| # | Test | Rationale |
|---|---|---|
| 🧪 Hypogonadism Workup (7 tests) | ||
| 1 | Total Testosterone ⚠️ Fasting, 7–10 AM draw required. Levels peak in the morning — afternoon draw will give falsely low result. |
Confirm prior ~200 ng/dL (Aug 2025) |
| 2 | Free Testosterone Equilibrium dialysis preferred. Bioavailable fraction — more clinically meaningful than total alone. |
SHBG may be high, making total look worse |
| 3 | SHBG (Sex Hormone–Binding Globulin) Required to interpret free testosterone accurately. |
Elevated in older men; binds T making it inactive |
| 4 | LH (Luteinizing Hormone) Differentiates primary (testicular failure — high LH) vs. secondary (pituitary suppression — low LH) hypogonadism. |
Axis localizer |
| 5 | FSH (Follicle Stimulating Hormone) Same axis evaluation. Also relevant to assess testicular reserve. |
Paired with LH for full picture |
| 6 | Estradiol (E2) — sensitive assay Baseline before any TRT. Adipose tissue converts T → E2 (aromatization); patient has BMI 36.6. |
Elevated E2 suppresses T + causes gynecomastia on TRT |
| 7 | Prolactin Rule out pituitary adenoma as cause of secondary hypogonadism (elevated prolactin suppresses GnRH → low LH/FSH → low T). |
Screen for pituitary cause |
| 💪 Statin / Muscle Pain Workup (2 tests) | ||
| 8 | Creatine Kinase (CK) Patient on atorvastatin 40mg. Gluteal muscle ache ongoing. Rule out statin-associated myopathy (statin myalgia vs. myositis). |
CK >10× ULN = myositis; <4× = myalgia |
| 9 | 25-Hydroxy Vitamin D Deficiency (<30 ng/mL) is a common and treatable cause of diffuse muscle aches + fatigue at this age, especially in LA (sunscreen use, indoor lifestyle). |
Low Vit D → myalgia + fatigue |
| 😴 Fatigue Differential (4 tests) | ||
| 10 | TSH (Thyroid-Stimulating Hormone) Last TSH 2.2 (Aug 2025 — normal). Repeat to rule out interval hypothyroidism as contributor to fatigue + weight gain. Low-cost screen. |
Prior normal; repeat for currency |
| 11 | Free T4 Paired with TSH for complete thyroid picture. TSH alone can miss subclinical thyroid disease. |
Thyroid hormone level |
| 12 | Vitamin B12 Patient on Metformin 1,000mg/day — metformin chronically depletes B12 via ileal absorption blockade. B12 deficiency → fatigue + neuropathy. Supplement started but confirm level. |
Metformin depletes B12 |
| 13 | Ferritin Iron-storage marker; iron-deficiency fatigue can occur without overt anemia (normal hemoglobin with low ferritin = iron-deficient without anemia). |
|
| 🛡️ Pre-TRT / Safety Baseline (5 tests) | ||
| 14 | CBC with Differential — flag Hematocrit & Hemoglobin Hematocrit baseline before any TRT decision. TRT raises RBC production (erythrocytosis) → raises hematocrit → thrombosis risk if >52%. CBC on file (May 2026): Hgb 15.8, Hct 47.8 — normal. Repeat for current baseline. |
TRT can raise Hct; baseline critical in CAD patient |
| 15 | Comprehensive Metabolic Panel (CMP) Renal function (metformin clearance — hold if eGFR <30) + hepatic baseline (on statin). Last eGFR 81, Cr 1.0 (Apr 2026). |
Renal + hepatic safety on current meds |
| 16 | PSA (Prostate-Specific Antigen) Post-brachytherapy 2020 surveillance. Last PSA 0.02 (Apr 2026) — excellent. Required baseline before any TRT discussion (testosterone can raise PSA in residual prostate tissue). |
|
| 17 | Lp(a) — Lipoprotein(a) Already tested (10 mg/dL, Apr 2026 — normal ✅). Genetic and lifelong stable — do NOT retest. Include here only if PCP has not seen the Apr 2026 result. |
Already done ✅ — skip if PCP has result |
| 18 | ApoB (Apolipoprotein B) Better atherogenic particle count than LDL-C alone, especially with low HDL (33) + borderline TG. Single best predictor of ASCVD risk beyond standard lipid panel. Has NEVER been measured — high-priority gap given CAC 581. |
Never measured; top priority for CAC 581 patient |
| Issue | Status | Next Step |
|---|---|---|
| Testosterone ~200 ng/dL | LOW | Full panel Jul 7 draw |
| HDL 33 mg/dL | CRITICALLY LOW | Dr. Natour Aug 7 |
| Exertional chest pressure (May 3) | WATCH | Report any recurrence immediately |
| Ascending aorta 4.1cm mild dilation | MONITOR | Repeat echo 2027 |
| IBS-D — not formally worked up | OPEN | GI consult when window allows |
| Post-RT secondary cancer surveillance | CURRENT | Cystoscopy clear Jun 24 · next per Dr. Baxter |
| Colonoscopy due ~2027 | SCHEDULE | 3yr interval per adenoma hx (2024) |
| Stamets Stack cardiac sign-off | PENDING | Dr. Natour Aug 7 |