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

That's mass stitis, breaststaps as, fibro adenoma, fibroastistic breast changes in god in coomastia.

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Thank you so much for that.

Let's go ahead and get started.

We'll start with mass STIs.

Mastitis is an inflammation of the breast perrancum up 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 mass stitis, 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 twenty five year old woman, postpartum period, recent on set 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 mass stitis 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 areas is going to be the most common cause of infectious mass stitis.

It's almost always going to be the organism that's present.

Most episodes of lactational masstitis are going to be from staff oureas.

You have a woman who's breastfeeding.

After time, the nipple can develop excoriation, this cracking, which introduces staff into the breast tissue.

Also, stagnant milk can be a nitis for infection, and that's why it's always encourage 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.

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 measures, 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 twelve to twenty four hours the symptoms aren't getting any better, patient has fever or other systemic symptoms, then we know we got an infection and then 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?

While as we talked about this before, this is almost always is caused from staff, So you want your anti staff antibiotics dicloxus cillin, cephalexin.

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 cephalexin or dicloxus sillin.

If there is a risk for MRSA they maybe had recent hospitalization, recent surgery, patients on hemodialysis, then you have to cover from methysillin resistance.

Staff areus so you either give them trimethoprim SOFA, methox is all aka bactrum clendomycin.

If it's a severe infection, vecomycin would be another option.

And then of course if there's a culture pending and it displays different organisms besides staff, adjust your antibiotics accordingly.

But most often you're going to be treating staff, So those are your antibiotex those are your antibiotics and no.

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 math stitis, she needs to keep breastfeeding.

This is really key to resolving the infection and improving the symptoms.

Have to remember this because you're going to get a question I know, I definitely did.

It's going to be mass stitis.

You're gonna remember the antibiotics, be all excited.

They're going to have two answer choices.

Both are going to say, let's say diclocks is scillin, but one's going to say diclocks is scillin plus continue breastfeeding, and the other will say diclocks iscillin 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 mass stitis.

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

And then obviously be aware that mass stitis, if not treated promptly, can lead to an abscess formation.

So breast abscess is a localized area of inflammatory exitate in the breast tissue.

It's just a fancy way of saying you have a walleduff collection of pus in the breast.

Clinical manifestations, you're going to have a fluctuent tender palpable mass, so they're going to have painful inflammation of the breast that can be associated with fever malaise, very similar to mass stitis.

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

Fluctuent is that key term.

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

So fluctuent tender mass.

Fluctution just means that there's this fluid filled structure presence, such as an abcess, and when you press down on it, it produces a wave like motion when it's palpated, kind of as the pus is displaced.

So remember that word.

It's really important fluctuent.

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 abcess, then you need to do an ultrasound so diagnosis can be confirmed via ultrasound.

It's going to demonstrate this hypoecoic lesion in the breast hypochoic just meaning it's going to be darker than the surrounding structure is normally a dark ray or black area.

And 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 treat a mass stitis.

While we start with our antibiotics as we did with mass stitis, it's assumed this is a staff infection, so you're empiric antibiotic therapy should cover for staff.

So, just as we went over before, in them with some diclockxucillencepholexin if it's not MARSA, if they're at risk for MARSA, hit them with klinda, trimethoprint solfamethox is all nothing new to know here.

The key difference is what you do next, and what you do next compared to mass stitis, 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 in drainage.

It's important to remember though this additional step in treatment for breast abcess draining the abscess plus antibiotics.

And then of course keep in mind just and it just as in mass stitis, 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 experience, but also encourages resolution of the infection.

So remember continue breastfeeding in both masstitis and breast abscess.

So key differences to look out for in the vignette to differentiate mass stitis 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 dicloxyscillin cephlex And moving on to fibroadenomas so fibro ad aenomas are benign breast tumors made up of both glandular tissue and stromal aka connective tissue.

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

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.

