Cram The Pance - S1E49 Breast Disorders

Episode Date: February 18, 2023

High Yield Breast Disorders Review.Review for your PANCE, PANRE, Eor's and other Physician Assistant exams. Merchandise Link: https://cram-the-pance.creator-spring.com/►Paypal Donation Link: https://bit.ly/3dxmTql (Thank you!)Included in review: Mastitis, Breast Abscess, Fibroadenoma, Fibrocystic Breast Changes, GynecomastiaBecome a supporter of this podcast: https://www.spreaker.com/podcast/cram-the-pance--5520744/support.

All right, so today we're going to do a high-yield review of breast disorders. That's mastitis, breast-absessed fibroedinoma, fibrocystic breast changes in gynecomastia. Thank you, as always, for the really nice comments, the support, the people who have made donations. I truly, truly do appreciate it. Thank you so much for that. Let's go ahead and get started. We'll start with mastitis. Massitis is an inflammation of the breast parankhamma. So simply, it's just an inflammation of the breast. It can be with or without infection. It can be lactational, meaning associated with breastfeeding or non-lactational, not associated with breastfeeding. Usually though, when we're talking about mastitis, when we're using this term, the term is generally used clinically to imply an infectious etiology. In addition,

I'd really focus on the lactational type, as that's almost always what they're going to give you in the vignette. It's going to be a 25-year-old woman, postpartum period, recent onset breast pain, swelling, noticing decreased milk output, etc. Focus on that type of presentation for the question that you'll likely get on the exam. Clinical manifestations, you're going to have a firm, red, painful, swollen area of the breast may be associated with fever. They may have systemic complaints, malaise, chills, flu-like symptoms, pretty straightforward. And usually what can be helpful to differentiate from other conditions, it's usually going to be unilateral. So just one breast affected. And then as a side note in real life when you're out there treating patients, you want to be really careful because

these clinical manifestations seen in mastitis can also be seen in a much more serious diagnosis, which is inflammatory breast cancer. So if these patients are treated with antibiotics, and there's no improvement, make sure you consider that as one of your differentials. Now, etiology, staff aureus is going to be the most common cause of infectious mastitis. It's almost always going to be the organism that's present. Most episodes of lactational mastitis are going to be from staff orius. You have a woman who's breastfeeding after time. The nipple can develop excreation, this cracking, which introduces staff into the breast tissue.

Also, stagnant milk can be a nitis for infection, and that's, That's why it's always encouraged for women who are breastfeeding to ensure they have frequent, complete emptying of the breast to avoid infection. Diagnosis, it's mainly going to be clinical. There's nothing really to know for diagnostic criteria. This is mostly a clinical diagnosis. You can culture the breast milk to guide selection of antibiotics. If there's any suspicion for an abscess of the breast, ultrasound is going to be the most

effective way to differentiate mastitis from breast abscess. Treatment, you start with your supportive measure, so warm and cold compresses, expressing or pumping milk from the breast between feeds, massaging the breast to clear any blockages. And then if it's been 12 to 24 hours, the symptoms aren't getting any better. Patient has fever, other systemic symptoms. Then we know we got an infection and we need some antibiotics, which is really what you need to know for the exam. Most of the time when they give you a question, they don't want you to know the supportive measures.

They really want you to know the antibiotics, even though the supportive measures are important. They always ask you about the antibiotics. That's just always what the exams always focus on. So which antibiotics are those going to be? Well, as we talked about this before, this is almost always caused from staff. So you want your anti-staffaithaithyxin. Diaclyxin, so if it's just plain old staff, it's a non-severe infection, there's no risk for MRSA, you're going to hit them either with cephaloxin or dichloxicillin.

If there is a risk for MRSA, they maybe had recent hospitalization, recent surgery, patients on hemodialysis, then you have to cover for methicillin-resistant staphoreus. So you either give them trimethympathicin sulfomythoxazol, aka back. Clindomycin. If it's a severe infection, vancomycin would be another option. And then, of course, if there's a culture pending and it displays different organisms besides staff, you adjust your antibiotics accordingly. But most often you're going to be treating staff. So those are your antibiotics. Those are your antibiotics to know. And then there's one additional measure that's super important that you need to know. And that's to continue breastfeeding. This is so crucial to remember

when a mother is being treated for lactational mastitis, she needs to keep breastfeeding. This is really key to resolving the infection and improving the symptoms. You have to remember this because you're going to get a question. I know I definitely did. It's going to be mastitis. You're going to remember the antibiotics. Be all excited. They're going to have two answer choices. Both are going to say, let's say, dichoxicillin, but one's going to say dieuoxicillin plus continue breastfeeding, and the other will say dichloxicillin and discontinue breastfeeding. And you need to know the mother should continue breastfeeding. Remember that. All right. So let's move on to breast abscess. So breast abscess, there's a lot of similarities with mastitis.

