Continuity Clinic Educational Didactic. December 8 th December 12 th

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1 Continuity Clinic Educational Didactic December 8 th December 12 th

2 MKSAP Question 1 A 60-year-old man is evaluated for a 1-year history of generalized fatigue and lack of energy. He has had erectile dysfunction for the past 9 months. He has chronic low back pain and hypertension. Current medications are metoprolol, hydrochlorothiazide, hydrocodone, and naproxen.on physical examination, vital signs are normal. Cardiac, lung, and thyroid examinations are all normal. Laboratory studies show a morning total serum testosterone level of 180 ng/dl (6.2 nmol/l). Complete blood count, metabolic panel, and thyroid-stimulating hormone level are all normal. Which of the following is the most appropriate next step in the management of this patient? A Discontinue hydrocodone B Discontinue metoprolol C Recheck testosterone level D Start testosterone replacement therapy

3 MKSAP Answer 1 Educational Objective:Manage androgen deficiency. Correct answer: A This patient's hydrocodone should be discontinued. Low testosterone levels can lead to decreased energy and libido, fatigue, and erectile dysfunction. Many drugs, including opioids, high-dose corticosteroids, and hormonal therapies, can lower testosterone levels, and a review of medications is an important initial step in the evaluation of men with low testosterone levels. It is also important to test morning levels of testosterone as opposed to random levels, as secretion is cyclical. In this patient, hydrocodone may be decreasing testosterone levels and should be discontinued, and the testosterone level should subsequently be retested before any testosterone replacement therapy is given. Whereas metoprolol and other β-blockers may cause erectile dysfunction and fatigue, they do not generally lower testosterone levels. While repeat morning testing of testosterone levels is recommended to confirm low values, it would be more appropriate to first discontinue the potential offending agent before retesting the testosterone level. As testosterone replacement therapy is usually a long-term treatment intervention, it should only be initiated after definitive confirmation of testosterone deficiency in the absence of testosterone-lowering therapies and after weighing the risks and benefits and discussing the multiple potential delivery options for the hormone with the patient. Bottom line: In men with low testosterone levels, a review of medications should be undertaken; many drugs, including opioids, high-dose corticosteroids, and hormonal therapies, can lower testosterone levels.

4 MKSAP Question 2 A 46-year-old man is evaluated for a 1-year history of low libido and erectile dysfunction. He underwent normal puberty and has two teenaged children. The patient has a history of hypertension. His only medication is chlorthalidone.on physical examination, temperature is normal, blood pressure is 125/72 mm Hg, and pulse rate is 80/min; BMI is 42. No gynecomastia is present, and testicular volume is normal. A normal male distribution of body hair is noted.results of laboratory studies show a serum follicle-stimulating hormone level of 5 mu/ml (5 units/l), a serum luteinizing hormone level of 4 mu/ml (4 units/l), and a serum total testosterone level of 210 ng/dl (7 nmol/l); the serum thyroid-stimulating hormone and prolactin levels are normal. Which of the following is the most appropriate next diagnostic test? A Free testosterone assessment B Karyotyping C Pituitary MRI D Sperm count

5 MKSAP Answer 2 Educational Objective: Diagnose hypogonadism in patients with obesity. Correct answer: A A free testosterone assessment, preferably one using equilibrium dialysis, is the most appropriate diagnostic test to determine whether this patient truly has hypogonadism. A random serum testosterone level greater than 350 ng/dl (12 nmol/l) excludes hypogonadism. Values consistently less than 200 ng/dl (6.9 nmol/l) almost always confirm hypogonadism, but values in the 200 to 350 ng/dl ( nmol/l) range are equivocal. Unless the total testosterone level is markedly reduced and the patient has a known pituitary or gonadal pathologic abnormality, a screening testosterone value of 350 ng/dl (12 nmol/l) or lower requires confirmation by a second measurement that includes determination of the free testosterone level. Bottom line: in male patients with obesity, hypogonadism is best diagnosed by a free testosterone assessment because the total testosterone level may be affected by a decrease in the sex hormone binding globulin level Of note, obesity can cause a decrease in sex hormone binding globulin levels. Therefore, the free testosterone level can be normal, even when the total testosterone level appears decreased. If the free testosterone level is normal, then hypogonadism is excluded and another etiology of this patient's erectile dysfunction, such as medications, must be explored. A karyotype is not appropriate in this patient in whom hypogonadism has not been diagnosed and who has normal follicle-stimulating hormone and luteinizing hormone levels, which exclude primary hypogonadism. A karyotype is useful in patients diagnosed with primary hypogonadism to exclude Klinefelter syndrome. A pituitary MRI is not indicated at this time because the diagnosis of secondary hypogonadism has not been confirmed. A sperm count is not indicated in this patient because a sperm count will not reliably indicate whether a patient has hypogonadism. Men with low sperm counts can have normal testosterone levels, and men with slightly decreased testosterone levels can have normal sperm counts. In addition, this patient is not seeking fertility at this time.

