Short Stature/Growth Evaluation Note

Visit Information

Date/Time: [Date and time]
Setting: [primary care clinic / pediatric endocrinology clinic / telehealth / inpatient consult]
Patient Age: [Age in years and months]
Sex at Birth: [Female / Male / Intersex]
Referral Source: [Referring clinician or self-referred]
Historian(s): [patient / parent / guardian / other]
Interpreter: [None / Language and modality]

Chief Concern

[Primary growth concern in one line] (State in plain language and link to measurable growth change when possible, e.g., "Short stature with crossing percentiles" or "Decreasing growth velocity over 12 months." Include brief direct quote from family only if helpful for framing.)

History of Present Illness

[Opening identification and timeframe] (Identify the patient and primary concern with timeframe. Summarize who noticed the change and what prompted evaluation.)

[Growth trajectory over time] (Describe longitudinal pattern, not just current percentile: prior percentiles/z-scores, crossing of percentiles, timing relative to illnesses or life events.)

Symptom screen relevant to growth differential: [Energy level]; [Appetite]; [Weight change]; [GI symptoms: abdominal pain, diarrhea, constipation, vomiting, blood in stool]; [Headaches or vision changes]; [Sleep quality and snoring/apnea]; [Polyuria/polydipsia]. (Document positives and pertinent negatives explicitly; indicate "Not assessed" if a domain was not addressed.)

Puberty: [Onset and progression]; [Menarche details or testicular changes]; [Growth spurt timing] (Include for age-appropriate patients. Omit for infants/young toddlers.)

Nutrition: [Typical intake]; [Dietary restrictions]; [Calcium/vitamin D sources]; [Infant/toddler feeding history if applicable] (Note adequacy, variety, and access.)

Growth-relevant medications/exposures: [Chronic glucocorticoids (inhaled or oral)]; [Stimulants]; [Prior chemotherapy/radiation]; [Other] (Include dose and duration if known. State "None" if no growth-relevant medications.)

Development and school: [Milestone attainment]; [Therapies]; [School functioning] (Emphasize any delays or regression.)

Psychosocial context: [Food insecurity / nutrition access]; [Significant stressors]; [Restrictive eating]; [High-level athletic training] (Include only if relevant or explicitly discussed.)

Auxology & Growth Data

(Present explicit numeric data separately from the HPI narrative. Use the same growth chart source consistently across entries.)

Current Measurements:
Height: [cm] ([percentile and/or z-score])
Weight: [kg] ([percentile and/or z-score])
BMI (if ≥2 years): [kg/m²] ([percentile and/or z-score])
Head circumference (if <2 years or neurodevelopmental concern): [cm] ([percentile and/or z-score])
Growth chart used: [WHO / CDC]
Measurement method: [Standing stadiometer / Recumbent length]
Measurement reliability concerns: [None / Specify concern]

Longitudinal Data: (List at least the last 2–3 measurements with dates. Include weight when relevant to the clinical picture.)

• [Date]: Height [cm] ([percentile/z-score]); Weight [kg] ([percentile/z-score])
• [Date]: Height [cm] ([percentile/z-score]); Weight [kg] ([percentile/z-score])
• [Date]: Height [cm] ([percentile/z-score]); Weight [kg] ([percentile/z-score])

Growth Velocity: Interval [start date] – [end date]; Velocity [cm/year]; [appropriate / low / high] for age

Mid-Parental/Target Height:
Mother: [height with units] ([measured / reported])
Father: [height with units] ([measured / reported])
Calculated MPH: [value] (formula: [sex-specific formula used])
Target height range: [MPH ± 8.5 cm]
Comparison to patient's projected trajectory: [within target range / below target range / above target range]
(If parental heights unavailable, state: "Mid-parental height not calculated—parental heights unavailable. Plan to obtain.")

Proportions: [Arm span vs height]; [Upper/lower segment ratio]; [Dysmorphology notes] (Include only if disproportionate appearance, unusual facies, or skeletal dysplasia is suspected. Otherwise omit this field.)

Past History

Birth/Perinatal: [Gestational age]; [Birth weight and length with percentiles if available]; [SGA/IUGR status]; [Prenatal exposures]; [NICU course]; [Catch-up growth history if applicable]

Medical/Surgical History: [Chronic conditions affecting growth (GI, renal, pulmonary, cardiac, inflammatory, malignancy, CNS)]; [Prior endocrine diagnoses]; [Recurrent infections]; [Prior fractures or bone pain]

Developmental History: [Milestone summary]; [Therapies]; [School supports]

Medications: [Medication name]; [dose]; [route]; [frequency]; [duration] (Include dose and duration for growth-relevant medications.)

Allergies: [Drug/food/environmental allergies and reactions]

Family History

• Mother's height: [value and units]; Age at menarche: [age / Unknown]
• Father's height: [value and units]; Pubertal timing: [on-time / delayed / early / Unknown]
• Siblings: [Heights and pubertal patterns if known]
• Family history of: [thyroid disease]; [celiac disease]; [IBD]; [autoimmune conditions]; [delayed puberty]; [genetic syndromes]; [skeletal dysplasias]
• Consanguinity: [Yes / No / Unknown]

Social History

[Household composition]; [Nutrition access / food insecurity screening result]; [High-level athletic training]; [Sleep schedule]; [Relevant psychosocial stressors]

Review of Systems

(Target growth-relevant systems. Document "Not assessed" for any system not addressed.)

