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Q1: A 48-year-old man comes to the clinic with symptoms of sexual dysfunction. He states that for the last year and a half, he has had a markedly decreased libido and trouble maintaining an erection. He has also occasionally noticed some milky-type of discharge from his nipples. He denies headaches, shortness of breath, or chest pain. He has had no abdominal or urinary symptoms. He has no significant past medical history and takes no medications. On physical examination, he is afebrile and has normal vital signs. His visual acuity, visual fields, extraocular movements, and pupillary response to light are normal. Remainder of neurologic examination is normal. Laboratory studies show a leukocyte count of 5,600/mm3, hematocrit 45%, platelets 230,000/mm3, glucose 100 mg/dL, creatinine 0.8 mg/dl, blood urea nitrogen 16 mg/dl, serum prolactin 1,000 ng/ml (normal <20 ng/ml). The next most appropriate step in management is

A. bromocriptine

B. mammography

C. a MRI of the brain

D. a MRI of the lumbar spine

E. sildenafil citrate Explanation: The correct answer is C. This patient has impotence, loss of libido, and galactorrhea related to hyperprolactinemia. The most common cause of this in men is probably medication induced, however, he is on no medications. The next main thing to rule out is a prolactin secreting microadenoma by an MRI of the brain. Bromocriptine (choice A) may end up being the treatment of choice for this patient if a microadenoma is found. However the diagnosis should be made prior to treatment. If bromocriptine therapy fails to relieve symptoms, or if the adenoma grows/begins causing other symptoms, referral to neurosurgery to evaluate for transphenoidal resection would be warranted. There is no indication for a mammogram (choice B) or an MRI of the lumbar spine (choice D) in this case. Sildenafil (choice E) also may end up being helpful in this case for the patient's symptoms. However, again making the underlying diagnosis is the most appropriate first step in the work up.

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