Dan

Dan, 34, a personal trainer, comes in about tender lumps behind both nipples that have developed over the last few months. He is embarrassed and wants a referral to have them removed, ideally on the NHS, and would rather it was not made a fuss of. He trains heavily six days a week, eats clean, does not drink or smoke, and is otherwise well. When you ask about his health more broadly he is guarded. His recent bloods, done privately, show a raised cholesterol, a mildly raised ALT, and a high-normal haemoglobin. His blood pressure today is 149/94. You have a limited-length appointment. Rank the following as an opening move, the option that best sets up a safe and useful consultation, given what you can see so far.

You have a limited-length appointment. Rank the following as an opening move, the option that best sets up a safe and useful consultation, given what you can see so far.

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1
Focus the consultation on his high blood pressure and cholesterol, and address the lump another time
2
Acknowledge his embarrassment and reassure him you can help, then explore the likely causes properly, including a non-judgemental question about supplements, anabolic steroids, and other performance-enhancing drugs, linking it to his blood results
3
Tell him the lumps are almost certainly from steroids and that he needs to stop them immediately
4
Reassure him gynaecomastia is common and often benign, and arrange a routine hormone profile before deciding on referral
5
Refer him to the breast or surgical clinic for assessment of the gynaecomastia as he requests, and leave it there