DATE OF CONSULTATION: MM/DD/YYYY
REQUESTING PHYSICIAN: John Doe, MD
CHIEF COMPLAINT AND REASON FOR CONSULTATION: Erectile dysfunction, penile curvature, and low testosterone.
IDENTIFICATION: This is a (XX)-year-old Hispanic married gentleman.
HISTORY OF PRESENT ILLNESS: The patient initially states he is here seeking information regarding trauma during intercourse that he had some years ago. He reports that approximately three years ago while on vacation, he sustained a penile fracture while having intercourse. He noticed a complete detumescence of the erection without bruising and pain.
Since that time, he has been complaining of a slight penile curvature, ventral, with penile instability. His curvature is approximately 30 to 40 degrees without pain. He is still able to penetrate. He has no history of Dupuytren’s contracture, and he has not been treated for this in the past.
Currently, his erectile grade is 7/10 with a profound lack of sustaining capability. He states that within seconds of achieving maximum penile rigidity, his erection decreases to approximately 30% erection. He is not experiencing loss of penile length in the erect or the flaccid state. He does state his libido is at 20%. He has no issues with ejaculation or orgasm.
PAST MEDICAL HISTORY: Anxiety disorder.
REVIEW OF SYSTEMS: Remarkable for shortness of breath and joint pain. Review of systems is negative otherwise.
FAMILY HISTORY: Unremarkable.
MEDICATIONS: Prozac.
SOCIAL HISTORY: The patient denies use of recreational drugs and tobacco. He has one alcoholic drink per week. He is employed. He does not have any children.
PHYSICAL EXAMINATION:
VITAL SIGNS: Pulse is 70. Blood pressure is 126/68. He weighs 214 pounds.
GENERAL: The patient is alert and oriented x3 with a normal mood and affect.
SKIN/NECK/CHEST: Examinations are grossly normal. There is no gynecomastia.
ABDOMEN: Abdominal examination reveals a soft, nontender, nondistended abdomen, without masses or hernias.
GENITOURINARY: Examination reveals a normal-appearing scrotum with bilaterally descended testicles. The right testicle is 18 mL and firm. The left testicle is 15 mL and firm. The epididymides are normal. There is no varicocele present. Penile examination reveals a circumcised phallus with good penile stretch and no Peyronie’s plaques present.
MUSCULOSKELETAL AND VASCULAR: Examinations are grossly normal.
IMPRESSION: Erectile dysfunction, penile curvature, status post penile trauma, and possible hypogonadism.
PLAN: We had a structured conversation with the patient regarding his issues. For his erectile dysfunction, we have given him a prescription for Viagra. He will take this medication in an effort to increase his erectile rigidity. For penile curvature/penile trauma, we will have him return to the office for curvature assessment and diagnostic ultrasound of the phallus. During this test, we will be able to assess the morphology as well as his erectile capacity. We will be able to discuss the results of this test immediately after completion. At the same time, we can discuss treatment options that are available to him.
With regard to his hypogonadism, we have reviewed his outside labs, which revealed a bioavailable testosterone of 101. We would like to confirm this result before prescribing a prolonged course of supplemental testosterone. Of note, the patient states that he and his wife were unable to have children so exogenous testosterone may not be the right answer for him, if he is hypogonadal. A better option may be a centrally-acting agent such as Clomid to increase his natural testosterone manufacturing capability.
