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You are the FY1 doctor sitting in on a medical clinic.Toby Culosis is a 32 year old man who has been referred from his GP for gynaecomastia.

Please take the history, including impact on his life, and perform a relevant examination. You will then be asked to discuss the case with the examiner.

You are Toby Culosis, 32 and sick of having boobs. You’ve noticed for the last three months that you have basically been developing breasts. There is a lump on both sides now, the right came first and is slightly bigger. You saw your regular doctor, who sent you here after having some normal test results. You think they were testing your liver.

HPC: You’ve been having a lot of troubles recently, not that you think they’re all connected. You’ve been getting this awful joint pain. It can happen anywhere. It just comes and goes randomly. You thought at first that it was injuries from rugby but you’re not so sure anymore. You’ve been feeling so weak and tired that you’ve had to stop playing rugby, which is really annoying, as you’ve always enjoyed it. Speaking of rugby, you’ve also noticed that your face can get a bit beaten up with rugby and you have bumps and bruises from it. As a result you think your face is a bit messed up and ‘out of shape’ as your mum puts it. You think this would get better after stopping playing rugby, but your friend who you hadn’t seen for a while pointied out that your face was looking ‘pretty rough’. Whilst you are a bit annoyed at him - after all he isn’t a looker himself - he has a point. Your face isn’t quite as symmetrical as it was.

You think the tiredness might be due to lack of sleep. Your other half says you have been snoring and you don’t feel rested when you wake up. It’s been making you feel pretty low actually. Although lots of things are making you feel low right now.

ICE: It’s just all really getting to you, you don’t feel like the man you were before. Your girlfriend isn’t too happy with you now. You feel like you’ve been letting her down in the bedroom. It’s not your fault and you’re pretty embarrassed by it. You just can’t seem to maintain an erection. So she is now convinced that you’re cheating on her, which you aren’t. You already think she’s totally out of your league!

PMH: You were diagnosed with high blood pressure a few months ago but they’re trying some lifestyle stuff first to manage. You don’t really like tablets. Other than that and some fractures from rugby you’ve been fine before all this.

FH: You’re not aware of anything that runs in your family.

Observe the student and give appropriate feedback for their history taking. A few examination are the appropriate following the history, including breast cardio, joint or endocrine exam: this will depend on what the focus of the history is. Ask them to summarise their findings succinctly, and then present their differentials.

Differentials may include acromegaly, pseudoacromegaly and hypothyroidism. There is a definite risk of depression here with the patient’s low mood featuring throughout the history, which should be discussed in conjunction with the physical presenting complaint.

Questions for discussion may include: - How would you investigate this patient acutely? - What are the classic clinical features of acromegaly? - What causes acromegaly? - How is acromegaly managed? - What are the common complications of acromegaly?