J Endocrinol Metab

Journal of Endocrinology and Metabolism, ISSN 1923-2861 print, 1923-287X online, Open Access

Article copyright, the authors; Journal compilation copyright, J Endocrinol Metab and Elmer Press Inc

Journal website https://www.jofem.org

Review

Volume 13, Number 2, June 2023, pages 43-48

Approach to the Patient With Pituitary Adenoma Using Telemedicine: Knowledge Gaps and Recommendations

Figure 1. Protocol for pituitary adenoma patient’s enrollment in TM. Initially, there should be no legal or technical aspects prohibiting a proper TM encounter. After that, if the patient exhibits any red flags or has technical difficulties, the physician should refer him/her to an emergency service or physical encounter. The following steps depend on visit status: first or follow-up visit. If it is a first visit, an adequately documented history, physical examination, and follow-up should be available before proceeding with the TM encounter. Without proper documentation, we suggest switching the patient to a physical clinic for the first visit. To ensure patient satisfaction, if the patient is a chronic patient with a previous TM, it is valuable to give the patient the option to choose between physical or the TM encounter before proceeding with the encounter. TM: telemedicine.

**Table 1.** Exclusion Criteria for the Implementation of TM With Pituitary Adenoma Patients
Type of factors	Factors
TM: telemedicine.
Legal	Absence of informed consent; country law
Technical	Lack of technological access or unfamiliarity with technological devices (such as telephone, computer, internet service) without support
Patient-related	Suspected pituitary apoplexy; pregnancy; unstable vital signs; inability to speak or hear; acute illness; advanced neurological or psychiatric diseases; presence of language barrier

Table 1. Exclusion Criteria for the Implementation of TM With Pituitary Adenoma Patients

Type of factors

Factors

TM: telemedicine.

Legal

Absence of informed consent; country law

Technical

Lack of technological access or unfamiliarity with technological devices (such as telephone, computer, internet service) without support

Patient-related

Suspected pituitary apoplexy; pregnancy; unstable vital signs; inability to speak or hear; acute illness; advanced neurological or psychiatric diseases; presence of language barrier

**Table 2.** Aspects of a Virtual Encounter With a Pituitary Adenoma Patient
Stage of the encounter	Commence
TM: telemedicine.
Before starting the encounter	Ensure the device has a stable power supply and internet access. Ensure the TM platform is ready. Review the patient’s file. Determine the format of the visit (audio only or video). Write down the most critical questions to ask the patient.
Starting the virtual encounter	Physician should introduce him/herself. Confirm the patient’s identity. Verify the quality of the connection. Look directly at the camera. Obtain informed consent. Ask the patient whether he/she wants anyone else to be present. Explain the reason for the encounter. Reassure the patient about the privacy of the encounter (the encounter is not being recorded).
Obtaining the history	Try to be systematic. Be concise. Use clear, simple words. Cover: 1) Symptoms suggestive of pituitary apoplexy; 2) Mass effect symptoms: visual impairment, headache altered level of consciousness, nausea, and vomiting; 3) Hypersecretion symptoms; 4) Hyposecretion symptoms. Complete the rest of the medical history (such as medications and allergies).
Physical examination	Examine mental status. Check vital signs (if the patient has the equipment or recent ones from a nearby medical facility) with orthostatic hypotension. Observe facial features of acromegaly or Cushing disease. Look for: 1) Peripheral signs of acromegaly; 2) Abdominal striae for Cushing disease; 3) Gynecomastia and nipple discharge. Optional use of assistance from the patient’s companion if he/she agrees.
Investigations	It may be helpful to share the screen and discuss the laboratory and imaging results with the patient.
Synchronous management	Physician with a patient: explanation of the management plan and education about investigations and medications, including dosage, frequency indication, and side effects. Physician with a physician: multidisciplinary meeting. Physicians with a patient: multidisciplinary meeting with the patient.
Asynchronous management	Patient with a physician: sending the lab results and images, such as new physical findings. Physician with a physician: medical report for expert consultation.
Closing the encounter	Order the lab results, imaging, medications, appointments, and needed referrals. Summarize the virtual encounter for the patient. Ensure the patient understands the plan. Ask if the patient has any further questions. Thank the patient and end the encounter.

Table 2. Aspects of a Virtual Encounter With a Pituitary Adenoma Patient

Stage of the encounter

Commence

TM: telemedicine.

Before starting the encounter

Ensure the device has a stable power supply and internet access. Ensure the TM platform is ready. Review the patient’s file. Determine the format of the visit (audio only or video). Write down the most critical questions to ask the patient.

Starting the virtual encounter

Physician should introduce him/herself. Confirm the patient’s identity. Verify the quality of the connection. Look directly at the camera. Obtain informed consent. Ask the patient whether he/she wants anyone else to be present. Explain the reason for the encounter. Reassure the patient about the privacy of the encounter (the encounter is not being recorded).

Obtaining the history

Try to be systematic. Be concise. Use clear, simple words. Cover: 1) Symptoms suggestive of pituitary apoplexy; 2) Mass effect symptoms: visual impairment, headache altered level of consciousness, nausea, and vomiting; 3) Hypersecretion symptoms; 4) Hyposecretion symptoms. Complete the rest of the medical history (such as medications and allergies).

Physical examination

Examine mental status. Check vital signs (if the patient has the equipment or recent ones from a nearby medical facility) with orthostatic hypotension. Observe facial features of acromegaly or Cushing disease. Look for: 1) Peripheral signs of acromegaly; 2) Abdominal striae for Cushing disease; 3) Gynecomastia and nipple discharge. Optional use of assistance from the patient’s companion if he/she agrees.

Investigations

It may be helpful to share the screen and discuss the laboratory and imaging results with the patient.

Synchronous management

Physician with a patient: explanation of the management plan and education about investigations and medications, including dosage, frequency indication, and side effects. Physician with a physician: multidisciplinary meeting. Physicians with a patient: multidisciplinary meeting with the patient.

Asynchronous management

Patient with a physician: sending the lab results and images, such as new physical findings. Physician with a physician: medical report for expert consultation.

Closing the encounter

Order the lab results, imaging, medications, appointments, and needed referrals. Summarize the virtual encounter for the patient. Ensure the patient understands the plan. Ask if the patient has any further questions. Thank the patient and end the encounter.