Thanks to Ceridwen Dawkins for suggesting this Case.
A request from a Family Doctor on a 68 year old man complaining of
increasing impotence. Serum results were:
LH: 8.3 IU/L (1.6 - 9.6)
FSH: 15.1 IU/L ( <6.0)
Testosterone: 9.7 nmol/L (9 - 30)
This Case attracted 25 participants, and produced a wide divergence of
opinion.. One assessor commented 'This was an interesting set of answers
because I don't think we know the answer - what the results mean'. He added
'What a horrible question to mark'. Despite this, there was only one large
divergence of opinion between assessors. I am awarding myself a bonus mark
- last year, I was challenged to find a case for which 'phoning the Doctor
would score a negative mark. This is the first such Case!
Only 2 participants would call the Family Doctor.(-0.4)
3 participants thought the results were likely to be normal for age;(0.0)
2 participants queried the male menopause.(-0.4)
5 queried mild/ partial/ early/ incipient primary testicular failure;(1.5)
1 each queried
secondary gonadal failure;(-0.6*)
abnormal tubular function;(-0.4)
early hypothyroidism.(-0.8)
In addition,
6 queried a drug effect; (-0.2)
2 queried psychological problems; (0.2)
1 each queried
galactorrhoea; (0.2)
alcohol intake; (0.8)
vascular disease; (0.4)
autonomic neuropathy; (0.0)
stress; (0.2)
systemic illness; (0.2)
germinal cell dysfunction; (-0.4)
testicular lesions. (0.0)
14 would measure Sex Hormone Binding Globulin/ free testosterone; (1.0)
8 would measure glucose; (0.6)
5 would measure prolactin; (0.6)
4 would measure free androgen index; (0.6)
4 would measure LFTs; (0.0)
4 would suggest repeating the tests; (0.6)
3 would suggest looking at sperm count and morphology; (-0.8)
3 would measure urea and electrolytes; (-0.2)
1 each would measure
thyroid function tests (0.2)
PSA; (-0.4)
ferritin. (-0.4)
2 participants would suggest referral to an endocrinologist. (1.2)
Perhaps surprisingly, no-one suggested referral to an urologist (or a
sexual psychiatrist).
Ceridwen commented 'Testosterone unremarkable for age. FSH rather high
?normal LFTs? Perhaps repeat, preferably 8 - 10am'
Best wishes
Gordon Challand
Li Ping
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