Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with symptoms suggestive of late-onset hypogonadism, including decreased libido, erectile dysfunction, fatigue, loss of muscle mass, and depressive mood. Symptoms are chronic and progressive. No history of pituitary trauma, radiation, or anabolic steroid use. AMS (Aging Males' Symptoms) scale score: [Insert Score].
Clinical Examination Findings
Physical examination reveals: BMI [Insert], waist circumference [Insert] cm. Secondary sexual characteristics: normal. Testicular volume: [Insert] ml bilaterally, firm consistency, no palpable masses. No gynecomastia. Prostate examination: smooth, non-tender, no nodules.
Treatment Protocol
Initiate Testosterone Replacement Therapy (TRT) via [Gel/Intramuscular injection]. Baseline labs: Total Testosterone, Free Testosterone, SHBG, LH, FSH, Prolactin, PSA, and Hematocrit. Follow-up scheduled in 6 weeks to monitor symptom improvement, PSA levels, and hematocrit. Contraindications reviewed: prostate cancer, breast cancer, severe sleep apnea, and uncontrolled heart failure.