Precocious Puberty Evaluation Note

Date/Time: [Encounter date and time]

Visit Type: [new evaluation / referral / second opinion] (If referral, include referring clinician and practice)

Informant: [parent/guardian / patient / other]; [reliable / limited / unknown]

Interpreter: [not needed / language and interpreter name/ID] (Only include if applicable)

Chaperone: [name and role / offered and declined / exam deferred with reason]

Chief Concern

[One-line reason for evaluation]

History of Present Illness

[Narrative summary of pubertal concerns including: age at onset and who first noticed; tempo and progression of changes; gonadal/HPG-axis signs such as breast development, testicular/penile enlargement, vaginal discharge or bleeding, voice change; adrenarche signs such as pubic hair, axillary hair, body odor, acne; presence or absence of neurologic/CNS symptoms including headaches, visual changes, emesis, seizures, polyuria/polydipsia; any virilization or feminization features; exogenous hormone exposure history including topical gels/creams, supplements, caregiver contact exposures; relevant medical context such as CNS disease, radiation, obesity, SGA/IUGR; psychosocial impact; and any prior evaluation with dates and key results] (Explicitly ask about and document hormone exposures; do not infer. Use "unknown" or "not obtained" when information is missing.)

Growth Data

• Anthropometrics (today): Height [value] ([percentile], Z=[Z-score]); Weight [value] ([percentile], Z=[Z-score]); BMI [value] ([percentile], Z=[Z-score])
• Growth velocity: [value over interval] (State interval dates and data source)
• Percentile crossing history: [trajectory description / insufficient data]
• Mid-parental target height: [calculated value with parent heights used / parent heights unknown]
• Data gaps: [incomplete records / unable to calculate velocity / none] (If gaps present, state plan to obtain prior measurements)

Birth and Development

• Birth history: [Gestational age]; [birth weight]; [birth length]; SGA/IUGR [yes / no / unknown]
• Development: [age-appropriate / concerns with brief description]

Past Medical History

• [CNS history including tumor, radiation, trauma, seizures]
• [Thyroid disease]
• [Known endocrine syndromes or genetic conditions]
• [Chronic illnesses affecting growth or puberty]
• [Relevant surgical history]

(Omit categories with no relevant history)

Medications and Allergies

• Medications: [Current medications and supplements with doses]
• Topical products: [Hormone-containing or androgen/estrogen-like products with application sites / none]
• Household hormone exposures: [Details / none identified] (Explicitly document; do not infer)
• Allergies: [Drug/food allergies with reactions / NKDA]

Family History

• Maternal menarche: [age / unknown]
• Paternal pubertal timing: [voice change/growth spurt timing / unknown]
• Sibling pubertal timing: [details / none / unknown / not applicable]
• Parental heights: Mother [height], Father [height] (for target height calculation)
• Endocrine/oncologic history: [Thyroid disease, CAH, PCOS, pituitary/adrenal/gonadal tumors, neurocutaneous disorders / none known]

Social History

• Living situation: [Details]
• School/grade: [Details]
• Nutrition/activity: [Brief summary] (Include if obesity or weight trajectory is relevant)
• Household medication exposure risks: [Details / none identified]

Review of Systems

• Constitutional: [Weight change, appetite, energy]
• Neurologic: [Headaches, vision changes, seizures]
• Endocrine: [Heat/cold intolerance, polyuria/polydipsia]
• Skin: [Acne, café-au-lait macules, hirsutism]
• GI: [Constipation]

(Conclude with "Otherwise negative per focused ROS" if applicable)

Physical Examination

Vitals and Anthropometrics: Height [value] ([percentile]); Weight [value] ([percentile]); BMI [value] ([percentile]); BP [value] ([percentile]); HR [value]

General Examination: Skin [acne, hirsutism, café-au-lait macules, striae findings]; Thyroid [size, nodules, tenderness]; Neurologic [grossly intact / abnormal findings; visual fields if indicated]; Abdomen [soft, nontender, no masses / abnormal findings]

Pubertal Staging (SMR/Tanner):

• Girls: Breast [B1–B5]; Pubic hair [PH1–PH5]; Axillary hair [present / absent]; Estrogen effect [vaginal mucosa findings]
• Boys: Genital [G1–G5]; Pubic hair [PH1–PH5]; Testicular volume [value mL, method: orchidometer / ultrasound]; Penile size [normal / abnormal]
• Discordant patterns: [Description / none]

(Do not infer staging without examination. If exam not performed, state reason and plan for in-person staging.)