• General: [fatigue / fevers / night sweats / negative / Not assessed]
• GI: [abdominal pain / diarrhea / constipation / blood in stool / negative / Not assessed]
• Endocrine: [heat or cold intolerance / polyuria / polydipsia / negative / Not assessed]
• Neuro: [headaches / vision changes / negative / Not assessed]
• Respiratory: [chronic cough / snoring / apnea / negative / Not assessed]
• MSK: [joint pain / bone pain / negative / Not assessed]
• GU/Reproductive: [pubertal progression / menses pattern / negative / Not assessed] (Age-appropriate only)

Physical Exam

(Document relevant normals and pertinent positives/negatives.)

General: [Appearance]; [Nutritional status]; [Presence or absence of dysmorphic features]

HEENT/Neck: [Midline defects]; [Thyroid size, texture, nodules]; [Visual fields if neurologic symptoms]

Cardiopulmonary: [Murmurs]; [Breath sounds]

Abdominal: [Hepatosplenomegaly]; [Tenderness]; [Masses]

Skin: [Café-au-lait macules]; [Striae]; [Acanthosis nigricans]

Musculoskeletal: [Body proportions]; [Scoliosis]; [Joint swelling]; [Gait]

Puberty: [Tanner stage—breast/genital/pubic hair]; [Testicular volume]; [Menarche status] (Include when indicated. If deferred, state reason.)

Data Reviewed

• External growth charts: [Source and date range reviewed]
• Prior labs: [Test names, dates, and key results]
• Prior imaging: [Bone age or other imaging with dates and interpretations]
• Specialist notes: [Specialty and date]

(If no external records available, state: "No prior growth records available for review.")

Assessment

[Synthesis paragraph] (Include: current height percentile/z-score and trajectory over time; growth velocity with interval and interpretation; weight/BMI pattern relative to height; mid-parental height comparison; puberty status and relevance; key positives and negatives for systemic disease; overall impression of whether this suggests normal variant vs pathologic etiology. Document uncertainty when evidence is incomplete, e.g., "Etiology unclear—insufficient interval data to confirm velocity.")

[Problem 1]: [Short stature with normal velocity / Growth deceleration with low velocity / Height below target range / Other phenotype]

[Problem-specific assessment] (Summarize the phenotype and most relevant supporting or contradictory findings.)

Differential diagnosis:

• Normal variants: [familial short stature / constitutional delay of growth and puberty]
• Endocrine: [hypothyroidism / GH deficiency or resistance / cortisol excess]
• Chronic systemic disease: [GI / renal / pulmonary / cardiac / inflammatory / malignancy / CNS]
• Nutritional insufficiency
• Genetic/syndromic: [Turner syndrome (girls) / SHOX-related / skeletal dysplasia / other]
• SGA without adequate catch-up
• Psychosocial factors

(Include only categories relevant to this patient's presentation.)

[Problem 2]: [Delayed puberty / Poor weight gain / Chronic symptom requiring workup / Other]

[Problem-specific assessment]

(Include additional problems only if explicitly identified during the encounter.)

Plan

(Organize by problem. Include rationale for testing and management decisions.)

[Problem 1] Plan

Diagnostics: [Labs ordered with clinical rationale for each] (Consider as indicated: CBC, CMP, ESR/CRP for inflammation; TSH and free T4 for thyroid function; tTG-IgA with total IgA for celiac screen; IGF-1 ± IGFBP-3 for GH axis; puberty labs; karyotype for girls with unexplained short stature or syndromic features. If deferring labs pending interval growth data, document rationale.)

Bone Age: [Ordered / Not indicated] (If ordered, state indication—growth deceleration, constitutional delay vs endocrine etiology, puberty timing, or adult height prediction—and how result will guide management.)

Management: [Nutrition optimization]; [Sleep hygiene]; [Physical activity recommendations]; [Address psychosocial stressors]; [Referrals: dietitian / social work / subspecialty] (Include condition-specific management if diagnosis suspected or confirmed.)

Counseling: [Topics discussed: growth charts and trajectory, importance of serial measurements and growth velocity, mid-parental height concept and limitations, bone age purpose if applicable, next steps]. Family understanding: [Verbalizes understanding / Has questions about specific topics]

Follow-up: [3–4 months / 6 months / other interval] (Use shorter interval for growth deceleration, systemic symptoms, or pending critical results; routine interval for likely normal variant.) Will review: [Repeat height and weight with consistent measurement method]; [Lab results]; [Bone age interpretation]. Return precautions: [Headaches, vision changes, rapid weight decline, or other specified symptoms].

[Problem 2] Plan

Diagnostics: [Tests with rationale]

Management/Referrals: [Interventions]

Follow-up: [Interval and what will be reviewed]

(Include only if additional problems were identified.)