Fibrod Aenomas are found in one half of all breast biopsies and on top see studies reveal these lesions are found in nine to ten percent of all women and generally fibrod anomas 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 fifteen to thirty five years of age.

You're looking for a woman in the reproductive years.

Fibrid Aenomas usually regress after menopause.

They can also increase in size during pregnancy or with estrogen therapy.

Physical exams is really important.

Firm, rubbery, highly mobile, non tender mass, so a couple really high old 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 that differentiate between fibrod aenoma and fibrocystic breast changes.

Fibrod Aenomas are most of the time non tender.

They can cause pain, but more often the more often they do not cause pain, and fibrocystic changes, on the other hand, which will go over next, are usually tender.

It's really important and while nothing is one hundred percent medicine for the sam, i'd remember fibro adenoma as no pain, fibro cystic 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 words, slippery.

Fibro Adenomas are sometimes known as a breast mouse because they move.

It'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 fibro adenoma, breast mouse.

It slips and moves all around, and a lot of times they will 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 of remember it as five ole adenoma fivell as in fievel.

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 five Will Goes West.

It was this old cartoon about this mouse that was named Fivile.

It was also a 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 fivele 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 momography.

Anytime you think about like a breast mass.

We're always thinking right away of momography, but ultrasound is the preferred imaging modality in young women under the age of thirty, which, as you remember, is the typical demographic for patients with a fibro adenoma.

And what is the reason why ultrasound is preferred to MAMMO in young women.

Well, there's a couple of reasons for this.

First, most benign lesions in young women are not visualized on momography because of the density of the breast tissue in young women.

This limits the sensitivity of momography, so ultrasound is actually better for younger women.

And then the second reason is because there is an increased radiation risk with momography, albeit minimal, but it's best to avoid any radiation and 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 fibro adenomas 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 request during menopause.

But if the size of the fibro adenoma 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 fibride aenoma's First, remember this is mainly going to be seen in young women fifteen to thirty five years of ages 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 fibride Remember your fible adenoma, your breast mouse.

Those are the key takeaways for fibrod aenoma.

Next, let's talk about fibrocystic breast changes, which in many ways is very similar to fibrod anomas.

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 cysts.

So fibrocystic breast changes.

Really, it's just this non specific 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 cysts, So fibrosis and cysts is what you should be thinking of when you see this term so fluid filled cysts and fibrosis.

Often what 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 fibrotic changes.

So we are we going to see this in thirty to fifty years of age will be the most common, so generally younger women more than fifty percent of females of reproductive age have fibrocystic changes.

And while the etiology isn't one hundred percent, certain fibrocystic changes are thought to result from this imbalance between estrogen and progesterone, which is why they're more common in premenopausal women who have these cyclical surges every month of estradilee and progesterone, and are relatively uncommon in post menopausal 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 menses that will usually improve during menstruation.

In addition, the breast tissue, particularly in the upper outer quad where this is most common, may increase in size prior to the onset of menses, 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 fibrocyst ac no longer fibrocystic it's now known as fibrocyst aacche.

To help you remember the pain or aching that's associated with this condition, fibrocyst ac 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 on fibro adenomas.

It of course can be, but generally this is just going to be these regular, diffuse A lot of times they say lumpy bumpy changes throughout the breasts.

You can have cysts of varying sizes, you can have fibrotic changes where the tissue is firm and hard, and often the fibrotic 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.

Homography 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 be supportive measures, So a seed, a metafin and said supportive bra reassurance.

Fine needle aspiration, as we discussed before, is another option, and again it can be both diagnostic and therapeutic because many in many patients it will collapse the cyst, which can cause lead to pain relief to moxif and danisol 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 most controlled studies have failed to demonstrate an association between caffeine and breast pain.

All right, so main takeaways for fibrotic changes, I'm sorry, fibrocystic changes of the breast.

This is generally going to be seen a women of reproductive age.