Chaperone: [Chaperone present: name and role / offered and declined]

Results

Bone Age: [Date]; method [Greulich-Pyle / other]; chronologic age [value]; bone age [value]; [advanced by X years / delayed by X years / concordant]; Predicted adult height [value / not calculated] (State "not available; ordered today" if pending)

Laboratory Results: [Date/time of draw]

• LH [value]; FSH [value]
• [Estradiol / Testosterone] [value]
• DHEAS [value]
• TSH [value]; Free T4 [value]
• 17-OHP [value] (If obtained for CAH evaluation)
• β-hCG [value] (If obtained for peripheral pattern in boys)

Interpretation: [Pattern suggests central activation / suppressed gonadotropins suggest peripheral source / indeterminate / pending]

Imaging:

• Pelvic ultrasound: [Date]; uterus [size], ovaries [volume, cysts], endometrial stripe [present / absent] (If performed)
• Brain MRI: [Date]; [normal / abnormal with findings]; contrast [yes / no] (If performed)

Assessment

[Age]-year-old [sex] evaluated for early pubertal changes characterized by [key findings and tempo]. Growth velocity [value with interpretation]. Bone age [advanced / delayed / concordant] by [magnitude]. Findings most consistent with [benign variant / central precocious puberty / peripheral precocious puberty / indeterminate requiring further evaluation].

• Supporting evidence: [Progression pattern, staging concordance, growth velocity, bone age, gonadotropin pattern]
• Opposing/uncertain factors: [Factors that do not fit working diagnosis / none]
• CNS lesion risk factors: [Male sex, age under 6, neurologic symptoms, known CNS disease / none identified] (Include if CPP suspected)
• Alternative considerations: [Exogenous hormone exposure, hypothyroidism, CAH, tumor / none] (Include if relevant)

Plan

Early Puberty Evaluation

• Approach: [Observation with serial exams in 3-6 months / laboratory workup / imaging] with rationale
• Laboratory orders: [Basal LH, FSH, estradiol or testosterone, DHEAS, TSH, free T4, other tests as indicated / none at this time] (Note if stimulation testing indicated)
• Bone age: [Ordered today / completed, see Results / deferred with rationale]
• MRI decision: [Indicated based on risk factors / shared decision-making with family / not indicated] (Document counseling about sedation and incidental findings if applicable)
• Pelvic/testicular ultrasound: [Ordered / not indicated] with rationale

Growth and Height Prognosis

• [Counseling provided regarding predicted adult height impact and uncertainty]
• [Plan for serial growth measurements at follow-up]

Counseling and Anticipatory Guidance

• [Education on normal vs early puberty, expected sequence, signs of progression]
• [Psychosocial support discussed]
• [Anticipatory guidance for menarche] (If relevant)

[Additional Problem]

[Problem-specific assessment and plan] (Include additional headings as needed for obesity, thyroid concern, exposure concern, etc.)

Return Precautions

New or worsening neurologic symptoms; rapid pubertal progression; vaginal bleeding in a young child; severe headaches or vision changes.

Follow-up

• Return in [timeframe] or sooner if [triggers]
• Pending results to be communicated by [method/person] within [timeframe]
• Communication to referring provider: [sent / will send / not applicable]

(Use explicit labels when information is missing: "unknown," "not obtained," "pending," or "deferred" with reason. Do not leave fields blank or infer data not directly obtained.)