6 MKSAP Question 3 A 35-year-old man is evaluated for a 2-month history of low libido. The patient had a normal puberty. Family history is unremarkable. He drinks two beers per week and takes no medication.on physical examination, vital signs are normal; BMI is 23. Visual field examination findings are normal, as is testicular size. No gynecomastia is noted. Laboratory studies: Follicle-stimulating hormone: 6 mu/ml (6 units/l) Luteinizing hormone: 5 mu/ml (5 units/l) Thyroid-stimulating hormone: 2.5 µu/ml (2.5 mu/l) Total testosterone (4 PM):200 ng/dl (7 nmol/l) Which of the following is the most appropriate next diagnostic test? A Measurement of serum ferritin and iron saturation levels B Morning serum free testosterone measurement C Morning serum total testosterone measurement D Testicular ultrasonography

7 MKSAP Answer 3 Educational Objective: Diagnose male hypogonadism. Correct Answer : C Obtaining a morning serum total testosterone level is the most appropriate next diagnostic test. According to Endocrine Society guidelines, an initial morning measurement of a patient's total testosterone level should be performed in assessing for hypogonadism; if results are abnormal, a second confirmatory morning measurement should be obtained before testing for secondary causes is begun. This recommendation is based on numerous studies showing that variability in testosterone levels from day to day or diurnally is common, with morning total testosterone levels being the most accurate in indicating a patient's androgen status. Iron studies to exclude hemochromatosis as a cause of central hypogonadism are not indicated in this patient because a diagnosis of hypogonadism has not been confirmed. Many free testosterone assays are grossly inaccurate and thus are not currently recommended to diagnose hypogonadism unless the assay measures free testosterone by equilibrium dialysis. Additionally, this patient has no risk factors for altered sex hormone binding globulin levels (obesity and older age), which would make a total testosterone level less reliable. Therefore, he has no need of a free testosterone assessment. Testicular ultrasonography is not indicated for the diagnosis of hypogonadism. A testicular examination is adequate for assessing testicular volume. Bottom line In evaluating a male patient for hypogonadism, a morning measurement of the total testosterone level is the most appropriate initial step.

8 MKSAP Question 4 Laboratory studies: A 42-year-old man is evaluated for infertility. He and his wife have been trying to conceive for 1 year. They have a 4-year-old child conceived without problems. The patient reports a slightly decreased libido that he attributes to increased stress at work. Puberty was normal. He has osteoarthritis of the hands. Family history is unremarkable. His only medication is ibuprofen as needed.on physical examination, vital signs are normal; BMI is 24. Testicular volume is decreased bilaterally. Visual field and thyroid examination findings are normal. No gynecomastia is noted. Alanine aminotransferase: 48 units/l Aspartate aminotransferase: 25 units/l Follicle-stimulating hormone: 2 mu/ml (2 units/l)(low) Luteinizing hormone: 2 mu/ml (2 units/l)(low) Prolactin:12 ng/ml (12 µg/l)(normal) Testosterone, total (8 AM)Initial measurement:200 ng/dl (6.9 nmol/l)repeat measurement:190 ng/dl (6.5 nmol/l)(low) TSH:1.2 µu/ml (1.2 mu/l) Free T4:1.2 ng/dl (15 pmol/l) An MRI of the pituitary gland is normal. Which of the following is the most appropriate next diagnostic test? A Ferritin and iron saturation measurement B Free testosterone measurement C Karyotyping D Testicular ultrasonography

9 MKSAP Answer 4 Educational Objective: Diagnose the cause of secondary hypogonadism. Correct Answer: A This patient should have iron saturation studies to determine a possible cause of his central hypogonadism, which is indicated by the low serum testosterone, follicle-stimulating hormone, and luteinizing hormone levels. The evaluation of secondary hypogonadism includes the exclusion of hyperprolactinemia and hemochromatosis as possible causes. This patient's serum prolactin level is normal, but hemochromatosis has not yet been excluded as a cause. His history of osteoarthritis is consistent with a diagnosis of hemochromatosis, as is his slightly elevated alanine aminotransferase level. Bottom line: The evaluation of secondary hypogonadism includes the exclusion of hyperprolactinemia and hemochromatosis as possible causes. Measuring the free testosterone level is not appropriate because this patient does not have any history or physical examination findings suggestive of abnormal sex hormone binding globulin levels, such as obesity, insulin resistance (for example, type 2 diabetes mellitus), or older age. If he had any of these findings, his total serum testosterone levels would be suspect, and the amount of free testosterone would be a better indicator of hypogonadism. Karyotyping and testicular ultrasonography are not useful tests in the evaluation of secondary hypogonadism. A karyotype is useful in patients with primary hypogonadism and increased gonadotropin levels to exclude Klinefelter syndrome.

10 Diabetic Shoes Not everyone who is diabetic qualifies. Risk categories 0 & 1 do not qualify and should be advised to buy a high quality shoe with a wide toe box (New Balance are often recommended). Before ordering, be sure there is a diabetic foot exam documented in the LPN s check in note or provider s note first. If not, arrange for a Nursing Clinic visit for a diabetic foot exam.

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