There's just a few key things to know to differentiate the two and then obviously be aware that mastitis, if not treated promptly, can lead to an abscess formation. So breast abscess is a localized area of inflammatory exudate in the breast tissue. It's just a fancy way of saying you have a walled off collection of pus in the breast. Clinical manifestations, you're going to have a fluctuan, tender, palpable mass. So they're going to have painful inflammation of the breast that can be associated with fever and malaise, very similar to mastitis. But the key, anytime you have an abscess, they're going to use the word fluctuant. Fluctuant is that key term.

When you see that one word, you know we're dealing with an abscess and not just mastitis. So fluctuent, tender mass. Fluctuant just means that there's this fluid-filled structure present, such as an abscess. And when you press down on it, it produces a wave-like motion when it's palpated, kind of as the pusses display. So remember that word. It's really important. Fluctuant. Look for that in the vignette. Diagnosis is most of the time going to be made clinically based on your physical exam findings, palpating that fluctuent tender mass in the breast. But if they ask you, how can you confirm the diagnosis to ensure this is an abscess? Then you need to do an ultrasound. So the diagnosis can be confirmed via ultrasound. It's going to demonstrate this hypoechoic lesion in the breast. Hypoechochoic, just meaning it's going to be darker than the surrounding structures. Normally a dark gray or black area. then this confirms there is an abscess present. So then how do we treat it? How is this going to be different than how we treated mastitis? Well, we start with our antibiotics, just as we did with mastitis. It's assumed this is a staff infection. So your empiric antibiotic therapy should cover for staff.

So just as we went over before, hit them with some dichloxicillin, cephalyxin, if it's not MRSA, if they're at risk for MRSA, hit them with Clinda, trimethythoprine, sulfomythylmothosol. Nothing new to know here. The key difference is what you do next. And what you do next, compared to mastitis is you drain that abscess. That's the key difference in treatment. So this can be done with either a needle aspiration. It can be done with an incision and drainage. It's important to remember, though, this additional step in treatment for breast abscess,

draining the abscess plus antibiotics. And then, of course, keep in mind, just as in mastitis, milk drainage, either by breastfeeding or pumping, is really important to continue. It's not contraindicated in the setting of an abscess. And in fact, studies have shown that it not only reduces the duration of the symptoms experienced, but also encourages resolution of the infection. So remember, continue breastfeeding in both mastitis and breast abscess. So key differences to look out for in the vignette to differentiate mastitis from a breast abscess.

First, remember that keyword fluctuent, a tender, fluctuent mass, that's an abscess. If they ask you to prove it, ultrasound and key difference with treatment is going to be the addition of some form of drainage, either with needle aspiration or an incision and drainage. Otherwise, the rest is the same between the two. Both are common in women who are breastfeeding. Both are commonly caused by staff, and both are treated with staff-sensitive antibiotics, like dichloxicillin, cellin, sephalexin.

Moving on to fibro adenomas. So fibroidinomas are benign breast tumors made up of both glandular tissue and stromal, aka connective tissue. There's different varieties, simple, complex, giant fibro adenomas. I wouldn't worry so much. about the different subtypes though they usually don't test you too much on those you should

know though that these are very common fibroidinomas are found in one half of all breast biopsies and autopsy studies reveal these lesions are found in 9 to 10% of all women and generally fibroidinomas are considered to be the most common benign tumor of the breast you should also know that you're going to find these mainly in young women so 15 to 35 years of age you're looking for a woman in the reproductive years fibroidinomas usually regress after menopause. They can also increase in size during pregnancy or with estrogen therapy. Physical exam, this is really important. Firm, rubbery, highly mobile, non-tender mass. So a couple really high-yield things in the physical exam. First is the fact that the mass is usually

going to be non-tender. That's going to be one of the keys to differentiate between fibroidinoma and fibrocystic breast changes. Fibroidinomas are most of the time non-tender. They can cause pain, but more often than not, the more often they do not cause pain. And fibrocystic changes, on the other hand, which we'll go over next, are usually tender. It's really important. And while nothing is 100% in medicine for the exam, I'd remember fibro adenoma as no pain, fibrocystic as painful. The other thing to know is the mobility of the mass. Fibro adenomas are notorious for being, for a lack of a better word, slippery.

