WEBVTT

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All right, so today we're going
to do a high yield review of breast

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disorders. That's mass stitis, breaststaps
as, fibro adenoma, fibroastistic breast changes

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in god in coomastia. Thank you
as always for the really nice comments,

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the support, the people who've made
donations. I truly, truly do appreciate

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it. Thank you so much for
that. Let's go ahead and get started.

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We'll start with mass STIs. Mastitis
is an inflammation of the breast perrancum

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up so simply, it's just an
inflammation of the breast. It can be

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with or without infection. It can
be lactational meaning associated with breastfeeding, or

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non lactational, not associated with breastfeeding. Usually, though, when we're talking

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about mass stitis, when we're using
this term, the term is generally used

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clinically to imply an infectious etiology.
In addition, i'd really focus on the

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lactational type, as that's almost always
what they're going to give you. In

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the vignette, it's going to be
a twenty five year old woman, postpartum

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period, recent on set breast pain, swelling, noticing decreased milk output,

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etc. Focus on that type of
presentation for the question that you'll likely get

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on the exam. Clinical manifestations.
You're going to have a firm, red,

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painful, swollen area of the breast, may be associated with fever.

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They may have systemic complaints, malaise, chills, flu like symptoms. Pretty

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straightforward and usually what can be helpful
to differentiate from other conditions. It's usually

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going to be unilateral, so just
one breast affected. And then, as

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a side note, in real life, when you're out there treating patients,

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you want to be really careful because
these clinical manifestations seen in mass stitis can

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also be seen in a much more
serious diagnosis, which is inflammatory breast cancer.

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So if these patients are treated with
antibiotics and there's no improvement, make

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sure you consider that as one of
your differentials. Now, etiology, staff

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areas is going to be the most
common cause of infectious mass stitis. It's

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almost always going to be the organism
that's present. Most episodes of lactational masstitis

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are going to be from staff oureas. You have a woman who's breastfeeding.

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After time, the nipple can develop
excoriation, this cracking, which introduces staff

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into the breast tissue. Also,
stagnant milk can be a nitis for infection,

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and that's why it's always encourage for
women who are breastfeeding to ensure they

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have frequent complete emptying of the breast
to avoid infection. Diagnosis it's mainly going

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to be clinical. There's nothing really
to know for diagnostic criteria. This is

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mostly a clinical diagnosis. You can
culture the breast milk to guide selection of

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antibiotics. There's any suspicion for an
abscess of the breast, ultrasound is going

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to be the most effective way to
differentiate mastitis from breast abscess. Treatment.

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You start with your supportive measures,
so warm and cold compresses, expressing or

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pumping milk from the breast between feeds, massaging the breast to clear any blockages.

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And then if it's been twelve to
twenty four hours the symptoms aren't getting

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any better, patient has fever or
other systemic symptoms, then we know we

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got an infection and then we need
some antibiotics, which is really what you

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need to know for the exam.
Most of the time when they give you

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a question, they don't want you
to know the supportive measures. They really

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want you to know the antibiotics.
Even though the supportive measures are important,

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they always ask you about the antibiotics. That's just always what the exams always

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focus on. So which antibiotics are
those going to be? While as we

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talked about this before, this is
almost always is caused from staff, So

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you want your anti staff antibiotics dicloxus
cillin, cephalexin. So if it's just

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plain old staff, it's a non
severe infection, there's no risk for MRSA.

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You're going to hit them either with
cephalexin or dicloxus sillin. If there

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is a risk for MRSA they maybe
had recent hospitalization, recent surgery, patients

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on hemodialysis, then you have to
cover from methysillin resistance. Staff areus so

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you either give them trimethoprim SOFA,
methox is all aka bactrum clendomycin. If

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it's a severe infection, vecomycin would
be another option. And then of course

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if there's a culture pending and it
displays different organisms besides staff, adjust your

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antibiotics accordingly. But most often you're
going to be treating staff, So those

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are your antibiotex those are your antibiotics
and no. And then there's one additional

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measure that's super important that you need
to know, and that's to continue breastfeeding.

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This is so crucial to remember when
a mother is being treated for lactational

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math stitis, she needs to keep
breastfeeding. This is really key to resolving

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the infection and improving the symptoms.
Have to remember this because you're going to

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get a question I know, I
definitely did. It's going to be mass

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stitis. You're gonna remember the antibiotics, be all excited. They're going to

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have two answer choices. Both are
going to say, let's say diclocks is

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scillin, but one's going to say
diclocks is scillin plus continue breastfeeding, and

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the other will say diclocks iscillin and
discontinue breastfeeding. And you need to know

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the mother should continue breastfeeding. Remember
that, all right, So let's move

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on to breast abscess. So breast
abscess, there's a lot of similarities with

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mass stitis. There's just a few
key things to know to differentiate the two.

