[doctor] next patient is paul , date of birth is january 15 , 1962 . this is a 59-year-old hiv positive gentleman here for hypogonadism . patient was last seen on november 24 , 2020 . he is . [patient] his notable things are # 1 , he is on 1 ml every 10 days . his levels were less than 300 to begin with . he is on finasteride currently . he also takes cialis daily , so he takes all his pills just from me , patient's other area of concern is gynecomastia , which is , which we will discuss with him today . his last psa was 0.66 and his last testosterone was greater than 1500 . [doctor] hey , how are you today ? [patient] alright , how you been ? [doctor] i'm good . [patient] good , good . [doctor] have you lost some weight or you at least putting on some muscle , you look trump . [patient] no , i think i'm pretty much the same as i've always been . [doctor] really ? okay , maybe it's just your black shirt , makes you look then . [patient] yeah , i guess that's it . [doctor] so health wise , how is everything going ? [patient] good , the testosterone is going well . [doctor] that's great . [patient] helped me out , i feel good , more vigorous , sleeping well and i think it's having some positive effects , not so much physically because like i said , i've i've been this way my whole life , but i'm seeing some good improvements in my blood work . [doctor] okay , well , that's good . [patient] so the finasteride i am only taking half a pill , it's the 5 mg one . [doctor] yeah , i remember you telling me that . [patient] and cialis on the days i work out , i take 5 mg , otherwise i take 2-1/2 mg pills , but i have been out of it . [doctor] okay . [patient] but overall i'm doing well . i'm actually taking the correct steps to get my life together . [doctor] good . it's always great to hear . let's look i'm gon na listen to your heart and lungs . [patient] okay . [doctor] please use my general exam template alright just take a few breaths . [patient] okay . [doctor] now . alright everything sounds good , no concerns there . [patient] great . so i wanted to show you something . [doctor] sure . [patient] look at this . [doctor] okay , this is your cholesterol . [patient] yeah , my cholesterol and triglycerides , i used to have high triglycerides , you see they were 265 mg/dl , then i took my first dose of the testosterone on the 28th . [doctor] right . [patient] now 5 months later look at my numbers . [doctor] wow , that's remarkable . [patient] this is the test , it's the only change . i do n't know , i have n't honestly seen many guys over the years that have cholesterol problems and this i mean there is a big correlation between diabetic control and testosterone replacement meaning those who get good levels of their tests see their diabetic control improve . [doctor] yeah . but i have n't seen a lot of data on the impact on cholesterol . regardless we will take it . [patient] i agree . i was very impressed with my triglycerides and was just wondering if the test may be what's helping . [doctor] yeah , that's an unbelievable difference . [patient] 145 mg/dl from 265 mg/dl is awesome . i also read that it it's cardioprotective . [doctor] absolutely . [patient] my red blood cell count has increased . [doctor] yeah , i saw that . it's fine though . [patient] stable . [doctor] your psa a today is also is good also . it's 0.6 i think . [patient] yeah is it ? [doctor] yeah , it was 0.5 last year and anything under four is good . [patient] nice , such good news . [doctor] so it just needs to be checked every year or so . [patient] so in terms of estrogen control , i've been hearing that indol three carbonal or broccoli extract , supposedly can improve my estrogen levels . have you ever heard of it ? yeah , i've heard of it , but i have n't had anybody consistently use it . i mean your levels are fine and we checked your estradiol and it was not elevated , so . okay . [doctor] i would argue that we could test that in the fall if you want , but we do n't need to do anymore tests anymore than test once a year , excuse me . [patient] okay . what about increasing my testosterone to 175 mg . i'm at 140 now . [doctor] well , your levels are high . [patient] are they right now ? [doctor] well , i mean they were last time . [patient] yeah , but i just just injected though where i had right before that was taken . [doctor] i know , i know you had then . when did you inject this time ? [patient] i figured i'm on my eighth day today . [doctor] okay . [patient] so i'm due to dose on thursday or friday . [doctor] alright . [patient] i have a little med calendar and i put checks and teas on it , that helps me . [doctor] that's a great idea . so look the biggest issue i've seen even if your levels today are around 700 is that your peaks are getting greater than 1500 , putting you at a higher chance of needing to come off due to blood thickness and your risk will only go up the higher the dose that we go on . [patient] okay . [doctor] you look well , your levels are good and you are feeling well . [patient] yeah , i'm feeling good . [doctor] i'm going to be blunt . unfortunately this happens often where you are feeling good but you want to feel really good . i mean i get it , and this is why people get into problems with this stuff , right ? it's like back in the day when it was n't prescribed by doctors and people would get it at gyms and stuff and they would take huge doses and then they would have a heart attack at 50 . [patient] yeah , they have to be taking a lot . [doctor] likely they are taking more than testosterone but still . [patient] and they are taking stuff for a long time . [doctor] true but right now i would not change your dose . [patient] okay . [doctor] makes sense ? [patient] it does , i appreciate the discussion . [doctor] no problem . what pharmacy are you using ? have you changed it or anything ? [patient] no changes , i use walmart pharmacy . i do need more cialis and finasteride . [doctor] okay . [patient] i would prefer the paper prescription . [doctor] for all of them ? [patient] sure . [doctor] alright , we will do . let me go get your prescriptions . [patient] okay , thank you .
CHIEF COMPLAINT