Fibro idanomas are sometimes known as a breast mouse because they move, that's right, breast mouse. because they move so freely and slip all around in the breast when being examined, gives us feeling that they're running away from the examining hands, as they say. So remember fibroidinoma, breast mouse, it slips and moves all around. And a lot of times they'll bring this up in the vignette, too. So it's important to remember this. And the way that I used to remember this is by instead of remembering fibro adenoma, I'd instead remember it as fival adenoma.

Fival as in F-I-E-V-E-L, and this is probably only going to work for a few people because most of you probably are too young to remember this movie. But when I was little, there was this movie called Fival Goes West. It was this old cartoon about this mouse that was named Fival. It was also a ride at Universal Studios for a while. It's definitely kind of old. So you may not be familiar with it, but it worked for me. So instead of fibro adenoma, remember fival adenoma.

To help you remember, this is also known as a breast mouse and to help you remember how freely mobile this mass is because they'll likely bring that up in the vignette. Now, diagnosis, you're going to start with your, ultrasound. And some of you might be thinking why ultrasound and not mammography. Anytime you think about like a breast mass, we're always thinking right away of mammography. But ultrasound is the preferred imaging modality in young women under the age of 30, which as you remember is the typical demographic for patients with a fibro adenoma. And what is the reason why ultrasound is preferred

to memo in young women? Well, there's a couple of reasons for this. First, most benign lesions in young women are not visualized on mammography because of the density of the breast tissue in young women. This limits the sensitivity of mammography. So ultrasound is actually better for younger women. And then the second reason is because there is an increased radiation risk with mammography, albeit minimal, but it's best to avoid any radiation in young patients if possible. So those are a couple of reasons why you're going to start with your ultrasound. Another option for diagnosis in young women would be a fine needle aspiration, although ultrasound is generally preferred as the initial test. Now treatment, most fibroidinomas don't need to be treated. Many

stop growing or even shrink on their own. So observation is completely appropriate for many patients. And as we discussed before, the majority will regress during menopause. But if the size of the fibroidinoma continues to increase, maybe it's causing a deformity of the breast, you do have surgical removal or cryoblation as some definitive treatment options. So what should you commit to memory about fibroidinomas? First, remember, this is mainly going to be seen in young women, 15 to 35 years of age is the most common. And then really important, remember those physical exam findings. Highly mobile, non-tender mass.

Highly mobile, non-tender. Those are the words that you should be repeating in your head when you hear fibroidinoma. Remember, your fival adenoma, your breast mouse. Those are the key takeaways for fibroidinoma. Next, let's talk about fibrocystic breast changes, which in many ways is very similar to fibroidinomas. So let's go over the key differences to make sure you get the answer right on the exam. So fibrocystic breast changes are these benign changes in breast tissue characterized by fibrosis and fluid-filled

cis. So fibrocystic breast changes really is just this nonspecific umbrella term that encompasses these changes women can experience in breast tissue. If we break down the word fibro as in fibrous tissues, fibrosis, and then cystic as in ciss. So fibrosis and cis is what you should be thinking of when you see this term. So fluid-filled cysts and fibrosis, often would have. happens is a breast lobule will dilate and form a cyst, and then that cyst will rupture, which leads to the scarring and inflammation, which causes the fibronic changes. So where are we going to

see this in? 30 to 50 years of age will be the most common, so generally younger women, more than 50% of females of reproductive age have fibrocystic changes. And while the etiology isn't a hundred percent certain, fibrocystic changes are thought to result from this imbalance between estrogen and progesterum, which is why. they're more common in premenopausal women who have these cyclical surges every month of estradile and progesterone and are relatively uncommon in postmenopausal women who have a decrease in production of these hormones. So be looking for your premenopausal or even perimenopausal patient.

Clinical manifestations, this is really important. Painful breast tissue. Painful breast tissue that fluctuates in size and severity with the menstrual cycle. So pain is the word I want you to focus on. because this is what will differentiate it from a fibro adenoma. Now, when are these women going to have pain? Generally, they're going to have pain in the breast tissue before mencies that will usually improve during menstruation.

