Patient: [Patient Name]
Date: [Date of Encounter]
I. Diagnosis:
Type of CAH: (21-hydroxylase deficiency, 11β-hydroxylase deficiency, other)
Age at diagnosis
II. Current Medications:
Glucocorticoid (type, dose, route)
Mineralocorticoid (type, dose, route) (if applicable)
III. History of Present Illness:
Reason for this visit (routine follow-up, new symptoms)
Current symptoms (select all that apply):
Fatigue
Weakness
Muscle cramps
Weight gain/loss
Hyperpigmentation
Hypertension
Hypoglycemia
Vomiting
Difficulty controlling blood sugar (if diabetic)
Virilization (females) or ambiguous genitalia (at birth)
Delayed puberty (males)
IV. Past Medical History:
Previous hospitalizations (adrenal crisis, surgery)
Complications (hypertensive crisis, electrolyte imbalances)
Growth history
V. Social History:
Medication adherence
Stressful life events
Access to healthcare
VI. Physical Exam:
Vital signs: (BP, HR, RR, Temp)
Weight and height (plot growth percentiles)
Blood pressure (elevated in mineralocorticoid deficiency)
Signs of virilization (females) or ambiguous genitalia (if not surgically corrected)
Secondary sexual development (delayed in males)
VII. Laboratory Studies (if available):
Electrolytes (serum sodium, potassium)
Blood glucose
17-hydroxyprogesterone (17-OHP) level (primary test for monitoring)
Other hormone levels (androstenedione, cortisol) – as indicated
VIII. Assessment:
Current disease control (based on symptoms, physical exam, and labs)
Medication adequacy
Risk of adrenal crisis
IX. Plan:
Medication adjustments (dose changes, adding/stopping medications)
Follow-up laboratory testing schedule
Education:
Importance of medication adherence and avoiding medication holidays.
Recognizing signs and symptoms of adrenal crisis.
Stress management techniques.
Importance of regular follow-up.
Referral (if indicated):
Nutritionist for weight management or blood sugar control.
Mental health professional for emotional well-being.
Pediatric endocrinologist for complex cases.
X. Notes:
Include any additional observations or concerns, such as patient’s understanding of the condition, adherence to recommendations, and social support system.
XI. Resources:
Consider providing patient education materials on CAH from reputable sources (e.g., Congenital Adrenal Hyperplasia Research Education and Support (CARES) Foundation, National Institutes of Health (NIH)).