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And then obviously be aware that mass
stitis, if not treated promptly,

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can lead to an abscess formation.
So breast abscess is a localized area of

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inflammatory exitate in the breast tissue.
It's just a fancy way of saying you

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have a walleduff collection of pus in
the breast. Clinical manifestations, you're going

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to have a fluctuent tender palpable mass, so they're going to have painful inflammation

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of the breast that can be associated
with fever malaise, very similar to mass

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stitis. But the key anytime we
have an abscess, they're going to use

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the word fluctuent. Fluctuent is that
key term. When you see that one

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word, you know we're dealing with
an abscess and not just mass stitis.

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So fluctuent tender mass. Fluctution just
means that there's this fluid filled structure presence,

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such as an abcess, and when
you press down on it, it

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produces a wave like motion when it's
palpated, kind of as the pus is

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displaced. So remember that word.
It's really important fluctuent. Look for that

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in the vignette. Diagnosis is most
of the time going to be made clinically

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based on your physical exam findings.
Palpating that fluctuent tender mass in the breast.

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But if they ask you, how
can you confirm the diagnosis To ensure

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this is an abcess, then you
need to do an ultrasound so diagnosis can

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be confirmed via ultrasound. It's going
to demonstrate this hypoecoic lesion in the breast

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hypochoic just meaning it's going to be
darker than the surrounding structure is normally a

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dark ray or black area. And
then this confirms there is an abscess present.

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So then how do we treat it? How is this going to be

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different than how we treat a mass
stitis. While we start with our antibiotics

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as we did with mass stitis,
it's assumed this is a staff infection,

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so you're empiric antibiotic therapy should cover
for staff. So, just as we

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went over before, in them with
some diclockxucillencepholexin if it's not MARSA, if

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they're at risk for MARSA, hit
them with klinda, trimethoprint solfamethox is all

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nothing new to know here. The
key difference is what you do next,

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and what you do next compared to
mass stitis, is you drain that abscess.

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That's the key difference in treatment.
So this can be done with either

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a needle aspiration, it can be
done with an incision in drainage. It's

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important to remember though this additional step
in treatment for breast abcess draining the abscess

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plus antibiotics. And then of course
keep in mind just and it just as

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in mass stitis, milk drainage,
either by breastfeeding or pumping, is really

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important to continue. It's not contraindicated
in the setting of an abscess, and

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in fact, studies have shown that
it not only reduces the duration of the

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symptoms experience, but also encourages resolution
of the infection. So remember continue breastfeeding

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in both masstitis and breast abscess.
So key differences to look out for in

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the vignette to differentiate mass stitis from
a breast abscess. First, remember that

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keyword fluctuent. A tender fluctuent mass, that's an abscess if they ask you

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to prove it ultrasound. And key
difference with treatment is going to be the

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addition of some form of drainage,
either with needle aspiration or an incision and

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drainage. Otherwise the rest is the
same between the two. Both are common

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in women who are breastfeeding. Both
are commonly caused by staff and both are

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treated with staff sensitive antibiotics like dicloxyscillin
cephlex And moving on to fibroadenomas so fibro

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ad aenomas are benign breast tumors made
up of both glandular tissue and stromal aka

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connective tissue. There's different varieties simple, complex, giant, fib giant fibroadenomas.

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I wouldn't worry so much about the
different subtypes though they usually don't test

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you too much on those. You
should know though, that these are very

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common. Fibrod Aenomas are found in
one half of all breast biopsies and on

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top see studies reveal these lesions are
found in nine to ten percent of all

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women and generally fibrod anomas are considered
to be the most common benign tumor of

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the breast. You should also know
that you're going to find these mainly in

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young women, so fifteen to thirty
five years of age. You're looking for

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a woman in the reproductive years.
Fibrid Aenomas usually regress after menopause. They

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can also increase in size during pregnancy
or with estrogen therapy. Physical exams is

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really important. Firm, rubbery,
highly mobile, non tender mass, so

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a couple really high old things in
the physical exam. First is the fact

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that the mass is usually going to
be non tender. That's going to be

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one of the keys that differentiate between
fibrod aenoma and fibrocystic breast changes. Fibrod

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Aenomas are most of the time non
tender. They can cause pain, but

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more often the more often they do
not cause pain, and fibrocystic changes,

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on the other hand, which will
go over next, are usually tender.

