General Internal Medicine Question 111

A 52-year-old man is evaluated for the sudden onset of erectile dysfunction that has persisted for 6 months. He reports having erections that are inadequate for vaginal penetration. He feels guilty about not being able to satisfy his wife's requests for sexual intercourse, although he still has sexual desires. He has been sleeping poorly and feeling fatigued throughout the day. He reports no snoring or daytime somnolence, and his review of systems is otherwise negative. His wife does not report that the patient has episodes of nocturnal gasping or apnea. He has firm erections upon waking in the morning. For years, he has run 2 miles daily without chest pain or exercise-limiting dyspnea, although he has not been interested in exercise over recent weeks. Medical history is notable for hypertension. Family history is notable for his father who died of a myocardial infarction at age 70 years and his mother who died of complications from a stroke at the age of 94 years. He has never smoked cigarettes. His 10-year risk of atherosclerotic cardiovascular disease is calculated to be 5% using the Pooled Cohort Equations. Medications are hydrochlorothiazide and lisinopril. He has taken these medications for 6 years without interruption.

On physical examination, the patient is afebrile, and blood pressure is 132/64 mm Hg. BMI is 26. Heart, lung, and abdominal examinations are normal. The penis is uncircumcised without abnormalities, and the testes are normal size.

Laboratory studies show a fasting plasma glucose level of 98 mg/dL (5.4 mmol/L).

Which of the following is the most likely cause of this patient's erectile dysfunction?

A Hypogonadism

B Mood disorder

C Obstructive sleep apnea

D Prolactinoma

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