Pediatric emergency medicine trisk 107

pseudopuberty, or exposure to exogenous estrogens, and careful follow-up with the primary physician is required Juvenile Breast Hypertrophy Juvenile breast hypertrophy is a rare disorder characterized by sudden, rapid, massive breast enlargement at a time of intense endocrine stimulation, usually between and 16 years of age, after onset of menarche It is believed to result from end-organ hypersensitivity to estrogen The hypertrophy is usually bilateral and asymmetric and may progress at an alarming rate over 36 months The differential diagnosis of this lesion includes cystosarcoma phyllodes, juvenile fibroadenoma, and precocious puberty; however, true endocrine or neoplastic lesions are uncommon In some cases, the hypertrophy regresses in to years, but referral to a breast surgeon is always indicated; breast reduction or even total ablation may become necessary This disorder is often associated with extreme emotional and psychosocial distress for patients and families Gynecomastia Gynecomastia is a term commonly used to describe a broad spectrum of clinical breast lesions in boys, including excess breast tissue, breast enlargement, and masses of tissue below the nipple that are discrete and nonadherent to the chest wall, and may occur unilaterally or bilaterally Gynecomastia has been described as the male equivalent of fibrocystic changes in the female breast, based on histologic evidence Typically, local breast tissue demonstrates evidence of mild estrogen–testosterone hormone imbalance, resulting from physiologic changes (neonatal, puberty, aging); exogenous medications; tumors of the testes, adrenal glands, and lungs; metabolic conditions (cirrhosis, hyperthyroidism, renal disease); or hypogonadism From a clinical perspective, gynecomastia occurs in about 50% of all boys between the ages of 11 and 18 years and typically lasts about years It can be associated with growth spurts and can also cause a significant degree of pain The glandular enlargement is about cm and resembles the early stages of female breast budding More commonly, gynecomastia presents to the emergency physician because of associated anxiety in adolescent boys If the patient has normal-sized genitalia and none of the predisposing conditions listed earlier, reassurance is all that is required, though inquiry about both prescription and illicit use of drugs should be sought There is often particular concern about gynecomastia in obese boys, since they may appear to have an overabundance of fatty tissue in the breast region Of note, the incidence of true gynecomastia is not increased in boys who are obese, compared with those who are not obese Rarely, a few conditions can be mistaken for physiologic gynecomastia, such as lipomastia, a round adipose tissue mass, or neoplasm If there is any concern for these entities or systemic diseases, then the patient should be urgently referred to an endocrinologist Overall, gynecomastia is best managed by referral to the primary care physician for continued follow-up Physiologic Mastalgia During the first trimester of pregnancy, some teenage girls may complain of breast fullness, though nongravid patients may experience breast pain as well, likely related to the hormonal milieu of the breast throughout the menstrual cycle Mastalgia is often described as a bilateral, poorly localized, dull, achy pain that radiates to the axillae The pain is often worse with activity and relieved with the onset of menses In general, there are no abnormal physical findings, except tender, nodular breasts Most patients will improve with reassurance, analgesics such as nonsteroidal anti-inflammatory medications, warm compresses, and breast support If the pain is refractory to these measures, other suggested therapies include caffeine avoidance, salt restriction, and diuretics Danazol, a synthetic androgen, is reserved for severe, debilitating pain EVALUATION AND DECISION History and Physical Examination Initial evaluation of a breast lesion begins with a careful history and physical examination ( Table 16.4 ) The two most common categories of breast lesions presenting in children are infections and structural or mass lesions In the absence of infection, evaluation of mass lesions requires a detailed menstrual history and a chronology of the development of secondary sexual characteristics Features of intracranial masses, including headaches or visual changes, should be assessed Pregnant or lactating patients may also present to a pediatric ED These patients should be queried regarding breastfeeding or breastfeeding attempts, as well as about general symptoms related to changes in the breast tissue Medications may have an effect on the growth of certain breast lesions and may also affect hormonal pathways, leading to abnormal breast secretions ( Table 16.1 ) Few breast disorders may have a familial pattern; however, a careful family history can be helpful A comprehensive physical examination should be performed on any pediatric patient who complains of a breast mass or lesion Premature appearance of secondary sexual characteristics, hirsutism, or abnormal skin coloring may indicate the presence of an endocrinopathy A detailed evaluation of the breasts and adjacent structures is essential The chest wall should be inspected for any gross deformities, asymmetry, or skin changes The physician should have the patient lean forward with hands on hips and again observe for any asymmetry or skin retraction With the patient supine with arms above the head, the physician should palpate each breast in a series of concentric circles radiating outward from the nipple, looking and feeling for nodules, cysts, masses, or inconsistencies in the breast tissue Each areola should be gently compressed to assess for masses or nipple discharge If present, the color, character, and odor of any discharge should be noted The physician should feel for the presence of any masses or lymphadenopathy in both axillae TABLE 16.4 IMPORTANT HISTORICAL AND PHYSICAL EXAMINATION COMPONENTS IN THE EVALUATION OF A BREAST LESION History Onset and duration of lesion Pain Nipple discharge Relationship of lesion with menses Complete menstrual and sexual development history, including sexual activity and previous pregnancies Family history of breast disease Diet Medications and illicit drugs Concomitant medical disorders Systemic symptoms: fever, weight loss, sweating, headaches, visual changes Physical Examination Breasts: symmetry, skin appearance, temperature, areola, nipples, secretions, masses, chest wall, axillae Lymph nodes Hair distribution Genitalia Diagnostic Testing The majority of patients presenting to the ED will not require intensive laboratory or radiologic testing All postmenarchal girls should have a pregnancy test performed; breast tenderness and swelling are among the earliest signs of pregnancy The most helpful test in the emergency setting is breast ultrasonography, which is useful in distinguishing between masses and cystic lesions as well as the presence of abscess with mastitis Other imaging studies are rarely helpful Mammography is of little value in children and adolescents, owing to the high proportion of fibroglandular tissue within the breast Chest radiography is rarely helpful, except when the examiner elicits signs and symptoms from the lungs or chest wall that may be referred to the breast If ... headaches or visual changes, should be assessed Pregnant or lactating patients may also present to a pediatric ED These patients should be queried regarding breastfeeding or breastfeeding attempts,... careful family history can be helpful A comprehensive physical examination should be performed on any pediatric patient who complains of a breast mass or lesion Premature appearance of secondary sexual... tenderness and swelling are among the earliest signs of pregnancy The most helpful test in the emergency setting is breast ultrasonography, which is useful in distinguishing between masses and