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It's really important and while nothing is
one hundred percent medicine for the sam,

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i'd remember fibro adenoma as no pain, fibro cystic as painful. The other

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thing to know is the mobility of
the mass. Fibro Adenomas are notorious for

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being, for a lack of a
better words, slippery. Fibro Adenomas are

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sometimes known as a breast mouse because
they move. It's right, breast mouse

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because they move so freely and slip
all around in the breast when being examined,

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gives us feeling that they're running away
from the examining hands as they say,

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so remember fibro adenoma, breast mouse. It slips and moves all around,

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and a lot of times they will
bring this up in the vignette too,

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so it's important to remember this.
And the way that I used to

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remember this is by instead of remembering
fibro adenoma, i'd instead of remember it

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as five ole adenoma fivell as in
fievel. And this is probably only going

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to work for a few people because
most of you probably are too young to

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remember this movie. But when I
was little, there was this movie called

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five Will Goes West. It was
this old cartoon about this mouse that was

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named Fivile. It was also a
at Universal Studios for a while. It's

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definitely kind of old, so you
may not be familiar with it, but

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it worked for me. So instead
of fibro adenoma, remember fivele adenoma to

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help you remember this is also known
as a breast mouse, and to help

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you remember how freely mobile this mass
is, because they'll likely bring that up

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in the vignette. Now, diagnosis, you're going to start with your ultrasound,

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and some of you might be thinking
why ultrasound and not momography. Anytime

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you think about like a breast mass. We're always thinking right away of momography,

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but ultrasound is the preferred imaging modality
in young women under the age of

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thirty, which, as you remember, is the typical demographic for patients with

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a fibro adenoma. And what is
the reason why ultrasound is preferred to MAMMO

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in young women. Well, there's
a couple of reasons for this. First,

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most benign lesions in young women are
not visualized on momography because of the

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density of the breast tissue in young
women. This limits the sensitivity of momography,

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so ultrasound is actually better for younger
women. And then the second reason

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is because there is an increased radiation
risk with momography, albeit minimal, but

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it's best to avoid any radiation and
young patients if possible. So those are

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a couple of reasons why you're going
to start with your ultrasound. Another option

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for diagnosis in young women would be
a fine needle aspiration. Although ultrasound is

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generally preferred as the initial test now
treatment, most fibro adenomas don't need to

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be treated. Many stop growing or
even shrink on their own, so observation

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is completely appropriate for many patients,
and as we discussed before, the majority

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will request during menopause. But if
the size of the fibro adenoma continues to

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increase, maybe it's causing a deformity
of the breast. You do have surgical

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removal or cryoblation as some definitive treatment
options. So what should you commit to

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memory about fibride aenoma's First, remember
this is mainly going to be seen in

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young women fifteen to thirty five years
of ages the most common. And then

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really important, remember those physical exam
findings highly mobile, non tender mass,

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highly mobile, non tender. Those
are the words that you should be repeating

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in your head when you hear fibride
Remember your fible adenoma, your breast mouse.

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Those are the key takeaways for fibrod
aenoma. Next, let's talk about

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fibrocystic breast changes, which in many
ways is very similar to fibrod anomas.

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So let's go over the key differences
to make sure you get the answer right

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on the exam. So, fibrocystic
breast changes are these benign changes in breast

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tissue characterized by fibrosis and fluid filled
cysts. So fibrocystic breast changes. Really,

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it's just this non specific umbrella term
that encompasses these changes women can experience

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in breast tissue. If we break
down the word fibro as in fibrous tissues,

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fibrosis and then cystic as in cysts, So fibrosis and cysts is what

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you should be thinking of when you
see this term so fluid filled cysts and

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fibrosis. Often what happens is a
breast lobule will dilate and form a cyst,

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and then that cyst will rupture,
which leads to the scarring and inflammation

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which causes the fibrotic changes. So
we are we going to see this in

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thirty to fifty years of age will
be the most common, so generally younger

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women more than fifty percent of females
of reproductive age have fibrocystic changes. And

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while the etiology isn't one hundred percent, certain fibrocystic changes are thought to result

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from this imbalance between estrogen and progesterone, which is why they're more common in

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premenopausal women who have these cyclical surges
every month of estradilee and progesterone, and

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are relatively uncommon in post menopausal women
who have a decrease in production of these

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hormones. So be looking for your
premenopausal or even perimenopausal patient clinical manifestations.

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This is really important. Painful breast
tissue. Painful breast tissue that fluctuates in

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size and severity with the menstrual cycle. So pain is the word I want

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you to focus on because this is
what will differentiate it from a fibro adenoma.

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Now, when are these women going
to have pain? Generally they're going

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to have pain in the breast tissue
before menses that will usually improve during menstruation.

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In addition, the breast tissue,
particularly in the upper outer quad where

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this is most common, may increase
in size prior to the onset of menses,

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then return to baseline after the onset
of menstrual flow. So really the

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main takeaway again is to remember this
is generally a painful condition, pain that

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fluctuates with menstrual cycles. You cannot
forget that associate pain with fibrocystic disease.

