Date:
Patient:
主诉 (zhǔ訴) (Chief Complaint):
This section may be not applicable as adrenal incidentalomas are usually asymptomatic.
Document any presenting complaints if present, such as:
Hypertension (uncontrolled or newly diagnosed)
Easy bruising
Central obesity with thin extremities (Cushingoid features)
Muscle weakness
Excessive sweating or heart palpitations
History of Present Illness:
Briefly describe the reason for the imaging study that identified the adrenal mass.
If the patient has symptoms suggestive of a hormonal syndrome, document their onset, duration, and severity.
Past medical history (hypertension, diabetes, other endocrine disorders)
Past surgical history (adrenal surgery)
Family history (multiple endocrine neoplasia (MEN) syndromes)
Physical Examination:
Vital signs (temperature, heart rate, blood pressure, respiratory rate) – May be normal or show signs of hypertension.
General examination: Assess for signs of Cushing syndrome (central obesity, easy bruising, plethora – reddish skin).
Look for evidence of virilization (masculinization) in females or feminization in males (acne, facial hair growth, breast development).
Laboratory Findings:
Serum electrolytes: May reveal hypokalemia (low potassium) in patients with Cushing syndrome.
24-hour urine cortisol: Elevated levels may suggest Cushing syndrome.
Plasma metanephrines and normetanephrines: Elevated levels may indicate pheochromocytoma (adrenal tumor secreting catecholamines).
Other hormone tests (depending on suspected hormonal syndrome): Plasma ACTH (adrenocorticotropic hormone), testosterone, DHEA-S (dehydroepiandrosterone sulfate)
Imaging Studies:
Review the original imaging study that identified the adrenal mass (e.g., CT scan, MRI).
If not already performed, consider:
CT scan with contrast: To assess the size, characteristics, and possible presence of fat within the mass.
PET scan (positron emission tomography): May be helpful in differentiating benign from malignant tumors.
Assessment:
Diagnose adrenal incidentaloma based on the presence of an adrenal mass identified incidentally on imaging.
Determine the size and characteristics of the mass based on imaging studies.
Evaluate for clinical features suggestive of a hormonal syndrome (Cushing syndrome, pheochromocytoma).
Consider the patient’s age, medical history, and family history for risk stratification.
Plan:
Management approach depends on the size, characteristics, and hormonal activity of the adrenal mass.
Observation: For small (<1 cm), non-functioning (not secreting hormones) incidentalomas, follow-up with periodic imaging (ultrasound, CT scan) may be sufficient.
Hormonal testing: Perform appropriate blood and urine tests to assess for hormonal activity if clinical suspicion or risk factors are present.
Surgical referral: Consider referral to an endocrine surgeon for adrenalectomy (removal of the adrenal gland) if the mass is large (>4 cm), suspicious for malignancy, or causing hormonal symptoms.
Medical management: Medications may be used to control symptoms of hormonal syndromes (e.g., blood pressure medications for Cushing syndrome).
Consultations (may be needed depending on the plan):
Endocrinologist (specialist in hormonal disorders)
Endocrine surgeon
Progress Notes:
Document the frequency of follow-up visits and any changes in the size or characteristics of the adrenal mass on imaging.
Note results of repeated hormonal testing.
Monitor for development or worsening of symptoms suggestive of a hormonal syndrome.
Update the plan as needed based on new information or changes in the patient’s condition.
Disclaimer: This template is for informational purposes only and should not be used as a substitute for professional medical advice. The management of adrenal incidentalomas requires a personalized approach based on individual risk factors and clinical presentation. Consultation with an endocrinologist is crucial for optimal care.