A physician-validated, board-style question from the Active Transport QBank. Try it, then check the reasoning for every option.
A 36-year-old man comes to the clinical for “bumps under his nipples.” He is anxious that this could be breast cancer as his sister was just recently diagnosed. Past medical history is unremarkable except for an appendectomy at age 13. He currently works as a personal trainer and reports a diet that consists mainly of lean meat. The patient reports drinking 1-2 beers over the weekends. Physical examination demonstrates a muscular physique with mobile smooth masses below the areola bilaterally with no discharge. What other physical exam finding is most likely to be seen in this individual?
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A
Fluid waveIncorrect. Fluid wave indicates ascites from cirrhosis or other portal hypertension; not expected in this trainer with minimal alcohol use.
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B
Palmar erythemaIncorrect. Palmar erythema is a sign of cirrhosis/hyperestrogenism from liver disease; not consistent with the otherwise healthy muscular phenotype here.
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C
Spider angiomasIncorrect. Spider angiomata reflect chronic liver disease with relative hyperestrogenism; less likely than AAS abuse given the clinical context.
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D
Testicular atrophyCorrect. Anabolic steroid use aromatizes to estradiol (gynecomastia) AND suppresses HPG axis, causing testicular atrophy and infertility.
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E
BupropionIncorrect. Bupropion is a non-stimulant antidepressant with mild stimulant properties; it is not first-line for ADHD and does not address parental concern about controlled substances as definitively as atomoxetine.
↑ Tap an answer to reveal the reasoning
Answer: D. A muscular personal trainer with bilateral mobile, smooth subareolar masses (gynecomastia) and concern for breast cancer — combined with the strong setting clue (personal trainer with 'lean meat' diet) — should raise immediate suspicion for ANABOLIC ANDROGENIC STEROID (AAS) abuse. Exogenous testosterone or its derivatives are aromatized peripherally to estradiol, producing breast glandular proliferation (gynecomastia). Negative feedback on the hypothalamic-pituitary axis suppresses GnRH, LH, and FSH, which leads to suppression of endogenous testicular testosterone production and spermatogenesis. The result is bilateral TESTICULAR ATROPHY — the classic associated finding.
Other physical findings of AAS abuse include severe acne, hair loss, muscle hypertrophy, mood lability ('roid rage'), elevated hematocrit, and adverse lipid profile (low HDL, high LDL).
The distractors point to chronic liver disease (alcoholic cirrhosis): spider angiomata, palmar erythema, fluid wave (ascites), and gynecomastia. While cirrhosis can cause gynecomastia, the patient drinks only 1-2 beers on weekends and the picture (muscular physique, personal trainer) far more strongly suggests AAS abuse.
Pearl: any young muscular man with new bilateral gynecomastia should be screened for AAS use; look for testicular atrophy on exam. Treatment is cessation; aromatase inhibitors and SERMs (tamoxifen) are sometimes used for persistent gynecomastia.
**Why each option:**
**A.** Fluid wave indicates ascites from cirrhosis or other portal hypertension; not expected in this trainer with minimal alcohol use.
**B.** Palmar erythema is a sign of cirrhosis/hyperestrogenism from liver disease; not consistent with the otherwise healthy muscular phenotype here.
**C.** Spider angiomata reflect chronic liver disease with relative hyperestrogenism; less likely than AAS abuse given the clinical context.
**D.** Correct. Anabolic steroid use aromatizes to estradiol (gynecomastia) AND suppresses HPG axis, causing testicular atrophy and infertility.