Thirty to fifty 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 fibrocystache, not fibrocystic, and then diagnosed with ultrasound treatment mainly supportive and that's fibrocystic breast changes.

Last, but not least, gynacomastia.

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 in large 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 gyndacomascia, There's there's a lot actually hyperthyroidism, so mail Patients with Graves disease often have a higher than normal serum LH level which can lead to increased estradio levels.

Chronic Kitte disease.

This is primarily due to late ex CEL dysfunction and Gindacomascia occurs actually enough to fifty percent of patient street with hemodialysis.

Some malignancies, testicular neoplasm, some adrenal tumors, hypogonadism puberty.

So during puberty some boys will have this transient imbalance of estrogen to androgen and can develop kindacamascia.

And then it can also be seen in older males due to the gradual decrease and testosterone production and resultant romatization of testosterone to estradio.

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 old causes that came up the exams a lot.

The first one and probably the highest yield cause for ghana caamastia is medication.

So you need to know a few important meds that can lead to ghana caamastia that are often tested on.

Let's first start with the king of all of the gyda camascia causing drugs, and that is spearinolactone.

If there were one med to know that can cause ginna caamastia, if you just want to memorize one medication, let it be spear and a lactone.

Spearon a lactone aka sparin a lactose as I used to call it in my head.

Because for some weird reason, sparinal lactose made me think of lactose as in breast milk.

That led me to gyda caamascia.

I don't know is really weird, but it just helped me make the association on a test.

Maybe that'll help you anyways.

This med increases aromatization of testosterone to estradile.

It also decreases testosterone production by the tests.

Because of these changes, among others, it's notorious for causing gna camastia.

Ten percent of patients taking low dose spar and a lactone for heart failure will develop gyna caamastia, and patients taking the high dose for liver failure or hypertension due to aldosterone access, that number reaches almost one hundred percent.

So remember spear and a lactone aka spear and a lactose.

This is the highest yield of all the meds.

Let's talk about a few other high yield ones.

Semetidine, which is an H two blocker used for gird.

This is another huge one that they often test on.

Semetidine we rarely use anymore because it has so many side effects.

Obviously, kind of camascity being one of them.

Ketoconazole 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, niphetepine, as well as other calcium channel blockers like dotai zem and then finally omeperzol, which is a proton pump inhibitor.

This list, by no means is all inclusive.

There's tons of other meds that can cause kind of camascia, amiodorone, methol, dopa, so nisi, feniton five, alpha reductase inhibitors, antabolic steroids.

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 remembering that these medications can cause you to grow some big knockers.

These drugs can cause some big knockers.

Knockers spelled K N O C K E r S and knocker stands for and by the way, no offense is meant by the pneumonic 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 ketoconazol, the N stands for knifetipine, o omeprazol, c semeditine, K stands for ketoconazole.

Again, because there's just not any other meds that start with a K.

For gnacamacs, 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 sparonal lactone.

One more time, knockers, ketoconazol, knifetipine, omeperzol, semeditine, ketoconazol, estrogen, recreational drugs, spirino lactone.

So those are the ones to focus on.

And again, if you just want to remember one by all means, let it be speirino lactone aka sparin a lactose.

And then the other cause you need to know that often seems to come up is crosis.

This one always seems to be tested on.

Scrosis can lead to gynacamacion.

Up to sixty seven percent of patients number of reasons for this that are theorized increased production rate of androstine dione from the adrenals, enhanced therromatization of androstine dione to estrone.

But the big reason why we see this in men with cirosis is due to a medication that's commonly prescribed for asites, which is a very common complication of cirosis, if not the most common.

And I'll give you a second to thing about what that medication is, and that's right, it's sparino lactone.

So if you know your mads, you know crosis, 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 point five centimeters in diameter.

So in patients with gynocomascia, you're usually going to palpate this rubbery or firm disc of tissue located directly beneath the area.

It's usually going to be over point five 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 palpatient, particularly during the early growth phase.