In addition, the breast tissue, particularly in the upper outer quadrant where this is most common, may increase in size prior to the onset of mencies, then return to baseline after the onset of menstrual flow. So really the main takeaway, again, is to remember this is generally a painful condition, pain that fluctuates with menstrual cycles. You cannot forget that, associate pain with fibrocystic disease. It's so important that in your brain I want you to replace fibrocystic, fibrocystic, with fibro cyst ache. No longer fibrocystic, it's now known as fibro cyst ache, ache, acche to help you remember

the pain or aching that's associated with this condition. Fibro cyst ache, that's going to be the key to differentiate it from other conditions in the vignette like fibro adenoma. All right, let's move on to your physical exam. So diffuse nodular areas. When you see fibrocystic changes, recognize this is often not going to be this discrete or well-defined mass as we saw in fibro adenomas. It of course can be, but generally this is just going to be these irregular diffuse. A lot of times they say lumpy, bumpy changes throughout the breasts. You can have cis of varying sizes. You can have fibroatic changes where the tissue is firm and hard. And often the

fibotic tissue is generally going to be found in the upper outer quadrants of the breast. Now, diagnosis is going to be with an ultrasound. The main thing I would know here is ultrasound. If there's any abnormality found on the ultrasound, mammography and a fine needle aspiration are some other options to assist in diagnosis. A fine needle aspiration, it can actually be both diagnostic as well as therapeutic because when it's performed, it often collapses the cyst and improves the discomfort experience. Next, let's talk about treatment. Mainly, it's going to to be supportive measures. So acetaminophen, ns, supportive bra, reassurance. Fine needle aspiration, as we discussed before, is another option. And again, it can be both diagnostic and

therapeutic because in many patients it will collapse the cyst, which can cause a lead to pain relief. Tamoxifen and danazol are also used sometimes off-label for patients who have severe pain that are refractory to other treatments. And then you may have heard of elimination of caffeine as being an effective supportive treatment option. But the evidence is mainly anecdotal. Most controlled studies have failed to demonstrate an association between caffeine and breast pain. All right. So main takeaways for fibrocystic changes of the breast.

This is generally going to be seen in women of reproductive age, 30 to 50 years old is the most common age bracket. You're looking for a painful, painful breast tissue that fluctuates with menstrual cycles. Remember, this is fibrosisic, not fibrocystic. and then diagnosed with ultrasound treatment mainly supportive, and that's fibrocystic breast changes. Last but not least, gynecumastia. So this is a benign proliferation of the glandular tissue of the male breast due to an increase in estrogen production or decreased androgen production.

So pretty straightforward, gynacomastia is enlarged male breast tissue caused by an imbalance between estrogen and testosterone, either have too much estrogen or not enough testosterone. What are some causes of gynecomastia? there's there's a there's a lot actually um hyperthyroidism so patient male patients with graves disease often have a higher than normal serum lh level which can lead to increased estradial levels chronic kidney disease this is primarily due to late cell dysfunction and gonachymastity occurs actually in up to 50 percent of patients treated with hemodialysis some malignancies testicular neoplasm some adrenalism hypogonadism puberty so during puberty some boys will have this transient

imbalance of estrogen to androgen and can develop gynecomastia. And then it can also be seen in older males due to the gradual decrease in testosterone production and resultant aromatization of testosterone to estradiol. Long story short, there's a ton of causes. But for the exam, this is the good news, I would really just suggest on narrowing it down to two high-yield causes that came up in the exams a lot. The first one and probably the highest yield cause for gynecumastia is medication. So you need to know a few important meds.

that can lead to gynecomastia that are often tested on. Let's first start with the king of all of the gynacomastia causing drugs, and that is spyrnalactone. If there were one med to know that can cause gynecumastia, if you just want to memorize one medication, let it be spironolactone. Spirnal lactone, aka spirnal lactose, as I used to call it in my head, because for some weird reason, spironolactose made me think of lactose, as in breast milk that led me to gynaecamastia.

I don't know. It was really weird, but it just helped me make the association on a test. Maybe that I'll help you. Anyways, this med increases aromatization of testosterone to estradiol. It also decreases testosterone production by the testes. Because of these changes, among others, it's notorious for causing gynecumastia. 10% of patients taking low-dose spyrinylactone for heart failure will develop gynecumastia. And patients taking the high dose for liver failure or hypertension due to aldosterone excess, that number reaches almost 100%. So remember, spyrnalactone, aka spyrnalactose. This is the highest yield of all the meds. Let's talk about a few other high yield ones.

Semedidine, which is an H2 blocker used for GERD. This is another huge one that they often test on. Cometide,ine we rarely use anymore because it has so many side effects. Obviously, Gondromasty being one of them. Ketoconazol is another one, which is a potent antifungal. Estrogen, obviously, is another one. Recreational drugs, many recreational drugs. Chronic alcohol abuse is a big one.