Hypogonadism.

HISTORY OF PRESENT ILLNESS

Mr. Paul Edwards is a 59-year-old male, an established patient, who presents to the clinic today for hypogonadism. He was last seen on 11/24/2020. The patient’s history includes positive for HIV, and today he is concerned with gynecomastia.

The patient is doing well, overall, and feels the testosterone is helping. He reports weight stability, feels lively, good, more vigorous, and he is sleeping well. He also thinks the testosterone is having a positive effect on his blood work. He endorses that his triglycerides have always been elevated and adds that they were as high as 265 mg/dL. The patient presented a copy of his bloodwork, showing a significant decrease in his cholesterol after 5 months. Mr. Edwards questioned if the changes in his blood work were due to the testosterone. He also noted that his red blood cell count has not increased. The patient inquired about possible benefits of Indole-3-carbinol, which is a broccoli extract for estrogen control.

Currently, the patient is dosing 140 ng/dL of testosterone per week and inquired if his dose could be increased to 175 ng/dL. He recalled that he had recently injected testosterone before his last testosterone blood work was performed; last testosterone levels were greater than 1500 ng/dL. The patient confirms continued daily use of Finasteride and Cialis, prescribed by me, and stated he needs a refill for both.

Mr. Edwards mentioned he is taking correct steps to get his life "together." He also uses a med calendar to help with medication compliance.

PAST HISTORY

Medical
HIV

SOCIAL HISTORY

Utilizes med calendar to support medication compliance.
Actively trying to get his life together.

CURRENT MEDICATIONS

Cialis 5 mg tablet by mouth on days he exercises, 2.5 mg tablet by mouth on days without exercise.
Finasteride 5 mg half tablet daily.
Testosterone cypionate 140 mg.

RESULTS

PSA 0.6 ng/mL.
Triglycerides 145 mg/dL.
Total testosterone 1500 ng/dL, 11/24/2021.

ASSESSMENT

• Hypogonadism.

PLAN

I recommend maintaining current management. The patient’s last testosterone levels were greater than 1500 ng/dL, although this level was likely related to his recent injection. He requested an increase to his testosterone cypionate from 140 mg to 175 mg, which I denied due to his already high testosterone levels. I counseled the patient on the risks associated with high testosterone levels and Indole-3-carbinol and it’s lacking evidence to support his estrogen levels. The last time his estradiol levels were checked, they were normal; recommend annual screening.

I provided paper prescription refills for Cialis and Finasteride.