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It's so important that in your brain, I want you to replace fibrocystic,

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fibrocystic with fibrocyst ac no longer fibrocystic
it's now known as fibrocyst aacche. To

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help you remember the pain or aching
that's associated with this condition, fibrocyst ac

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that's going to be the key to
differentiate it from other conditions in the vignette,

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like fibro adenoma. All right,
let's move on to your physical exam.

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So diffuse nodular areas. When you
see fibrocystic changes, recognize this is

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often not going to be this discrete
or well defined mass as we saw on

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fibro adenomas. It of course can
be, but generally this is just going

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to be these regular, diffuse A
lot of times they say lumpy bumpy changes

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throughout the breasts. You can have
cysts of varying sizes, you can have

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fibrotic changes where the tissue is firm
and hard, and often the fibrotic tissue

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00:15:11.919 --> 00:15:16.080
is generally going to be found in
the upper outer quadrants of the breast.

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00:15:16.279 --> 00:15:18.799
Now, diagnosis is going to be
with an ultrasound. The main thing I

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would know here is ultrasound if there's
any abnormality found on the ultrasound. Homography

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00:15:24.679 --> 00:15:30.080
and a fine needle aspiration are some
other options to assist in diagnosis a fine

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00:15:30.120 --> 00:15:33.799
needle aspiration. It can actually be
both diagnostic as well as therapeutic because when

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it's performed it often collapses the cyst
and improves the discomfort experience. Next,

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let's talk about treatment. Mainly,
it's going to be supportive measures, So

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a seed, a metafin and said
supportive bra reassurance. Fine needle aspiration,

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00:15:48.639 --> 00:15:52.360
as we discussed before, is another
option, and again it can be both

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00:15:52.480 --> 00:15:56.720
diagnostic and therapeutic because many in many
patients it will collapse the cyst, which

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00:15:56.799 --> 00:16:02.000
can cause lead to pain relief to
moxif and danisol are also used, sometimes

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00:16:02.039 --> 00:16:06.039
off label for patients who have severe
pain that are refractory to other treatments.

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00:16:06.320 --> 00:16:10.840
And then you may have heard of
elimination of caffeine as being an effective supportive

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treatment option, but the evidence is
mainly anecdotal. Most most controlled studies have

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00:16:15.320 --> 00:16:19.519
failed to demonstrate an association between caffeine
and breast pain. All right, so

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00:16:19.679 --> 00:16:26.320
main takeaways for fibrotic changes, I'm
sorry, fibrocystic changes of the breast.

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00:16:26.600 --> 00:16:30.720
This is generally going to be seen
a women of reproductive age. Thirty to

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00:16:30.799 --> 00:16:33.840
fifty years old is the most common
age bracket you're looking for a painful,

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00:16:34.320 --> 00:16:40.279
painful breast tissue that fluctuates with menstrual
cycles. Remember this is fibrocystache, not

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00:16:40.399 --> 00:16:45.120
fibrocystic, and then diagnosed with ultrasound
treatment mainly supportive and that's fibrocystic breast changes.

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00:16:45.399 --> 00:16:49.440
Last, but not least, gynacomastia. So this is a benign proliferation

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00:16:49.519 --> 00:16:53.919
of the glandular tissue of the male
breast due to an increase in estrogen production

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00:16:55.039 --> 00:17:00.559
or decreased androgen production. So pretty
straightforward, gynacomastia is in large male breast

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00:17:00.600 --> 00:17:04.599
tissue caused by an imbalance between estrogen
and testosterone. Either have too much estrogen

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or not enough testosterone. What are
some causes of gyndacomascia, There's there's a

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lot actually hyperthyroidism, so mail Patients
with Graves disease often have a higher than

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00:17:17.640 --> 00:17:22.799
normal serum LH level which can lead
to increased estradio levels. Chronic Kitte disease.

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00:17:22.880 --> 00:17:26.480
This is primarily due to late ex
CEL dysfunction and Gindacomascia occurs actually enough

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00:17:26.519 --> 00:17:32.480
to fifty percent of patient street with
hemodialysis. Some malignancies, testicular neoplasm,

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00:17:32.599 --> 00:17:37.480
some adrenal tumors, hypogonadism puberty.
So during puberty some boys will have this

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00:17:37.599 --> 00:17:41.000
transient imbalance of estrogen to androgen and
can develop kindacamascia. And then it can

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00:17:41.039 --> 00:17:45.799
also be seen in older males due
to the gradual decrease and testosterone production and

