Gynaecomastia
Doctor Information
Mark Jacobs 32
Past medical history:
Nill
Drug History:
No routine medication
Allergies:
None
Past medical history:
Nill
Drug History:
No routine medication
Allergies:
None
Patient Information
Mark Jacobs 32
Opening sentence: This is a bit embarrassing doctor, but I've noticed over the past few months that I seem to be developing breasts!
Reveal Readily: You’ve always been a slim chap, but over the past few months you’ve noticed that your chest is appears to be growing, and looking more like breasts. You’ve been obviously very concerned about this, so have done some reading up on the internet about this, and it seems to be a condition called gynaecom… something. You cant quite remember. Everywhere you read, it said to go see your doctor so thats why you’re here.
Reveal only if asked: You’ve not noticed any headaches, your vision is fine, you have no loss of peripheral vision. You only take paracetamol or ibuprofen on an PRN basis for intermittent back pain that you’ve had for many years. You don’t take any other over the counter medications such (including ranitidine/PPI/domperidone). You enjoy working out at the gym, it is your stress relief, but you don’t use any steroids or testosterone boosters.
Your weight has remained very stable over the last few years, You don't smoke, take any recreational drugs nor any alcohol. You work as an accountant and are very busy. You live at home with your girlfriend Joy, and have no children. There are no problems that run in the family.
If asked directly: you have noticed a testicular lump in the left testis, you don’t think its related, and have actually booked another appt next week to discuss that problem. It’s been there for 2 months now, and you’re not sure, but you think it may be getting bigger. It feels firm and is not tender at all.
The ongoing problem with the breasts is a bit embarrassing down at the gym as you used to wear T-shirts, but now find that you wear a hoodie on top to hide your chest. No one has commented, but you suspect they have noticed.
Ideas: You suspect after reading on the internet forums that this may be due to weight training, and wonder if this is the case
Concerns: it’s only 6 months before beach season, and you would like to be able to get rid of it by then. With regards to the testicular lump you are not too concerned.
Expectations: The internet forums mentioned oestrogen blockers: Tamoxifen, and you were wondering if you could try that out.
Opening sentence: This is a bit embarrassing doctor, but I've noticed over the past few months that I seem to be developing breasts!
Reveal Readily: You’ve always been a slim chap, but over the past few months you’ve noticed that your chest is appears to be growing, and looking more like breasts. You’ve been obviously very concerned about this, so have done some reading up on the internet about this, and it seems to be a condition called gynaecom… something. You cant quite remember. Everywhere you read, it said to go see your doctor so thats why you’re here.
Reveal only if asked: You’ve not noticed any headaches, your vision is fine, you have no loss of peripheral vision. You only take paracetamol or ibuprofen on an PRN basis for intermittent back pain that you’ve had for many years. You don’t take any other over the counter medications such (including ranitidine/PPI/domperidone). You enjoy working out at the gym, it is your stress relief, but you don’t use any steroids or testosterone boosters.
Your weight has remained very stable over the last few years, You don't smoke, take any recreational drugs nor any alcohol. You work as an accountant and are very busy. You live at home with your girlfriend Joy, and have no children. There are no problems that run in the family.
If asked directly: you have noticed a testicular lump in the left testis, you don’t think its related, and have actually booked another appt next week to discuss that problem. It’s been there for 2 months now, and you’re not sure, but you think it may be getting bigger. It feels firm and is not tender at all.
The ongoing problem with the breasts is a bit embarrassing down at the gym as you used to wear T-shirts, but now find that you wear a hoodie on top to hide your chest. No one has commented, but you suspect they have noticed.
Ideas: You suspect after reading on the internet forums that this may be due to weight training, and wonder if this is the case
Concerns: it’s only 6 months before beach season, and you would like to be able to get rid of it by then. With regards to the testicular lump you are not too concerned.
Expectations: The internet forums mentioned oestrogen blockers: Tamoxifen, and you were wondering if you could try that out.
Examination Findings
Examination:
Pulse 70
BP 120/70
RR16
Afebrile
Chest: bilateral slightly tender gynaecomastia, no discrete lumps palpable, no axilliary LN.
Testicular exam: hard, irregular swelling noticed in body of left testis, non tender.
BMI 22
Inguinal lymph nodes palpable.
Pulse 70
BP 120/70
RR16
Afebrile
Chest: bilateral slightly tender gynaecomastia, no discrete lumps palpable, no axilliary LN.
Testicular exam: hard, irregular swelling noticed in body of left testis, non tender.
BMI 22
Inguinal lymph nodes palpable.
