54 years white male engineer presents for tiredness and mental fog. Patient does not complaint of any joint pain, muscle pain or fever. Patient has been healthy all of his life and has not taken any medicines before. Patient denies any chest pain, abdominal pain or shortness of breath. Patient has been to his family MD who has done regular check up and blood tests for anemia, thyroid tests and blood chemistry which was normal. Patient was told that tiredness is probably from stress from his work as nothing was found on blood tests. Patient was recommended to take multivitamin and reduce the stress.
Patient came to this office because he continued to be tired and had no improvement. Patient is an engineer and has been working long hours on the project but he has been sleeping well. Patient is having no family or work problems except working long hours.
Past history is unremarkable. Patient denies history of any surgery. Patient has no allergies. Patient does not drink or smoke.
Family history: No history of thyroid or heart problems.
Physical exam:
- Vitals:: Temp 98.0 F BP 117/79 P 52 R 12 SPO2 98
- Well developed well nourished white male
- Alert and oriented x 3
- HEENT normal
- Neck supple, thyroid normal, no neck masses
- Heart RRR, S1 and S2 normal
- Lungs clear, no retraction
- Abdomen soft without any hepatosplenomegaly or masses
- Skin of face and chest normal
- Lymphatics negative lymph nodes
- Scrotum and testicles normal
- Rectal exam normal hemoccult is normal and prostrate exam is normal
Lab studies:
- CBC, CMP, Lipid
- T4, Free T3 reverse T3 and TSH normal
- PSA normal
- CRP and homocysteine normal
- HgA1C, insulin normal
- Cortisol normal
Lab Studies: (cont.)
- Testosterone 299 range is 250-1100
- Free testosterone is 67.0
- FSH 5.1 (1.6-8.0)
- LH 5.2
- DHEA Sulfate 114 range 15-240
- Estradiol 45 (13-54)
- PSA 1.5
- Vitamin D 25 (30-100)
- UA and microalbumin is normal
Chest X ray is normal and no evidence of cancer.
Treatment
- Patient was given testosterone gel 40 mg per day
- Patient was given Zinc citrate 25 mg tid
- DHEA 25 mg daily
- Patient was given vitamin D10,000 daily
- Patient was given multivitamin,
- Vitamin C and omega 3 (1,000 mg)
- Nutrition: Patient is advised to have balanced food with vegetables and fruits
- Regime of exercise
Follow up
- Patient testosterone was 567 which was in the mid range
- Patient’s estradiol was 15
- Rpt PSA same as the start
- Rpt CBC and COMP is normal
- Rpt vitamin D was 60
Patient felt much better and his tiredness improved. He is still working long hours but not feeling tired and he is advised to continue the present treatment including vitamin D 5,000 as the maintenance dose.
Patient is advised to have a follow up in 3 months.
