Date:
Patient:
MRN:
Clincian: (Endocrinologist, Pediatrician)
Reason for Visit:
Evaluation for gynecomastia
Assessment of breast enlargement and potential underlying causes
Review of laboratory and imaging results (if applicable)
Discussion of treatment options and prognosis
History of Present Illness:
Briefly describe the patient’s current symptoms:
Onset, duration, and progression of breast enlargement (unilateral or bilateral)
Severity of breast tenderness or discomfort
Any associated symptoms (nipple discharge, changes in libido)
Past Medical History:
Underlying medical conditions (liver disease, Klinefelter syndrome)
Medications with gynecomastia as a side effect (anabolic steroids, testosterone replacement therapy)
Past history of substance abuse (alcohol, marijuana)
Social History:
Use of recreational drugs or bodybuilding supplements
Family History:
Family history of gynecomastia
Physical Exam:
General: Assess for signs of androgen deficiency (decreased muscle mass, reduced body hair).
Breast exam:
Evaluate size, symmetry, and tenderness of breast tissue.
Assess for nipple discharge or galactorrhea (milky discharge).
Labs:
Testosterone levels: Low testosterone levels may be associated with gynecomastia.
Consider mentioning other labs ordered as needed (estrogen levels, liver function tests, prolactin levels to rule out pituitary tumors).
Imaging:
Mammography or ultrasound: May be used in some cases to differentiate gynecomastia from breast cancer, especially in older patients.
Assessment:
Summarize the diagnosis and potential cause(s):
Confirmation of gynecomastia based on physical exam findings.
Identify the underlying cause of gynecomastia if possible (hormonal imbalance, medication side effect, etc.).
Plan:
Outline the treatment plan based on the assessment:
Addressing the underlying cause: If gynecomastia is due to a medication, stopping the medication may be sufficient. Treatment of underlying medical conditions like liver disease may also be necessary.
Hormonal therapy: Testosterone replacement therapy may be considered in some cases of hypogonadism (low testosterone).
Medications: Anti-estrogen medications like tamoxifen may be used in specific cases.
Surgery: Liposuction or surgical excision of breast tissue may be an option for patients with bothersome gynecomastia and no improvement with other treatment approaches.
Prognosis:
Briefly discuss the prognosis. The prognosis for gynecomastia depends on the underlying cause. Gynecomastia caused by hormonal imbalance may resolve with treatment, while gynecomastia caused by medication side effects may improve after stopping the medication. Surgery typically provides definitive correction.
Education:
Document any education provided to the patient regarding:
The nature of gynecomastia and potential causes
The details of the treatment plan and potential side effects
The importance of following up with regular visits to monitor progress
The emotional impact of gynecomastia and the availability of support resources
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of the diagnosis and treatment plan, and any concerns they may have about masculinity, body image, or sexual function.
Consider the reassurance and support needed for the patient, especially if gynecomastia is causing emotional distress.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with an endocrinologist or pediatrician for diagnosis, treatment recommendations, and prognosis.