Gynaecomastia

These findings should have been discovered during the general examination. Breast swelling in male with disc of firm tissue. If there is no disc, it is fatty tissue only

Some differential diagnoses and typical outline evidence

Immature testis	Suggested by: adolescence and no testicular lump.
	Confirmed by: normal testosterone, estrogen and LH levels normal ultrasound scan of testis.
Digoxin, Spironolactone	Suggested by: taking of drug and no testicular lump.
	Confirmed by: improvement when drug stopped.
High alcohol intake	Suggested by: high alcohol intake and no testicular lump.
	Confirmed by: improvement when alcohol stopped.
Hepatic cirrhosis	Suggested by: long history of high alcohol intake (usually), spider naevi, abnormal liver size (large or small) and consistency (fatty or hard).
	Confirmed by: very abnormal biochemical liver function tests, ↓LH, ↑oestrogens, ↓testosterone.
	Management: OHCM p232.
Testicular tumours	Suggested by: scrotal mass ± pain, tenderness if haemorrhage occurs. (Sometimes arising in undescended testis).
	Confirmed by: testicular ultrasound, inguinal exploration, ↑α-fetoprotein, ↑β-hCG.
	Management: OHCM 512.
Hypogonadism (primary to testicular disease, or secondary to low LH from pituitary defect or tumour)	Suggested by: sparse pubic hair, no drug or alcohol history, poor libido.
	Confirmed by: Testosterone↓, LH↑ (in primary testicular disease), LH↓ or normal (when secondary to pituitary diseases).
	Management: OHCM pp316, 318.
Bronchial carcinoma	Suggested by: smoking history, haemoptysis, weight loss, clubbing.
	Confirmed by: CXR, bronchoscopy with biopsy.
	Management: OHCM p182.
Klinefelter's syndrome	Suggested by: poor sexual development, infertility, eunuchoid.
	Confirmed by: 47, XXY karyotype.
Obesity	Suggested by: no breast tissue, only mammary fat.
	Confirmed by: improvement with weight loss.
	Management: OHCM p208.