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00:17:47.000 --> 00:17:52.240
resultant romatization of testosterone to estradio.
Long story short, there's a ton of

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00:17:52.400 --> 00:17:55.279
causes, but for the exam this
is the good news. I would really

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00:17:55.359 --> 00:18:00.119
just suggest on narrowing it down to
two high old causes that came up the

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00:18:00.200 --> 00:18:03.119
exams a lot. The first one
and probably the highest yield cause for ghana

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00:18:03.160 --> 00:18:07.319
caamastia is medication. So you need
to know a few important meds that can

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00:18:07.440 --> 00:18:12.160
lead to ghana caamastia that are often
tested on. Let's first start with the

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00:18:12.519 --> 00:18:18.279
king of all of the gyda camascia
causing drugs, and that is spearinolactone.

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00:18:18.279 --> 00:18:21.759
If there were one med to know
that can cause ginna caamastia, if you

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00:18:21.880 --> 00:18:25.519
just want to memorize one medication,
let it be spear and a lactone.

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00:18:25.880 --> 00:18:29.559
Spearon a lactone aka sparin a lactose
as I used to call it in my

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00:18:29.720 --> 00:18:33.160
head. Because for some weird reason, sparinal lactose made me think of lactose

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00:18:33.279 --> 00:18:37.920
as in breast milk. That led
me to gyda caamascia. I don't know

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00:18:37.119 --> 00:18:40.880
is really weird, but it just
helped me make the association on a test.

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00:18:40.960 --> 00:18:45.559
Maybe that'll help you anyways. This
med increases aromatization of testosterone to estradile.

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00:18:45.839 --> 00:18:49.960
It also decreases testosterone production by the
tests. Because of these changes,

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00:18:51.039 --> 00:18:55.759
among others, it's notorious for causing
gna camastia. Ten percent of patients taking

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00:18:55.839 --> 00:18:59.559
low dose spar and a lactone for
heart failure will develop gyna caamastia, and

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00:18:59.680 --> 00:19:03.359
patients taking the high dose for liver
failure or hypertension due to aldosterone access,

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that number reaches almost one hundred percent. So remember spear and a lactone aka

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spear and a lactose. This is
the highest yield of all the meds.

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Let's talk about a few other high
yield ones. Semetidine, which is an

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00:19:15.480 --> 00:19:18.799
H two blocker used for gird.
This is another huge one that they often

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00:19:18.839 --> 00:19:22.799
test on. Semetidine we rarely use
anymore because it has so many side effects.

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00:19:23.599 --> 00:19:26.759
Obviously, kind of camascity being one
of them. Ketoconazole is another one,

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00:19:26.799 --> 00:19:32.279
which is a potent antifungal estrogen obviously
is another one. Recreational drugs,

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many recreational drugs. Chronic alcohol abuse
is a big one. Amphetamines, heroin,

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00:19:36.599 --> 00:19:40.799
marijuana, niphetepine, as well as
other calcium channel blockers like dotai zem

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00:19:41.079 --> 00:19:45.160
and then finally omeperzol, which is
a proton pump inhibitor. This list,

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00:19:45.359 --> 00:19:48.440
by no means is all inclusive.
There's tons of other meds that can cause

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00:19:48.519 --> 00:19:52.319
kind of camascia, amiodorone, methol, dopa, so nisi, feniton five,

279
00:19:52.359 --> 00:19:56.039
alpha reductase inhibitors, antabolic steroids.
List just goes on and on.

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00:19:56.240 --> 00:19:59.279
But the meds I listed above,
those are the common ones. Those are

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00:19:59.319 --> 00:20:00.920
the ones that usually test you on. So that's what you really need to

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00:20:00.960 --> 00:20:04.519
focus on. So how can you
remember those main meds. Well, you

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00:20:04.640 --> 00:20:10.759
remember them by remembering that these medications
can cause you to grow some big knockers.

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00:20:11.160 --> 00:20:15.880
These drugs can cause some big knockers. Knockers spelled K N O C

285
00:20:15.359 --> 00:20:19.039
K E r S and knocker stands
for and by the way, no offense

286
00:20:19.160 --> 00:20:22.599
is meant by the pneumonic to anyone
who has this condition, but it's just

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00:20:22.799 --> 00:20:26.839
a memory tool and that's how I
remember them. So the K and knocker

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00:20:26.960 --> 00:20:33.319
stands for ketoconazol, the N stands
for knifetipine, o omeprazol, c semeditine,

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00:20:33.680 --> 00:20:36.759
K stands for ketoconazole. Again,
because there's just not any other meds

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00:20:36.799 --> 00:20:40.200
that start with a K. For
gnacamacs, I just use that twice.

