Subjective
Date of visit
Reason for visit (routine follow-up, new symptoms, medication adjustment)
History of present illness:
For new symptoms:
Changes in behavior (irritability, hyperactivity, learning difficulties)
Seizures
Eczema (itchy skin rash)
Developmental delays
Dietary adherence (challenges, changes)
Psychosocial concerns (emotional well-being, social interactions)
Past medical history (age at diagnosis, initial blood phenylalanine levels)
Medications (current PKU formula, other medications)
Allergies
Objective
Vital signs (temperature, heart rate, blood pressure)
Physical exam (looking for signs of developmental delay or neurological abnormalities)
Assessment
Phenylketonuria (confirmed diagnosis)
Blood phenylalanine level (current level and trends)
Metabolic control (well-controlled, poorly controlled)
Nutritional status (adequate intake of formula, potential deficiencies)
Developmental progress (meeting milestones, any delays)
Psychosocial well-being (emotional state, social integration)
Plan
Dietary management:
Review PKU formula intake and adherence
Assess for potential nutritional deficiencies (vitamins, minerals)
Discuss dietary modifications as needed (age-appropriate)
Blood testing:
Monitor blood phenylalanine levels (frequency based on age and control)
Consider other blood tests as needed (e.g., thyroid function, carnitine levels)
Treatment adjustments:
Modify PKU formula dosage based on blood phenylalanine levels and growth
Consider additional medications for specific complications (e.g., carnitine supplements)
Referral (if indicated):
Nutritionist for personalized dietary guidance
Mental health professional for addressing emotional or social difficulties
Education
Provide ongoing education about PKU management for the patient and family
Importance of dietary adherence for long-term health
Strategies for managing social situations and promoting social inclusion
Follow-up
Schedule for next appointment
Discuss any upcoming changes in diet or medications
Address any concerns or questions from the patient or family
Note: This template is a guide and may need to be modified based on the individual patient’s age, severity of PKU, and response to treatment.
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and management of Phenylketonuria.