Q 1:
A 14-year-old boy complains of breast enlargement on the left side. He denies pain, discharge,
or any drug use. He is on no medications and is otherwise healthy. On physical examination, his both genitalia and pubic hair growth. Initial management should include which of the following?\
(A) magnetic resonance imaging of the head
(B) urine drug screen for marijuana
(C) chromosome analysis
(D) reassurance that this is a normal condition
(E) ultrasound imaging of the abdomen and testes
Answers :
(D) Gynecomastia is the enlargement of male breast tissue and occurs in approximately onethird of adolescent males during early- to midpuberty.
It usually resolves spontaneously and requires no further evaluation beyond a careful history and physical examination. Features include: breast tissue <4 cm in diameter and resembling female breast budding, and pubertal development between Tanner stage II and IV.
Pubertal development signs precede gynecomastia by at least 6 months. It may be more
noticeable in obese boys. A drug and medication history should be obtained; these include estrogens, androgens, human chorionic gonadotropin (hCG), cardiovascular drugs (reserpine, methyldopa, digitalis),
cytotoxic agents (busulfan, vincristine), antituberculosis drugs (INH), psychoactive drugs (tricyclic antidepressants, diazepam), ketoconazole, spironolactone, cimetidine, and phenytoin. Illegal drugs include marijuana, heroin, methadone, amphetamines, as well as alcohol.
If there is evidence of precocious puberty, hypogonadism or macrogynecomastia (breast tissue >5 cm diameter), laboratory testing should be done including dehydroepiandrosterone sulfate (DHAS), FSH, and LH, hCG, estradiol, and testosterone. Thyroid-stimulating hormone (TSH) may be obtained to rule out
hyperthyroidism. Boys with Klinefelter syndrome have hypogonadism (testes <3 cm in diameter), delayed pubertal development, and gynecomastia. Laboratory tests reveal increased FSH and LH, and decreased testosterone; the diagnosis is confirmed by chromosome
analysis.
If DHAS, hCG, or estradiol levels are increased, an MRI of the head to exclude a CNS tumor and ultrasound of abdomen and testes to rule out an adrenal, liver, or testicular tumor should be considered.
Answers :
(D) Gynecomastia is the enlargement of male breast tissue and occurs in approximately onethird of adolescent males during early- to midpuberty.
It usually resolves spontaneously and requires no further evaluation beyond a careful history and physical examination. Features include: breast tissue <4 cm in diameter and resembling female breast budding, and pubertal development between Tanner stage II and IV.
Pubertal development signs precede gynecomastia by at least 6 months. It may be more
noticeable in obese boys. A drug and medication history should be obtained; these include estrogens, androgens, human chorionic gonadotropin (hCG), cardiovascular drugs (reserpine, methyldopa, digitalis),
cytotoxic agents (busulfan, vincristine), antituberculosis drugs (INH), psychoactive drugs (tricyclic antidepressants, diazepam), ketoconazole, spironolactone, cimetidine, and phenytoin. Illegal drugs include marijuana, heroin, methadone, amphetamines, as well as alcohol.
If there is evidence of precocious puberty, hypogonadism or macrogynecomastia (breast tissue >5 cm diameter), laboratory testing should be done including dehydroepiandrosterone sulfate (DHAS), FSH, and LH, hCG, estradiol, and testosterone. Thyroid-stimulating hormone (TSH) may be obtained to rule out
hyperthyroidism. Boys with Klinefelter syndrome have hypogonadism (testes <3 cm in diameter), delayed pubertal development, and gynecomastia. Laboratory tests reveal increased FSH and LH, and decreased testosterone; the diagnosis is confirmed by chromosome
analysis.
If DHAS, hCG, or estradiol levels are increased, an MRI of the head to exclude a CNS tumor and ultrasound of abdomen and testes to rule out an adrenal, liver, or testicular tumor should be considered.
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