Amphetamines, heroin, marijuana. Nipetapine, as well as other calcium channel blockers like Diltaism. And then finally, Omeprosol, which is a proton pump inhibitor. This list by no means is all-inclusive. There's tons of other meds that can cause gynecumascia, amyodorone, methyl dopopa, isonisid, phenytoin, 5 alpha reductase inhibitors, anabolic steroids. The list just goes on and on. But the meds I listed above, those are the common ones. Those are the ones that usually test you on.

So that's what you really need to focus on. So how can you remember those main meds? Well, you remember them by remember. that these medications can cause you to grow some big knockers. These drugs can cause some big knockers. Knockers spelled K-N-O-C-E-R-S. And knocker stands for, by the way, no offense is meant by the mnemonic to anyone who has this condition, but it's just a memory tool, and that's how I remember them.

So the K and knocker stands for ketoconazole. The N stands for nipetapine, O-O-O-Meprosol, C, c, c-medididine. K stands for ketoconazole again, because there's just not any other meds. Let's start with a K for Gynocomastia, so I just use that twice. E stands for estrogen. R stands for recreational drugs. Remember your chronic alcohol use, marijuana, et cetera. And then finally, the S is the king of them all, and that's spyrinalactone.

One more time, knockers, ketocon, nipetopin, omeprosol, cemeterine, ketocon, estrogen, recreational drugs, spyrnalactone. So those are the ones to focus on. And again, if you just want to remember one, by all means, let it be spyrinal lactone, aka spyrnal lactose. and then the other cause you need to know that often seems to come up is cirrhosis. This one always seems to be tested on. Sorosis can lead to gynechmastia and up to 67% of patients.

Number of reasons for this that are theorized, increased production rate of androstine deone from the adrenals, enhanced rheumatization of androstine deone to estrone. But the big reason why we see this in men with cirrhosis is due to a medication that's commonly prescribed for ascites, which is a very common complication of cirrhosis, if not the most common. and I'll give you a second to think about what that medication is. And that's right, it's spyrinolactone. So if you know your meds, you know cirrhosis, you'll probably get the question right. Let's move on to your physical exam.

So physical exam, you're going to find a palpable glandular breast tissue over 0.5 centimeters in diameter. So in patients with gynochomastia, you're usually going to palpate this rubbery or firm disc of tissue located directly beneath the ariola. It's usually going to be over 0.5 centimeters. the glandular tissue is usually going to be centrally located, symmetric in shape, and most often it's going to be bilateral and tender to palpation, particularly during the early growth phase. There's nothing really high yield to know here. Just as an FYI, be careful when you're diagnosing gynecomastia

because overweight patients can have what's known as pseudo-gynacomastia, which is just due to an increase in breast fat, but not glandular tissue. So unless you palpate that firm disc of tissue under the ariola, it's probably not going to bea. and probably just excess adipose tissue, which is known as pseudogynochimastia. Diagnosis, this is usually going to be a clinical diagnosis based on physical exam findings. If there's any suspicion for breast cancer, maybe the patient has skin dimpling, regional lymphadenopathy, ultrasound or mammography can be utilized.

Otherwise, there's nothing really to know here. Treatment initially, you're going to discontinue the offending drugs. You're going to treat the underlying conditions, observe. So if they're taking a medication that caused, is gynecomastia like spiroinolactone. If you can stop that med, go ahead and stop it. If they have an underlying treatable disorder like hypogonadism or hyperthyroidism, treat the disorder. And then as gynacomastia, gynacomastia usually regresses in time spontaneously. So for a lot of people, observation is an acceptable option, especially in those patients that are going through puberty.

A lot of times it will just resolve on its own. But if the patient's experiencing pain, they're having tenderness, embarrassment that interferes with their normal daily activities. Then we can consider some meds. And then when we're talking about medication for gynecomastia, there's really just two to know. And that's tamoxifen and testosterone. So testosterone replacement, this is really only effective and should only be used in hypogonatal men. And men with normal testosterone levels, this can actually make things worse as the excess testosterone gets converted into estradiol. So you want to avoid it unless the patient is hypogonatal.

