Date:
Patient:
主诉 (zhǔ訴) (Chief Complaint):
Describe the patient’s main reason for presentation, which may include:
Fatigue and decreased energy levels
Decreased muscle mass and strength
Increased body fat, particularly around the abdomen
Difficulty sleeping (insomnia)
Decreased quality of life
In some cases, no specific symptoms (identified on screening due to risk factors)
History of Present Illness:
Onset, duration, and severity of symptoms
Impact of symptoms on daily activities and quality of life
Past medical history (previous pituitary surgery, radiation therapy to the head, head trauma)
Past surgical history (relevant surgeries, especially pituitary surgery)
Medications (current medications and any history of prior GH therapy)
Family history (growth hormone deficiency in family members)
Physical Examination:
Vital signs (temperature, heart rate, blood pressure, respiratory rate) – May be normal.
General examination: Assess for body composition (muscle mass, fat distribution).
Skin assessment: Look for signs of dry skin, easy bruising.
Laboratory Findings:
Insulin-like growth factor 1 (IGF-1) level: Low IGF-1 level is a key diagnostic indicator of GH deficiency.
Growth hormone stimulation test: This test is performed to assess the body’s ability to produce GH in response to stimulation.
Other tests (may be ordered depending on suspected cause): Pituitary function tests (prolactin, TSH, FSH, LH), cortisol level
Imaging Studies (may be ordered to assess the pituitary gland):
MRI scan of the brain: To visualize the pituitary gland and check for any structural abnormalities.
Assessment:
Diagnose adult growth hormone deficiency based on clinical presentation, low IGF-1 level, and abnormal growth hormone stimulation test.
Consider the cause of GH deficiency (pituitary surgery, radiation therapy, idiopathic).
Evaluate the impact of GH deficiency on the patient’s overall health and quality of life.
Plan:
Growth hormone replacement therapy: The mainstay of treatment for adult GH deficiency is daily injections of synthetic GH.
Dosage is individualized based on the patient’s IGF-1 level, response to treatment, and potential side effects.
Monitoring: Regular monitoring of IGF-1 levels, blood sugar levels (GH can affect blood sugar), and potential side effects like carpal tunnel syndrome.
Lifestyle modifications: A healthy diet, regular exercise, and adequate sleep can improve symptoms and overall health.
Consultations (may be needed depending on the case):
Endocrinologist (specialist in hormonal disorders)
Progress Notes:
Document the response to GH therapy, including changes in IGF-1 levels, body composition, and symptoms.
Note any side effects and how they are managed.
Discuss medication adherence and any challenges faced by the patient.
Update the treatment plan as needed based on the patient’s progress.
Disclaimer: This template is for informational purposes only and should not be used as a substitute for professional medical advice. Early diagnosis and treatment with growth hormone replacement therapy can improve symptoms and quality of life in adults with GH deficiency. Consultation with an endocrinologist is crucial for diagnosis, treatment planning, and monitoring.