It's nothing really high yel to know here, Just as an FYI, be careful when you're diagnosing gynacomastia because overweight patients can have what's known as pseudogynocomastia, 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 areola, it's probably not gynocomastia and probably just excess adipose tissue, which is known as pseudogynocomastia.

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 lymphatinopathy, ultrasound or momography 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 observed.

So if they're taking a medication that causes kind of camastia like spironolactone, 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 ghanacomastia.

Ganacamascia 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'll 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 ghanacomastia, 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 hypogonato men and men with normal testosterone levels.

This can actually make things worse as the excess testosterone gets converted into estradile, so you want to avoid it unless the patient is hypogonato 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 ghanacomastia because remember, as we discussed before, gynaicomastia 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 gynocomascia?

What are your key takeaways here?

Remember this is a benign proliferation of the glandular tissue of the male breast due an imbalance of between estrogen and testosterone.

Remember the meds that can cause ganacomastiat the meds that cause big knockers ketoconazol, niphetepino, meperzol semeditine, ketoconazole, estrogen recreational drugs, and sperinolactum.

And then the other high y old cause remember cerrosis, treatment, stop offending meds, observe if you need meds, testosterone and tamoxifen, and if all else fails, surgery.

And that's kind of comastia.

And those are the breast disorders that you need to know for your exam.

Let's wrap it up with five quick quick questions to test your knowledge.

Question one thirty four 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 a decreased milk output and flu like symptoms.

Her temperature is one of one point two thirty eight point four degrees celsius and on exam, her left breast is noted to be engorged and tender to palpatient.

In addition, a fluctuent perieriolar mass is noted in the left breast.

The patient is promptly started on disclosus sillin 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 palpatient on her left breast.

She also had a fluctuent perieriolar mass in the left breast.

So I 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 fluctuant mass indicating we likely have an abscess and a breast abscess in addition to being treated with antibiotics like that clocks as scillin.

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 Stapphorius.

So stapph Oreus is the most frequent pathogen isolated in both mastitis and primary breast abscess.

Question three.

A thirty nine 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 breasts that seem to get bigger as her menstrual cycle approaches.

Physical examination reveals diffuse nodularity through throughout both breasts and fibrotic 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 asked what is the most likely most likely diagnosis and most likely diagnosis in a thirty nine year old female with breast pain that gets worse prior to hermenses, that improves after lumps and bumps, that increase in size prior to menses, and decrease after diffuse nodularity on physical exam, that would be fibrocystic changes fibroidenoma.

Whilst not impossible to cause pain, it's much less likely and fibridenomas are more commonly described as a rubbery walls circumscribed, freely mobile mass rather than these diffused changes that we saw on this patient throughout both breasts.

Question four, forty eight year old male presents for his annual physical exam.

He has a history of hyperlipidemia, hyperaldosteronism, and type two diabetes.

His current medications include a zetamybe, met formIn glmepide, and spirit lactom.

On physical exam, two point five centimeter of firm breast tissue is palpated concentrically under the areola of each breast.

What is the most likely cause of the proliferation of glandular breast tissues seen in this patient?

So that's going to be sparin elactone most likely cause of kindicomacy and is patient this is a pretty easy one patients taking spironolactone, So in this patient this is certainly the most likely cause.

And then finally question five, twenty four year old female presents to the office with concerns about a mass she found in her left breast wall showering.

During the clinical breast examination, a three centimeter firm, freely mobile, non tender mass is found in the upper lateral quadrant of the left breast.

Skin changes, nipple discharge, and axleray lymphatinopathy are all absent on exam.

What initial diagnostic studies 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.

Fibrodenoma should be high on the list of differentials.

And while fibro adenoma can often be diagnosed clinically in women under thirty with a palpable breast mass that requires further diagnostic studies, ultra sound is usually going to be your first line imaging modality.

Find new aspiration is another option, but most guidelines suggests 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 panry yours, and thank you again