And then we have tamoxifen. So tamoxifen is a selective estrogen receptor modulator. It essentially blocks the effect of estrogen in breast tissue. And that's why we use it in estrogen receptor positive breast cancer, as well as treating gynecomastia, because remember, as we discussed before, gynecumastia can be caused from excess estrogen. So using a medication that blocks the effect of estrogen on the breast tissue, obviously makes sense. And then surgery is an option for patients with more severe cases.

what do you need to know for gynecomastia? What are your key takeaways here? Remember, this is a benign proliferation of the glandular tissue of the male breast due to an imbalance of between estrogen and testosterone. Remember the meds that can cause gynecomastia, the meds that cause big knockers, ketoconazole, nipetepidine, omeprosal, cedocin, ketoconosol, estrogen, recreational drugs, and spiroactone. And then the other high-yield cause, remember cirrhosis, treatment, stop offending meds, observe, if you need meds, testosterone, and tomoxifen, and if all else, fails, surgery, and that's gynecomastia, and those are the breast disorders that you need to know for your exam. Let's wrap it up with five quick questions to test your knowledge.

Question one, 34-year-old female in her third postpartum week presents to the office complaining of acute onset breast pain in her left breast. She reports she has noticed decreased milk output and flu-like symptoms. Her temperature is 101.2, 38.4 degrees Celsius, and on exam, her left breast is noted to be engorged and tender to palpation. In addition, a fluctuant periaryolar mass is noted in the left breast. The patient has promptly started on dichloxicillin and advised to continue breastfeeding. What additional treatment is recommended in this patient given the likely diagnosis? So remember, she had an engorged tender to palpation on her left breast.

She also had a fluctuate perioreolar mass in the left breast. So remember, in addition to the antibiotics, we're going to have a drainage. of the abscess. So remember I told you to look out for that word, fluctuent, fluctuate mass indicating we likely have an abscess, and a breast abscess in addition to being treated with antibiotics like dichloxicillin. Remember, we also need to drain the abscess via a needle aspiration or incision and drainage to ensure complete resolution of the infection. Question two, and the patient listed above, if a culture were performed, which infectious organism would likely be isolated. So that is going to be staphoreus. So staphoreus is the most frequent pathogen isolated in both mastitis

and primary breast abscess. Question three, a 39-year-old female presents to the office today complaining of bilateral breast pain. She finds the pain increases prior to her menstrual cycle and seems to improve a couple days after her cycle begins. She also describes lumps and bumps throughout her breast that seem to get bigger as her menstrual cycle approaches. Physical examination reveals diffuse nodularity through both, throughout both breasts, and fibronic tissue is palpated in the upper outer quadrants. What is the most likely diagnosis in this patient? So that is going to be fibrocystic changes of the breast. So the question asks, what is the most likely, most likely diagnosis and most likely diagnosis in a 39-year-old female with breast pain that

gets worse prior to her mencies that improves after, lumps and bumps that increase in size prior to mencies and decrease after? Diffuse nodularity on physical. physical exam, that would be fibrocystic changes. Fibroidinoma, while it's not impossible to cause pain, it's much less likely. And fibroidinomas are more commonly described as a rubbery, well-circumcribed, freely mobile mass rather than these diffused changes that we saw in this patient throughout both breasts. Question four, 48-year-old male presents for his annual physical exam. He has a history of hyperlipidemia, hyperaldastronism, and type 2 diabetes. Its current medications include isetamide metformin glomephydride and spiroctome on physical exam 2.5 centimeter of firm breast tissue is

palpated concentrically under the ariola of each breast what is the most likely cause of the proliferation of glandular breast tissue seen in this patient so that's going to be spironalactone most likely cause of gynecumasty on this patient this is a pretty easy one this patient's taking spyrinalactone so in this patient this is certainly the most likely cause and then finally question In Section 5, 24-year-old female presents to the office with concerns about a mass she found in her left breast while showering. During the clinical breast examination, a 3-centimeter, firm, freely mobile, non-tender mass is found in the upper lateral quadrant of the left breast. Skin changes, nipple discharge, and axillary lymphadenopathy are all absent on exam. What initial diagnostic study should be considered in this patient to assist in making the diagnosis?

So that's going to be ultrasound. So we have a young woman with a non-tender, firm, freely mobile mass in the breast. Fibroidinoma should be high on the list of differentials. And while fibroidinoma can often be diagnosed clinically, in women under 30 with a palpable breast mass that requires further diagnostic studies, ultrasound is usually going to be your first line imaging modality. Fine needle aspiration is another option, but most guidelines suggest starting with an ultrasound in young women. All right, so those were your breast disorders.

I hope that was helpful. Thank you, as always, for listening to the podcast. and the support and the really nice comments and good luck in PA school your pants your panes your pannery you again