Pituitary/Adrenal Axis Evaluation Note

Date/Time: [Date and time of encounter]

Setting: [outpatient / inpatient]

Note Type: [initial evaluation / test result review / interval follow-up]

Referral Source: [Referring clinician and specific clinical question]

Information Sources and Reliability

• [Patient interview and symptom history] (Note interpreter use and historian reliability)
• [Outside records reviewed: sources and date range] (List key gaps in available records)
• [Imaging reports and prior endocrine notes reviewed] (State if images were personally reviewed vs report only)
• [Medication reconciliation and pharmacy verification status]
• [Limitations and missing critical data] (Flag unknowns explicitly; do not infer)

Patient Summary

One-sentence summary: [Age], [relevant clinical context], evaluated for [primary HPA axis question: suspected primary vs central adrenal insufficiency / ACTH-dependent vs ACTH-independent hypercortisolism / pituitary lesion with possible mass effect or hormone dysfunction].

Safety status: [Adrenal crisis risk / pituitary apoplexy or mass effect concern / significant electrolyte derangements / pregnancy status]. [Actions taken today if urgent risk present: empiric stress-dose coverage, urgent specialty referral, ED referral].

Chief Concern and Clinical Questions

Chief concern: [Patient's phrasing of main concern] (Include when informative)

Clinical framing: [Clinical statement translating concern into HPA axis terms]

• [Testable clinical question #1] (e.g., Is cortisol deficiency present and is it primary vs central?)
• [Testable clinical question #2] (e.g., Is hypercortisolism present vs pseudo-Cushing physiology?)
• [Additional clinical questions as applicable]

History of Present Illness

[Narrative time course and trigger] (Begin with onset and context: post-surgery, glucocorticoid taper, new pituitary lesion, postpartum, intercurrent illness. Describe why evaluation is occurring now and why pre-test probability is non-trivial. Reference prior testing with dates and clinical context. Embed only key dated results here; reserve detailed data for Objective.)

Since Last Visit: [Interval symptoms, intercurrent illnesses, steroid exposures, hospitalizations, new testing] (Include for follow-up notes only; omit for initial evaluations)

Symptom Review

• Hypocortisolism symptoms: [Fatigue, weight loss, anorexia, nausea, orthostasis, salt craving, hyperpigmentation] (Include onset, frequency, severity; document pertinent negatives)
• Hypercortisolism symptoms: [Proximal weakness, easy bruising, wide/purple striae, facial rounding, dorsocervical fat pad, mood/menstrual changes, new or worsening hypertension/diabetes/osteoporosis] (Include onset, frequency, severity; document pertinent negatives)
• Pituitary lesion symptoms: [Headache pattern, visual symptoms, galactorrhea, symptoms of other pituitary hormone deficits] (Include pertinent negatives)

Medication and Exposure Confounders

(Required section for HPA axis interpretation. Document all routes with agent, dose, frequency, duration, indication, taper, and exact last use date/time.)

Current medications:

• [Systemic glucocorticoids: agent, dose, frequency, start date, taper plan, last dose date/time]
• [Non-oral glucocorticoids: inhaled / intranasal / topical / intra-articular / epidural / ophthalmic with agent, potency, frequency, last use]
• [Medications affecting HPA axis or assays: oral estrogen, enzyme inducers/inhibitors, opioids, antifungals, anti-epileptics]
• [Current endocrine replacements and timing relative to planned labs]

Prior relevant exposures:

• [Past glucocorticoid courses: indication, cumulative dose/duration, stop date]
• [Recent procedures with steroid injections: type, site, date]

Uncertain exposures: [Exposure history uncertain or incomplete] (Document verification plan: pharmacy records, outside prescriber contact, prior EMR)

Relevant Past History

• Pituitary: [Tumors, surgery, radiation, apoplexy, head trauma, postpartum hemorrhage, checkpoint inhibitor exposure]
• Adrenal: [Incidentaloma, prior surgery, congenital adrenal hyperplasia, TB/fungal risk]
• Autoimmune: [Thyroiditis, T1DM, celiac, vitiligo, pernicious anemia] (Include if primary AI possible)
• Reproductive: [Pregnancy/lactation status if affecting test selection]
• Metabolic: [Fractures, osteoporosis, diabetes, hypertension]
• Psychiatric/substance: [Depression, alcohol use, conditions contributing to pseudo-Cushing]