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00:20:40.480 --> 00:20:44.920
E stands for estrogen. R stands
for recreational drugs, remember your chronic alcohol

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00:20:45.000 --> 00:20:48.200
use, marijuana, et cetera.
And then finally the S is the king

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00:20:48.359 --> 00:20:51.559
of them all, and that sparonal
lactone. One more time, knockers,

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00:20:51.839 --> 00:20:56.240
ketoconazol, knifetipine, omeperzol, semeditine, ketoconazol, estrogen, recreational drugs,

295
00:20:56.359 --> 00:21:00.400
spirino lactone. So those are the
ones to focus on. And again,

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00:21:00.519 --> 00:21:03.559
if you just want to remember one
by all means, let it be speirino

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00:21:03.599 --> 00:21:07.319
lactone aka sparin a lactose. And
then the other cause you need to know

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00:21:07.440 --> 00:21:11.039
that often seems to come up is
crosis. This one always seems to be

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00:21:11.160 --> 00:21:15.079
tested on. Scrosis can lead to
gynacamacion. Up to sixty seven percent of

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00:21:15.200 --> 00:21:19.240
patients number of reasons for this that
are theorized increased production rate of androstine dione

301
00:21:19.240 --> 00:21:23.799
from the adrenals, enhanced therromatization of
androstine dione to estrone. But the big

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00:21:23.880 --> 00:21:27.599
reason why we see this in men
with cirosis is due to a medication that's

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00:21:27.640 --> 00:21:33.039
commonly prescribed for asites, which is
a very common complication of cirosis, if

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00:21:33.119 --> 00:21:34.680
not the most common. And I'll
give you a second to thing about what

305
00:21:34.880 --> 00:21:38.759
that medication is, and that's right, it's sparino lactone. So if you

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00:21:38.839 --> 00:21:41.839
know your mads, you know crosis, you'll probably get the question right.

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00:21:42.039 --> 00:21:45.039
Let's move on to your physical exam. So physical exam, you're going to

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00:21:45.200 --> 00:21:52.559
find a palpable glandular breast tissue over
point five centimeters in diameter. So in

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00:21:52.599 --> 00:21:56.079
patients with gynocomascia, you're usually going
to palpate this rubbery or firm disc of

310
00:21:56.200 --> 00:22:02.400
tissue located directly beneath the area.
It's usually going to be over point five

311
00:22:02.480 --> 00:22:06.799
centimeters. The glandular tissue is usually
going to be centrally located, symmetric in

312
00:22:06.920 --> 00:22:10.839
shape, and most often it's going
to be bilateral and tender to palpatient,

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00:22:11.160 --> 00:22:15.799
particularly during the early growth phase.
It's nothing really high yel to know here,

314
00:22:15.240 --> 00:22:21.079
Just as an FYI, be careful
when you're diagnosing gynacomastia because overweight patients

315
00:22:21.119 --> 00:22:25.599
can have what's known as pseudogynocomastia,
which is just due to an increase in

316
00:22:25.680 --> 00:22:30.240
breast fat but not glandular tissue.
So unless you palpate that firm disc of

317
00:22:30.279 --> 00:22:34.680
tissue under the areola, it's probably
not gynocomastia and probably just excess adipose tissue,

318
00:22:34.960 --> 00:22:40.079
which is known as pseudogynocomastia. Diagnosis, this is usually going to be

319
00:22:40.160 --> 00:22:45.240
a clinical diagnosis based on physical exam
findings. If there's any suspicion for breast

320
00:22:45.279 --> 00:22:51.720
cancer, maybe the patient has skin
dimpling, regional lymphatinopathy, ultrasound or momography

321
00:22:51.759 --> 00:22:55.759
can be utilized. Otherwise, there's
nothing really to know here. Treatment Initially,

322
00:22:55.880 --> 00:22:59.440
you're going to discontinue the offending drugs. You're going to treat the underlying

323
00:22:59.480 --> 00:23:03.960
conditions observed. So if they're taking
a medication that causes kind of camastia like

324
00:23:03.119 --> 00:23:07.640
spironolactone, if you can stop that
med go ahead and stop it. If

325
00:23:07.680 --> 00:23:11.359
they have an underlying treatable disorder like
hypogonadism or hyperthyroidism, treat the disorder,

326
00:23:11.799 --> 00:23:18.759
and then as ghanacomastia. Ganacamascia usually
regresses in time spontaneously, so for a

327
00:23:18.839 --> 00:23:22.799
lot of people, observation is an
acceptable option, especially in those patients that

328
00:23:22.880 --> 00:23:26.559
are going through puberty. A lot
of times it'll just resolve on its own.