Mark scheme
Data Gathering
|
POSITIVE INDICATORS
Organised and systematic in gathering information from history taking, examination Identifies abnormal findings or results and/or recognises their implications Enquires about possible causes of gynaecomastia (see below) and enquires about social / personal impact Data gathering does appears to be guided by the probabilities of disease Undertakes physical examination competently |
NEGATIVE INDICATORS
Makes immediate assumptions about the problem Intervenes rather than using appropriate expectant management Is disorganised/unsystematic in gathering information Data gathering does not appear to be guided by the probabilities of disease. Fails to identify abnormal data or correctly interpret them Appears disorganised/unsystematic in the conduct of physical examinations |
Clinical Management Skills
|
POSITIVE INDICATORS Makes appropriate diagnosis Develops a management plan (including prescribing and referral) that is appropriate and in line with current best practice Makes appropriate prescribing decisions - in this case, best to prescribe nothing for the time being Manages risk effectively, by suggesting a fast track referral Explains to the patient the concern regarding the lump, making it clear that the referral is to exclude cancer. Arranges close follow up after specialist review. |
NEGATIVE INDICATORS
Fails to consider common conditions in the differential diagnosis Does not suggest how the problem might develop or resolve Decisions on whether/what to prescribe are inappropriate or idiosyncratic. Referral arrangements are unclear, and reason for referral (to exclude cancer) not made clear Follow-up arrangements are absent or disjointed |
Inter Personal Skills
|
POSITIVE INDICATORS
Identify patient’s agenda, health beliefs & preferences Works with the patient to develop a shared management plan or clarify the roles of doctor and patient Offers chaperone for examination Uses explanations that are relevant and understandable to the patient Shows sensitivity for the patient’s feelings in all aspects of the consultation including physical examination Does not allow own views/values to inappropriately influence dialogue |
NEGATIVE INDICATORS
Doesn't enquire about patients ICE Takes a doctor centered approach towards management Uses an explanation that is filled with jargon, or forgets to explain at all Fails to offer chaperone Doesn't show any sympathy / empathy towards the patient's situation Inappropriately influences patient interaction through own views/values |
Management
Explanation:
Gynaecomastia: Everyone, including men have some breast tissue, this is normal. Gynaecomastia is a common condition that causes boys’ and men’s breasts to swell and become larger than normal. It is most common in teenage boys and older men. There are many causes for this, in your case it may be due to….
Testicular swelling: Lumps and bumps in the testis are very common, most lumps are not serious, however there is always a risk that a lump in the testis may be cancer. In your case, there are some features of the lump that gives me some concern, and I suggest it may be a good idea to get you seen by a specialist to rule out cancer.
Gynaecomastia:
Very common in older men and pubertal boys - considered physiological in these age groups. For most boys it will go on its own given time, and is a normal part of puberty. See below for a list of pathological causes:
Gynaecomastia: Everyone, including men have some breast tissue, this is normal. Gynaecomastia is a common condition that causes boys’ and men’s breasts to swell and become larger than normal. It is most common in teenage boys and older men. There are many causes for this, in your case it may be due to….
Testicular swelling: Lumps and bumps in the testis are very common, most lumps are not serious, however there is always a risk that a lump in the testis may be cancer. In your case, there are some features of the lump that gives me some concern, and I suggest it may be a good idea to get you seen by a specialist to rule out cancer.
Gynaecomastia:
Very common in older men and pubertal boys - considered physiological in these age groups. For most boys it will go on its own given time, and is a normal part of puberty. See below for a list of pathological causes:
Cancers:
testicular, gastric, liver, lung, prostate.
Renal or Liver disease
Congenital:
Kleinfelter's, congenital absence of testes, congenital adrenal hyperplasia
Hyperthyroidism
Obesity
Medications:
Others: Digoxin, amiodarone, alcohol,
Testosterone production inhibitors: metronidzole, spironolactone, GNRH agonists
Testosterone action inhibitors: finasteride, Ranitidine, PPI’s
Increase Prolactin: antipsychotics, tricyclic antidepressants, metoclopramide, domperidone,
Drug Abuse:
Steroids, testosterone, marijuana
Investigations:
Blood test: Renal function, LFT’s, TFT’s, Hormone profile: oestrogen, testosterone, prolactin BHCG, AFP, LH
Scans: Ultrasound breast tissue if concern over breast Ca (may need to fast track for this), ultrasound testes if concern over lump (again fast track referral may be more appropriate depending on level of concern). If lung ca suspected, then CXR.
Management:
Most CSA cases are focussed around option sharing, however in this case, the only safe option is a referral onwards to exclude testicular cancer.
Treatment of gynaecomastia first starts with treating the underlying cause if found - i.e remove any offending medication or replace androgen if missing.
If no cause is found, then managing expectations is the next step, for some a simple reassurance that no sinister cause is found may be sufficient. However if cosmetic appearance is of primary concern, then start by advising weight loss.. Aim for a BMI of around 22. Other options include garments that hide the excessive breast tissue. Medications such as tamoxifen are also an option, as it has an anti oestrogen effect (discussion with a specialist may be advisable before trialling them however)
If all else has failed, then the final option is cosmetic surgery. This is not done on the NHS, but you may be able to get funding through the exceptional cases committee (individual funding requests)
Blood test: Renal function, LFT’s, TFT’s, Hormone profile: oestrogen, testosterone, prolactin BHCG, AFP, LH
Scans: Ultrasound breast tissue if concern over breast Ca (may need to fast track for this), ultrasound testes if concern over lump (again fast track referral may be more appropriate depending on level of concern). If lung ca suspected, then CXR.
Management:
Most CSA cases are focussed around option sharing, however in this case, the only safe option is a referral onwards to exclude testicular cancer.
Treatment of gynaecomastia first starts with treating the underlying cause if found - i.e remove any offending medication or replace androgen if missing.
If no cause is found, then managing expectations is the next step, for some a simple reassurance that no sinister cause is found may be sufficient. However if cosmetic appearance is of primary concern, then start by advising weight loss.. Aim for a BMI of around 22. Other options include garments that hide the excessive breast tissue. Medications such as tamoxifen are also an option, as it has an anti oestrogen effect (discussion with a specialist may be advisable before trialling them however)
If all else has failed, then the final option is cosmetic surgery. This is not done on the NHS, but you may be able to get funding through the exceptional cases committee (individual funding requests)