Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
Chief Complaint: This section will vary depending on the sex and presenting symptoms of the patient.
Females: Irregular menstrual periods, amenorrhea (absence of periods), infertility, galactorrhea (milk production from non-pregnant breasts), decreased libido
Males: Erectile dysfunction, decreased libido, gynecomastia (breast enlargement)
Both: Headaches, vision problems
History of Present Illness:
Onset, duration, and severity of symptoms
Recent hospitalizations or emergency department visits
Changes in menstrual cycle (females) or sexual function (males)
Presence of vision problems (blurred vision, headaches)
Medications (current and recent) – some medications can elevate prolactin levels
Past Medical History:
Underlying medical conditions that can contribute to hyperprolactinemia (pituitary tumors, hypothyroidism)
Prior surgeries or procedures (brain surgery, head trauma)
History of headaches or vision problems
Family History:
Family history of pituitary tumors (rare)
Social History:
Use of medications, herbal supplements, or recreational drugs (some can increase prolactin)
Pregnancy or breastfeeding history (elevated prolactin is normal during pregnancy and breastfeeding)
Physical Examination:
Vital signs (blood pressure, heart rate, temperature)
General appearance (signs of hormonal imbalance)
Breast exam (females) – to assess for galactorrhea
Genital exam (males) – to assess for gynecomastia
Visual field exam (if vision problems reported)
Laboratory Tests:
Prolactin level (confirmed diagnosis) – repeat testing may be needed to confirm persistent elevation
Thyroid function tests (TSH, free T4) – to rule out hypothyroidism
Pituitary function tests (other hormone levels) – may be considered depending on clinical suspicion
Gonadotropin levels (FSH, LH) – may be helpful to assess fertility and menstrual function
Imaging Studies:
Magnetic resonance imaging (MRI) of the brain with contrast – to visualize the pituitary gland and identify potential tumors
Diagnosis:
Hyperprolactinemia (confirmed by elevated prolactin level)
Underlying cause of hyperprolactinemia (if identified) – e.g., pituitary tumor, hypothyroidism, medication-induced
Treatment Plan:
Treatment depends on the underlying cause and severity of hyperprolactinemia.
Medications:
Dopamine agonists (cabergoline, bromocriptine) – the mainstay of treatment for pituitary tumors, act to lower prolactin levels
Thyroid hormone replacement therapy (if hypothyroidism is present)
Surgery (pituitary surgery for large tumors or if medications are ineffective)
Observation (if prolactin levels are mildly elevated and no symptoms are present)
Prognosis:
Discuss the outlook based on the underlying cause, severity, and response to treatment.
Hyperprolactinemia caused by medications or hypothyroidism can often be well-controlled with treatment.
Pituitary tumors may require ongoing monitoring and treatment.
Patient Education:
Importance of medication adherence (if prescribed)
Expected side effects of medications and importance of reporting them
Importance of regular follow-up to monitor prolactin levels and assess response to treatment
Potential impact of hyperprolactinemia on fertility (if applicable)
Importance of discussing pregnancy plans with the doctor (if medications can harm the fetus)
Next Follow-up:
Schedule for the next appointment depends on the severity of hyperprolactinemia and treatment plan.
Close monitoring of prolactin levels is essential until they are normalized.
Regular follow-up to monitor for recurrence and manage underlying condition.