Mr X age 61y
Very few prev. consultations. No regular medication. BP 2012 136/80
Consultation 13.8.14
Problem: Erectile dysfunction
History: having problems with “erectile dysfunction”. Hoping there will be a medical cause for it.
Doesn’t want to think its psychological. Married for 32y. No other partners. Struggling to get an
erection. No early morning hardness. Had a vasectomy in past. Got 1 son. Affecting his relationship
with wife. No significant PMH. Not checked for diabetes. Dad had DM. Feeling well in self. No other
symptoms at present. No urinary complaints. Admitted drinking excessive alcohol. Lager 4-5 cans
everyday 4.8% alcohol. Around 60 units. Doesn’t think alcoholic as doesn’t need it first thing in the
morning. Ex-smoker. Also c/o numbness both feet ongoing for 4 weeks. No pain just numbness. No
h/o intermittent claudication.
Social: retired lives with wife. Used to work in IT
Examination: Looks well, poor eye contact during consultation. Bilateral pitting oedema both legs up
to mid shins. Good pulses. CRT 2 seconds. Mormal temp. No sensory impairment. JVP not visible.
Abdominal examination normal. Chest clear.
Comment: advised to book for blood tests. Will need FBC, ferritin, TFTs, LFTs, glucose, lipid profile,
PSA, testosterone and CRP/ ESR. Also asked to bring urine sample to test for proteinuria. Will see
him in 2-3 days after the results for further discussion and management plan. Offered help with
alcohol intake. Will think about it and will discuss at next appt.
Consultation with HCA 15.8.14
BP 140/80 BMI 26.5 PR 88 urinalysis positive for glucose and ketones- sent for an ACR and HbA1c
added to bloods
Results: Glucose 17.8 HbA1c 11.3%/ 100mmol/mol PSA 0.7 eGFR>60 Hb 15.5
Consultation 20.8.14
Problem: Type 2 Diabetes
History: Came to discuss blood result. Initially seen for ED
Comment: Results explained. Not worried about the diagnosis. Agreed to start on tablets. Asked to
book appointment with Nurse Practitioner for further assessment and f/u. Discussed options for
treatment of ED. Wants to try sugar control first rather than taking sildenafil. Change metformin to
MR formulation if gets diarrhoea. Increase if tolerating fine. Also discussed cutting down alcohol as
drinking 60u/ week
Medication: Metformin 500mg one to be taken with breakfast and evening meal