Family and Social History

• [Family history: endocrine tumors, MEN syndromes, pituitary/adrenal tumors, autoimmune clustering]
• [Social/logistical factors: shift work, irregular sleep, transportation constraints, fasting tolerance, caregiver support]

Objective

Vitals and Physical Exam

• Vitals: [BP, HR, Temp, RR, SpO2, weight/BMI with trend, orthostatics if AI suspected]
• General: [Appearance, volume status]
• Skin: [Hyperpigmentation, bruising, striae width/color, acne]
• Musculoskeletal: [Proximal muscle strength]
• Neuro-ophthalmic: [Visual fields by confrontation] (Note limitations and need for formal testing)
• [Other focused exam findings] (Document only what was performed)

Laboratory Data

(Include test name, result, units, reference range, collection date/time, context, and internal vs outside. If key context is missing, mark as not interpretable.)

• Cortisol/ACTH: [AM cortisol and ACTH with collection time and context]
• Electrolytes: [Na, K, Cr with reference ranges]
• Hypercortisolism screening: [Late-night salivary cortisol / overnight DST / 24-hour UFC with collection adequacy]
• Dynamic testing: [ACTH stimulation / ITT / metyrapone: protocol, time points, results, adverse events]
• Other pituitary axes: [TSH/Free T4, LH/FSH/sex steroids, IGF-1, prolactin]
• [Additional relevant labs as indicated]

Imaging

• Pituitary MRI: [Date, lesion size/location, enhancement, optic apparatus/cavernous sinus involvement] (State: images personally reviewed vs report only)
• Adrenal CT/MRI: [Date, side, size, imaging characteristics, interval growth]

Assessment

(Organize by problem using calibrated language: "consistent with," "suggestive of," "cannot exclude," "indeterminate." Maintain stable problem numbering across visits. Add or remove problems as clinically indicated.)

Problem 1: [Working diagnosis or concern]

• Supporting features: [Phenotype and key objective data]
• Features against: [Contradictory findings]
• Confounders: [Steroid exposure, estrogen use, assay issues, test contraindications]
• Interpretation: [Synthesis with calibrated language]
• Next step rationale: [Why this diagnostic or therapeutic action is chosen]

Problem 2: [Working diagnosis or concern]

• Supporting features: [Phenotype and key objective data]
• Features against: [Contradictory findings]
• Confounders: [Steroid exposure, estrogen use, assay issues, test contraindications]
• Interpretation: [Synthesis with calibrated language]
• Next step rationale: [Why this diagnostic or therapeutic action is chosen]

(Add additional problems as needed)

Plan

Safety Actions

• [Adrenal crisis risk assessment and interim coverage plan]
• [Emergency triggers reviewed: vomiting preventing oral intake, severe weakness/syncope, hypotension, confusion]
• [Glucocorticoid emergency education and supplies: sick-day rules, injection kit] (If not completed, document reason and plan)

Diagnostic Testing

• [Screening tests: modality selection rationale based on sleep schedule, renal function, pregnancy, medications]
• [Dynamic testing: indication, preconditions, contraindications screened, monitoring/rescue plan, institutional protocol reference]
• [Sequencing: confirm hypercortisolism before ordering localization imaging]

Therapeutic Plan

• [Medication changes: drug, dose, route, frequency, start date, taper, rationale]
• [Deferred therapy with interim risk mitigation if awaiting testing]
• [Referrals: neurosurgery, ophthalmology, genetics, endocrine surgery with urgency level]

Follow-up and Coordination

• [Follow-up timing tied to clinical risk and testing schedule]
• [Communication plan: referring clinician update, responsibility for tracking pending results]

Patient Education

• [Condition and diagnostic strategy explained; risks/benefits of planned tests]
• [Medication adjustments and sick-day rules reviewed]
• [Safety-netting and contact information provided]
• [Patient preferences/constraints and how plan was adapted]

(When information is missing or uncertain, document as unknown—do not infer. Omit inapplicable subsections rather than leaving empty.)