Chief ComplaintA 46 yo male presents to the clinic with a chief complaint of fatigue.

HPI -- He was in excellent health until about 4 months ago when he noticed a loss of energy, going to sleep earlier and abstaining from jogging which prior to he enjoyed doing 3x per week. In addition, he noticed over this time period a loss in libido and symptoms of erectile dysfunction. This past month he has noted an increase in urination during the day and at night. He denies any history of SOB, Orthopnea, or chest pain.

PMH: childhood asthmaPSH: inguinal hernia repair as a childSH: drinks about 2 beers a night, on weekends a little more, Denies smoking, Denies illicit drug useMedications None

Review of SystemsGeneral - increased fatigue, denies fever, chills

HEENT- normalChest – childhood AsthmaC-V negativeAbdomen - No history of hepatitisGU - noted above, increased frequency and volume of urinationM-S - complains of diffuse arthralgias which wax and wane and self-treats with Ibuprofen

Physical ExamGeneral – thin male in NADVS BP 100/60—Pulse 88---RR14—T 37.0Skin tannedHEENT- wnlChest clearC-V nl rate and rhythm no murmurs or S3 or S4Abdomen - without tenderness, liver palpated 3cm below the right costal margin no splenomegalyGU - testicles palpated in the scrotum, atrophy noted prostate normalMSS - without bony deformities

Patients Reference range CBCWBC 4500 4500-11000/ulHemoglobin 13.1 13.5-17.5 g/dlHemotocrit 39.2 41-53%Platelet count 101,000 150000-350000/ul

Reticulocyte countReticulocyte % 1.0 0.5-1.5 Liver PanelALT (U/L) 125 10-55AST (U/L) 97 10-40Bilirubin, total (mg/dL) 1.3 0.0-1.0Bulirubin, direct (mg/dL)

1.1. 0.0-0.4

Alkaline phospatase (U/L)

125 45-115

Albumin (g/dL) 2.8 3.1-4.3 Iron StudiesIron(ug/dL) 175 30-160Total iron binding capacity (ug/dL)

181 228-428

Tranferrin saturation (%)

97 20-50

Ferritin (ng/ML) 2875 30-300

HaptoglobinHaptoglobin(mg/dL) 30 36-195 Hemoglobin ElectrophoresisHemoglobin A (%) 97 95-98%Hemoglobin A2 2 2-3%Hemoglobin F 1 0.8-2%Hemoglobin S 0.0 0.0%Hemoglobin C 0.0 0.0% PT/PTTPT 13.6 11.4-13.4 secondsPTT 33.0 22.1 – 34.1 seconds ThyroidTSH (uU/mL) 4.0 0.5-5.0Thyroxin, total (T4) (ug/dL)

9.0 4.9-10.9

Amylase/LipaseAmylase (U/L) 46 30-110Lipase (U/L) 20 7-60 LH/FSHLH(U/liter) 1.2 2.1-12.0(men)FSH(U/liter) <0.5 1.0-12.0 EstradiolEstradiol(pg/mL) 6 10-50 ProlactinProlactin(ug/L) 6.6 0.0-15.0 GlucoseGlucose, fasting (mg/dL)

305 70-110

Glycated hemoglobin (%)

7.1 3.8-6.4

Glucose tolerance test Abnormal <200 ThyroidTSH (uU/mL) 4.0 0.5-5.0Thyroxin, total (T4) (ug/dL)

9.0 4.9-10.9

Testosterone