Clinical Vignette X

• Which of the following is the most appropriate next step in management of this patient?

A 26-year-old male is evaluated in the medtigo Medical Clinic for a 2-year history of chronic fatigue, reduced energy, feeling slightly depressed, decreased motivation in some activities, increased irritability, and difficulty losing body fat despite many years of consistent weighting training, cardiovascular exercise, and consuming a mostly well-balanced diet. The patient spent six years in the military before being honorably discharged late 2019. While in the military, the patient suffered a severe lower back injury during a pre-deployment combat training exercise in early 2017 which was treated with physical therapy and chronic opioid pain management. After being treated with increasing dosages of opiates for 18 months, he was suddenly and without warning switched to Gabapentin for his chronic pain management. After only 3 months of taking the Gabapentin, the patient told the military doctors the Gabapentin did nothing for his pain and only fogged his mental state. He reportedly told the military doctors he would rather not take anything and try to deal with the pain without the use of any prescription medications. Relying on physical therapy and NSAIDs, the patient somehow managed to deal with the pain as he continued to participate in daily physical training workouts and frequent combat training exercises without any significant loss in physical performance. Eventually, the pain subsided to a manageable level such that he no longer required physical therapy or NSAIDs and has since been able to return to lifting weights on a regular routine without any significant pain in his lower back. Upon further questioning, the patient reports gradual worsening of his symptoms over the past two years. He also reports noticing new symptoms within the past 12 months which includes significantly decreased libido and frequently occurring erectile dysfunction. With the exception of the lower back trauma treated with physical therapy and chronic opioid pain management, the patient has no other notable medical history. He does not consume alcohol, smoke cigarettes, chew tobacco, or use recreational drugs. He currently takes no medications and has no known allergies.

On physical examination, vital signs are normal. He is fairly well-built with noticeable overall muscular development. He is 5’11” and weighs 200 lbs (90.9 kg). His body mass index is 27.9 kg/m² with an estimated body fat percentage of 18%. The testes measure 3.4 cm in length each. The remainder of the physical examination is unremarkable. An initial 15-panel toxicology screen performed in the clinic was negative. 

 Based on the patient’s medical history, clinical exam findings, and lab test result, which of the following is the least appropriate next step in management of this patient?

• The lab testing result of the morning total Testosterone level reveals the following:

Given the new lab testing results, which of the following is the most appropriate next step in management of this patient?

• The appropriate set of lab testing results reveal the following:

Given the patient’s history of present illness, signs and symptoms, medical history, clinical exam findings, and all the available lab testing results performed thus far, which of the following is the most likely diagnosis?

• The lab testing result of the morning Prolactin level reveals the following:

• Now that the patient has been correctly diagnosed with hypogonadism and evaluated for cardiovascular disease risk assessment, which of the following is the most appropriate next step in management of this patient’s medical condition if he is not planning on having any children in the future?

• After carefully reviewing the patient’s medical history, which of the following is the most likely cause of his hypogonadism?