Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
Follow-up for male hypogonadism / New or worsening symptoms suggestive of hypogonadism (specify)
History of Present Illness:
For follow-up visits, inquire about any new or worsening symptoms since the last encounter (e.g., decreased libido, erectile dysfunction, fatigue, mood changes, decreased muscle mass, gynecomastia (breast enlargement)).
Describe the character, duration, and severity of new symptoms.
Mention any recent changes in medications, lifestyle habits, or exposures that may affect testosterone levels (e.g., new medications, weight changes, injury/surgery).
Past Medical History:
Include the date of hypogonadism diagnosis and the underlying cause (if known):
Primary hypogonadism (testicular dysfunction)
Secondary hypogonadism (hypothalamic-pituitary axis dysfunction)
Undetermined/idiopathic
List any relevant past medical history, including:
Childhood illnesses or genetic conditions that may contribute to hypogonadism (e.g., Klinefelter syndrome)
Chronic medical conditions (e. testosterone deficiency is common in obesity, diabetes)
Previous surgeries or injuries involving the testes or pituitary gland
History of medications that can affect testosterone levels (e.g., anabolic steroids, opioids)
Medications:
List all current medications, including any testosterone replacement therapy (TRT) medications being used.
Social History:
Inquire about tobacco use, alcohol consumption, and illicit drug use (all can impact testosterone levels).
Ask about occupational exposures to environmental toxins that may affect hormone function.
Family History:
Inquire about a family history of hypogonadism or delayed puberty in male relatives.
Physical Exam:
General observation: Assess for signs of:
Decreased muscle mass and increased body fat
Gynecomastia
Loss of facial and body hair
Genital exam: Evaluate testicular size and symmetry.
Assess for signs of varicocele (enlarged veins in the scrotum).
Laboratory Tests:
Total testosterone: The primary test to assess testosterone levels.
Free testosterone: May be measured in some cases to account for testosterone bound to sex hormone-binding globulin (SHBG).
Luteinizing hormone (LH) and follicle-stimulating hormone (FSH): Levels can help differentiate between primary and secondary hypogonadism.
Prolactin: Elevated prolactin levels can suppress testosterone production.
Complete blood count (CBC): May reveal anemia (common in some hypogonadism cases).
Metabolic panel: May be checked to assess for underlying medical conditions that can affect testosterone levels.
Imaging Studies (if indicated):
Scrotal ultrasound: May be used to assess testicular size, identify abnormalities like varicocele, and evaluate blood flow.
MRI scan of the brain (rarely): May be indicated if a pituitary tumor is suspected.
Assessment:
Hypogonadism type: State whether primary, secondary, or undetermined hypogonadism is most likely based on clinical presentation, laboratory findings, and imaging results (if available).
Testosterone deficiency severity: Classify the severity of testosterone deficiency based on total testosterone levels and symptom presentation.
Impact on patient: Describe how hypogonadism is impacting the patient’s physical and psychological well-being.
Plan:
Treatment:
Outline the treatment plan based on the type and severity of hypogonadism and the patient’s individual needs. This may include:
Testosterone replacement therapy (TRT): This is the mainstay of treatment for most cases of hypogonadism. Different forms of TRT (gels, injections, patches) are available.
Lifestyle modifications: Encourage weight loss, exercise, and smoking cessation to improve overall health and potentially increase testosterone levels.
Treating underlying conditions: If an underlying medical condition is contributing to hypogonadism, addressing that condition may improve testosterone levels.
Discuss the potential benefits and risks of TRT, including monitoring plan for side effects (e.g., increased hematocrit, acne, mood changes).
Follow-up: Schedule regular follow-up visits to monitor testosterone levels, symptoms, and compliance with TRT (if used).