329
00:23:26.960 --> 00:23:33.319
But if the patient's experiencing pain,
they're having tenderness embarrassment that interferes with

330
00:23:33.400 --> 00:23:36.920
their normal daily activities, then we
can consider some meds. And then when

331
00:23:36.960 --> 00:23:40.519
we're talking about medication for ghanacomastia,
there's really just two to know, and

332
00:23:40.599 --> 00:23:45.079
that's tamoxifen and testosterone. So testosterone
replacement. This is really only effective and

333
00:23:45.279 --> 00:23:51.279
should only be used in hypogonato men
and men with normal testosterone levels. This

334
00:23:51.400 --> 00:23:56.359
can actually make things worse as the
excess testosterone gets converted into estradile, so

335
00:23:56.440 --> 00:24:00.400
you want to avoid it unless the
patient is hypogonato and then we have tamoxifen.

336
00:24:00.519 --> 00:24:06.599
So tamoxifen is a selective estrogen receptor
modulator. It essentially blocks the effect

337
00:24:06.640 --> 00:24:11.039
of estrogen in breast tissue and that's
why we use it in estrogen receptor positive

338
00:24:11.119 --> 00:24:15.559
breast cancer as well as treating ghanacomastia
because remember, as we discussed before,

339
00:24:15.960 --> 00:24:21.440
gynaicomastia can be caused from excess estrogen, So using a medication that blocks the

340
00:24:21.519 --> 00:24:26.319
effect of estrogen on the breast tissue
obviously makes sense. And then surgery is

341
00:24:26.319 --> 00:24:29.799
an option for patients with more severe
cases. What do you need to know

342
00:24:29.880 --> 00:24:33.599
for gynocomascia? What are your key
takeaways here? Remember this is a benign

343
00:24:33.680 --> 00:24:38.039
proliferation of the glandular tissue of the
male breast due an imbalance of between estrogen

344
00:24:38.119 --> 00:24:42.279
and testosterone. Remember the meds that
can cause ganacomastiat the meds that cause big

345
00:24:42.359 --> 00:24:48.319
knockers ketoconazol, niphetepino, meperzol semeditine, ketoconazole, estrogen recreational drugs, and

346
00:24:48.400 --> 00:24:52.440
sperinolactum. And then the other high
y old cause remember cerrosis, treatment,

347
00:24:52.559 --> 00:24:56.960
stop offending meds, observe if you
need meds, testosterone and tamoxifen, and

348
00:24:57.079 --> 00:25:00.640
if all else fails, surgery.
And that's kind of comastia. And those

349
00:25:00.720 --> 00:25:03.599
are the breast disorders that you need
to know for your exam. Let's wrap

350
00:25:03.640 --> 00:25:08.359
it up with five quick quick questions
to test your knowledge. Question one thirty

351
00:25:08.400 --> 00:25:12.559
four year old female in her third
postpartum week presents to the office complaining of

352
00:25:12.680 --> 00:25:17.960
acute onset breast pain in her left
breast. She reports she has noticed a

353
00:25:18.079 --> 00:25:22.559
decreased milk output and flu like symptoms. Her temperature is one of one point

354
00:25:22.599 --> 00:25:26.599
two thirty eight point four degrees celsius
and on exam, her left breast is

355
00:25:26.680 --> 00:25:32.319
noted to be engorged and tender to
palpatient. In addition, a fluctuent perieriolar

356
00:25:32.440 --> 00:25:36.640
mass is noted in the left breast. The patient is promptly started on disclosus

357
00:25:36.680 --> 00:25:41.240
sillin and advised to continue breastfeeding.
What additional treatment is recommended in this patient

358
00:25:41.440 --> 00:25:47.880
given the likely diagnosis? So remember
she had an engorged tender to palpatient on

359
00:25:47.960 --> 00:25:51.920
her left breast. She also had
a fluctuent perieriolar mass in the left breast.

360
00:25:52.119 --> 00:25:53.880
So I remember, in addition to
the antibiotics, we're going to have

361
00:25:55.000 --> 00:25:57.000
a drainage of the abscess. So
remember I told you to look out for

362
00:25:57.039 --> 00:26:03.200
that word fluctuent fluctuant mass indicating we
likely have an abscess and a breast abscess

363
00:26:03.240 --> 00:26:06.839
in addition to being treated with antibiotics
like that clocks as scillin. Remember,

364
00:26:06.920 --> 00:26:11.279
we also need to drain the abscess
via a needle aspiration or incision and drainage

365
00:26:11.319 --> 00:26:15.839
to ensure complete resolution of the infection. Question two, and the patient listed

366
00:26:15.960 --> 00:26:21.640
above, if a culture were performed, which infectious organism would likely be isolated?

