Initial consultation note (Sexology)

HISTORY: The patient presents with issues of decreased libido and erectile dysfunction. He reports difficulty in maintaining an erection and a lack of sexual desire over the past six months. Past Medical History: The patient has a history of hypertension and type 2 diabetes. Drug History: Currently taking Metformin and Lisinopril. TD related medications: - AAS: No - Corticosteroids: No - Opioid use: No - Antipsychotics, SSRIs: No Allergies: - Peanut: No - Drugs: Penicillin Past Surgical History: Appendectomy in 2010. Family History: Father had coronary artery disease; mother has osteoporosis. Mental & Emotional Health: Reports feeling anxious and stressed due to work. Sex & Relationships: Married for 10 years, reports a supportive relationship. Fertility: Past fertility issues resolved with IVF; considering future options. Social History: - Occupation: Accountant - Stress: High work-related stress - Smoking / Alcohol / recreational drugs: Occasional alcohol, non-smoker, no recreational drugs - Diet / Exercise / Sleep: Balanced diet, exercises twice a week, sleeps 6 hours per night QUESTIONNAIRE SCORES: Ageing male symptom (AMS) Score: 45 Epworth Sleepiness Scale (ESS) Score: 8 International Index of Erectile Function (IIEF-15) score: 12 EXAMINATION: Height: 180 cm Weight: 85 kg BMI: 26.2 Blood pressure: 130/85 mmHg Waist Circumference: 95 cm INVESTIGATIONS: Blood test results: DATE: 1 November 2024 Haematocrit: 45% Total Testosterone 1: 300 ng/dL Total Testosterone 2: 310 ng/dL Calculated free testosterone: 8 ng/dL PSA: 1.2 ng/mL IMPRESSION & DIAGNOSIS: Impression: Symptoms consistent with testosterone deficiency. Diagnosis: Hypogonadism DISCUSSED AS PART OF TREATMENT RECOMMENDATION: Discussed differences between TRT and supra-physiological testosterone / PEDS. Discussed risks benefits & evidence base for safety of different licensed and unlicensed preparations. Discussed side effects including – VTE, cardiovascular risk, haematocrit, fluid retention, nipple tenderness and gynaecomastia, hair loss, acne, fertility testicular shrinkage. Informed patient that medication must be taken as prescribed. Any changes to dose or frequency must be confirmed by Numan in writing. Changes in dose or frequency without my direction may lead to ending of prescriptions. Patient has been given lifestyle advice on alcohol, smoking, weight and exercise. Patient made aware the following are included in the Numan programme: - Ongoing blood tests at clinic or via nurse visits - 24/7 access to clinical team - Ongoing support with our patient specialist managers - Nurse visits for medicines administration and guidance - All included as part of a monthly fee depending on the treatment. PLAN: Next action: Initiate testosterone replacement therapy (TRT) Preferred treatment choice: Transdermal testosterone gel Is HCG recommended? Yes Has semen analysis been recommended? Yes Other comments: Follow-up appointment in 3 months to assess treatment efficacy.