MRN] | [DOB / Age] | [Sex]
Date: [Encounter date]
Visit Type: New patient endocrine consultation
Referring Clinician: [Name, Specialty, Contact]
Reason for Consultation: [Brief referral question]

Consult Summary

Referral Question: [Stated or paraphrased referral question]
Clinical Context: [One-sentence clinical context]
Working Diagnostic Impression: [Most likely diagnosis or differential with uncertainty explicitly noted when present]

• Recommendations (Completed Today): [Actions taken during this visit]
• Recommendations (Pending): [Next steps with timing and prerequisites]
• Consultant Role and Follow-up: [consult only / co-management / assuming longitudinal care]; [Follow-up interval and modality]

Communication Plan: [How and when consult report will be communicated to referring clinician]

History Source

[History obtained from patient / family / caregiver / interpreter]. [Outside records reviewed with source and dates]. (Note any reliability limitations affecting confidence in the history. If key records are unavailable, state what is missing and plan to obtain.)

Outside Records and Data Reconciliation

(Summarize externally obtained information before interpretation. Use concise entries with dates; do not paste full reports.)

• Prior Endocrine Diagnoses: [Diagnosis] — [Year of onset / timeline / course]
• Key Prior Labs: [Test: value (date) → value (date)] (Include trends when relevant.)
• Imaging/Procedures: [Date] | [Modality] | [Key findings]
• Prior Specialist Assessments: [Clinician/Service] | [Date] | [Main conclusions]
• Prior Treatments: [Therapy] | [Dates] | [Response and reason for change/discontinuation]
• Records Gaps: [What is missing] — [Plan to obtain]

History of Present Illness

[Chief concern and referral context. Onset, course, severity. Prior evaluation and treatments. Relevant symptoms and red flags. Patient goals and preferences. Functional impact.] (Organize by problem if multiple endocrine issues. Use direct patient quotes only when clinically relevant.)

(Include problem-specific details only as relevant to the referral: Diabetes: hypoglycemia/DKA/HHS history, technology use, complications, adherence barriers; Thyroid: compressive or eye symptoms, iodine/supplement exposure; Adrenal: glucocorticoid use, orthostasis, episodic symptoms; Pituitary: headaches, visual changes, galactorrhea; Calcium/Bone: nephrolithiasis, fractures, antiresorptive history, fall risk; Reproductive/Androgen: cycle history, fertility goals, virilization; Obesity: weight trajectory, prior interventions, eating patterns, sleep apnea.)

Past History

• Past Medical History: [Endocrine-relevant comorbidities: CKD, CAD, liver disease, osteoporosis, malignancy, bariatric surgery]
• Surgical History: [Endocrine-relevant surgeries with dates]
• Reproductive Status: [Pregnancy status/plans or menopause status] (Include when relevant to management.)
• Family History: [Endocrine diseases, early cardiovascular disease, endocrine tumors, fractures]
• Social History: [Tobacco, alcohol, substances; occupation/shift work; diet pattern; physical activity] (Include only details relevant to management.)

Medications and Allergies

Medication Reconciliation: [Completed / partially completed] — Sources: [Patient list / pharmacy records / outside records]

• Current Medications: [Name | Dose | Route | Frequency | Indication] (Note recent changes, adherence issues, and access barriers.)
• Diabetes Technology/Regimens: [Pump model/settings] | [CGM model and wear time] | [Insulin regimen details] | [Rescue glucagon availability] (Include only if applicable.)
• Supplements Affecting Endocrine Testing: [Biotin, iodine/kelp, calcium, vitamin D] (Note dose and timing relative to labs.)
• Allergies: [Agent] — [Reaction type: allergy vs intolerance]
• Information Gaps: [Missing medication/allergy details and plan to obtain] (Do not omit; document if incomplete.)

Review of Systems

[Focused endocrine ROS with pertinent positives and high-value negatives tailored to active problems] (Avoid exhaustive system-by-system documentation unless clinically necessary.)

Physical Examination

Vitals: Ht [height] | Wt [weight] | BMI [BMI] | BP [BP] | HR [HR] | [Orthostatics if indicated]

• General: [Appearance, distress, body habitus]
• Thyroid: [Size, nodules, tenderness, bruit, surgical scars]
• Eyes: [Lid lag, proptosis, conjunctival findings, EOMs] (Include when relevant.)
• Cardiovascular: [Rate, rhythm, edema]
• Neurologic: [Tremor, reflexes, visual fields]
• Skin: [Acanthosis, hyperpigmentation, striae, hair changes]
• Diabetic Foot Exam: [Pulses, sensation/monofilament, ulcers, deformities] (Include when indicated.)
• Other Focused Findings: [Additional findings relevant to referral]

Results Reviewed

(Include completed results with dates. Highlight abnormal values and trends. Do not list pending studies here.)

• Laboratory Data: [Test: value (units) (date)] (Note trends and interpretation.)
• Imaging: [Date] | [Modality] | [Region] | [Impression]
• Device Data: [CGM: time in range, time below range, GMI] | [DXA: T-scores with FRAX if applicable] (Include when relevant.)

Assessment

(Organize by problem in order of clinical priority. Distinguish known facts from assumptions; label interpretive statements with phrases such as "most consistent with" or "concerning for.")

[Problem 1]: [Working diagnosis] — [new / established / uncontrolled / uncertain]

• Key Evidence: [2–5 points supporting assessment]
• Differential/Uncertainty: [Competing diagnoses and rationale] (Include when diagnostic uncertainty exists.)
• Risk Considerations: [Severity, complications, prognostic factors]

[Problem 2]: [Working diagnosis] — [Status]

• Key Evidence: [Supporting points]
• Differential/Uncertainty: [As applicable]
• Risk Considerations: [As applicable]

(Add additional problems as needed.)

Plan

(Mirror the Assessment problem by problem.)

[Problem 1]

• Actions Today: [Medication changes with doses and rationale; counseling provided; procedures performed]
• Diagnostics Ordered: [Tests with timing and prerequisites (e.g., fasting, hold biotin 48–72 hours)]
• Contingencies: [If/then logic based on pending results or clinical changes]
• Patient Instructions: [What to do, preparation steps, how results will be communicated, when to call urgently] (Use plain language.)
• Follow-up: [Interval] | [Modality] | [Requirements before next visit]

[Problem 2]

• Actions Today: [As above]
• Diagnostics Ordered: [As above]
• Contingencies: [As above]
• Patient Instructions: [As above]
• Follow-up: [As above]

(Add additional problems as needed.)

Care Coordination

• Communication to Referrer: [How and when consult report was or will be transmitted]
• Responsibility Assignment: [Which clinician handles refills, lab monitoring, follow-up imaging orders]
• Patient Understanding: [Confirmed understanding of plan; contact information for questions]