367
00:26:22.119 --> 00:26:26.160
So that is going to be Stapphorius. So stapph Oreus is the most

368
00:26:26.200 --> 00:26:32.000
frequent pathogen isolated in both mastitis and
primary breast abscess. Question three. A

369
00:26:32.119 --> 00:26:36.640
thirty nine year old female presents to
the office today complaining of bilateral breast pain.

370
00:26:37.000 --> 00:26:40.920
She finds the pain increases prior to
her menstrual cycle and seems to improve

371
00:26:40.960 --> 00:26:45.599
a couple days after her cycle begins. She also describes lumps and bumps throughout

372
00:26:45.640 --> 00:26:48.920
her breasts that seem to get bigger
as her menstrual cycle approaches. Physical examination

373
00:26:48.960 --> 00:26:55.759
reveals diffuse nodularity through throughout both breasts
and fibrotic tissue is palpated in the upper

374
00:26:55.799 --> 00:27:00.200
outer quadrants. What is the most
likely diagnosis in this patient? So that

375
00:27:00.359 --> 00:27:03.880
is going to be fibrocystic changes of
the breast. So the question asked what

376
00:27:04.000 --> 00:27:08.759
is the most likely most likely diagnosis
and most likely diagnosis in a thirty nine

377
00:27:08.839 --> 00:27:12.960
year old female with breast pain that
gets worse prior to hermenses, that improves

378
00:27:14.079 --> 00:27:17.880
after lumps and bumps, that increase
in size prior to menses, and decrease

379
00:27:17.960 --> 00:27:23.480
after diffuse nodularity on physical exam,
that would be fibrocystic changes fibroidenoma. Whilst

380
00:27:23.519 --> 00:27:27.920
not impossible to cause pain, it's
much less likely and fibridenomas are more commonly

381
00:27:29.000 --> 00:27:33.599
described as a rubbery walls circumscribed,
freely mobile mass rather than these diffused changes

382
00:27:33.640 --> 00:27:37.559
that we saw on this patient throughout
both breasts. Question four, forty eight

383
00:27:37.640 --> 00:27:41.920
year old male presents for his annual
physical exam. He has a history of

384
00:27:41.039 --> 00:27:48.039
hyperlipidemia, hyperaldosteronism, and type two
diabetes. His current medications include a zetamybe,

385
00:27:48.119 --> 00:27:52.160
met formIn glmepide, and spirit lactom. On physical exam, two point

386
00:27:52.240 --> 00:27:56.880
five centimeter of firm breast tissue is
palpated concentrically under the areola of each breast.

387
00:27:57.240 --> 00:28:02.359
What is the most likely cause of
the proliferation of glandular breast tissues seen

388
00:28:02.400 --> 00:28:07.000
in this patient? So that's going
to be sparin elactone most likely cause of

389
00:28:07.039 --> 00:28:11.599
kindicomacy and is patient this is a
pretty easy one patients taking spironolactone, So

390
00:28:11.720 --> 00:28:15.480
in this patient this is certainly the
most likely cause. And then finally question

391
00:28:15.640 --> 00:28:18.640
five, twenty four year old female
presents to the office with concerns about a

392
00:28:18.799 --> 00:28:22.920
mass she found in her left breast
wall showering. During the clinical breast examination,

393
00:28:23.039 --> 00:28:27.359
a three centimeter firm, freely mobile, non tender mass is found in

394
00:28:27.400 --> 00:28:32.920
the upper lateral quadrant of the left
breast. Skin changes, nipple discharge,

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and axleray lymphatinopathy are all absent on
exam. What initial diagnostic studies should be

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00:28:37.880 --> 00:28:41.319
considered in this patient to assist in
making the diagnosis, So that's going to

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be ultrasound. So we have a
young woman with a non tender, firm,

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00:28:47.119 --> 00:28:49.880
freely mobile mass in the breast.
Fibrodenoma should be high on the list

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00:28:49.920 --> 00:28:55.559
of differentials. And while fibro adenoma
can often be diagnosed clinically in women under

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00:28:55.680 --> 00:29:00.319
thirty with a palpable breast mass that
requires further diagnostic studies, ultra sound is

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00:29:00.400 --> 00:29:03.400
usually going to be your first line
imaging modality. Find new aspiration is another

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00:29:03.440 --> 00:29:07.480
option, but most guidelines suggests starting
with an ultrasound in young women. All

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00:29:07.559 --> 00:29:11.240
right, so those were your breast
disorders. I hope that was helpful.

404
00:29:11.519 --> 00:29:14.599
Thank you as always for listening to
the podcast and the support and the really

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00:29:14.680 --> 00:29:18.640
nice comments and good luck in PA
school, your pants, your panry yours,

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00:29:18.720 --> 00:29:18.559
and thank you again