Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
Chief Complaint: Briefly describe the patient’s main reason for this visit. This could include:
Unwanted hair growth on the face, chest, abdomen, or back (typical male pattern)
Increased hair growth compared to what is typical for race or ethnicity
Emotional distress or social anxiety due to hirsutism
History of Present Illness:
Age at onset of hirsutism
Progression of hair growth (gradual or sudden)
Severity and location of excess hair
Any recent changes in hair growth pattern
Use of hair removal methods (shaving, waxing, etc.)
Past Medical History:
Menstrual history (regularity, presence of ovulation)
Previous diagnoses (polycystic ovary syndrome (PCOS), congenital adrenal hyperplasia (CAH))
Medications (oral contraceptives, hormonal medications)
Family history of hirsutism or hormonal disorders
Family History:
History of hirsutism or PCOS in first-degree relatives
Social History:
Ethnicity (influences typical hair growth patterns)
Physical Examination:
General appearance (signs of virilization, e.g., clitoromegaly)
Skin exam – distribution and terminalization (thick, coarse) of excess hair
Pelvic exam (if indicated)
Blood pressure measurement
Laboratory Tests:
Serum testosterone and free androgen index (FAI) – elevated levels suggestive of hyperandrogenism
Follicle-stimulating hormone (FSH) and luteinizing hormone (LH) ratio (may be abnormal in PCOS)
17-hydroxyprogesterone (17-OHP) – elevated level suggestive of CAH
Blood sugar and lipid profile (if PCOS suspected)
Imaging Studies:
Pelvic ultrasound (may show polycystic ovaries in PCOS)
Diagnosis:
Hirsutism (classify as idiopathic, PCOS-related, medication-induced, etc. based on workup)
Suspected underlying condition (e.g., PCOS, CAH)
Treatment Plan:
Address underlying cause if identified (PCOS treatment, medication switch)
Hormonal therapy (oral contraceptives with anti-androgenic properties)
Spironolactone (anti-androgen medication)
Hair removal methods (laser therapy, electrolysis) – can be complementary but not curative
Prognosis:
Discuss the long-term management plan and potential for improvement
Importance of adherence to treatment for optimal results
Patient Education:
Explain hirsutism and the underlying cause (if known)
Importance of following the treatment plan for hair growth control
Options for hair removal methods and their limitations
Support groups and resources available for patients with hirsutism
Importance of regular follow-up to monitor progress and adjust treatment as needed
Next Follow-up:
Schedule for the next appointment to assess response to treatment, address any side effects, and discuss ongoing management.