A 43-yo man presents to your office with fatigue. He complains of decreased energy, libido and “just not having the get up and go that I used to, Doc.” He has diabetes and hypertension, which he states are relatively well controlled; he has chronic back pain, status/post a failed laminectomy. He denies depression, and any specific complaints such as SOB, chest pain, orthopnea, GI or GU symptoms. His appetite and weight have been normal, and maybe even a little increased lately. He has not had any med changes in at least the last two years.

PMH:                                                                          MEDS:

hypertension                                                           amlodipine 10mg QD

diabetes Type II                                                      lisinopril 20mg QD   

chronic low back pain                                             metformin 500mg BID         

erectile dysfunction                                                vicodin 5/500 q4-6h

                                                                                    sildenafil 1 tab PRN

PSxH:                                                                         Vitamin C 500mg QD          

vasectomy, 5ya ago                                                   

L1-2 laminectomy, 2 ya

FAM Hx:

Father DM, d. MI @ 67

Mother with HTN, alive

Sister, hypothyroidism, alive

SOCIAL HX:

social EtOH

smoked 1ppd x 10y, quit 20 y ago

denies recreational drugs

construction worker, now on disability (back pain)

married, 2 kids, monogamous

PEx:    98.6 F              146/76             82                    12                    98%RA         

GEN: NAD, AOx3, pleasant, overweight (BMI 30), mild gynecomastia

HEENT: unremarkable, no LAD, visual fields intact

CV: RRR, no m/r/g

LUNG: CTAB

ABD: obese, NABS, soft, no masses or organomegaly

MSK: no joint pain or swelling, no spinal ttp, limited ROM @ lumbar spine d/t pain

GU: normal male genitalia, testes 18-ml bilaterally with normal texture. Normal Tanner 5 hair distribution.

SKIN: normal turgor, fair complexion

EXT: no clubbing, cyanosis, or edema

You order some labs to further work-up the problem:

CBC   WBC 7.2   Hct 38%   Plt 244

BMP   WNL

Testosterone (Total)  146 ng/dL

Prolactin                     11 ng/dl

FSH                            1.1 mU/ml

LH                              1.5 mU/ml

Sex-hormone binding globulin  41 nmol/L

IGF 1                          193 ng/ml