Here is the case for week 9 SOAP note. As with prior assignments, please answer the questions at the end of the SOAP note. Make sure to outline your specific plans in your SOAP note.
Marcia is a 28 year old female who comes in with a complaint of nipple drainage. She says that the discharge started about three months ago and it appears milky. She says that she has also felt tired, and has been constipated lately. Her periods have been very light. She is worried that she “might have cancer”.
What are the three classifications of nipple discharge?
Based on the above description, what classification does this fit into?
- Aside from the above concerns, name three other things this woman may be experiencing.
- Women with a strong family history of breast cancer may be candidates for genetic testing for __________ mutations.
- You do a thorough breast examination on this pt. What are two important components of this exam on anyone with nipple drainage?
- You do a complete medication history as well as elicit past medical history, including endocrine and reproductive history. What are four important parts of the exam on this pt and why?
- Name five chemical agents that can cause nipple discharge and galactorrhea.
- What should the nipple discharge be tested for?
- Why are cytologic studies not recommended?
- Should diagnostic mammography be performed?
- Following diagnostic mammography, what other imaging study might be performed and why?
- What are two important lab tests to obtain?
- When would an MRI of the brain be indicated?
- Name three possible diagnoses for this patient.
- If galactorrhea is suspected due as a result of a chemical origin, what must be done?
- Galactorrhea is more common in _____________ (premenopausal/postmenopausal) women.
- All patients with spontaneous or unilateral nipple discharge regardless of color, should be referred for surgical evaluation.
- Patients should be educated that most causes of breast discharge are malignant.
- In women with galactorrhea, where the prolactin level is normal and menses are normal, women should be informed of the normal physiologic association with ______________________.
- Why is nipple discharge so concerning to most women?
Expert Solution Preview
Introduction:
Nipple discharge can be a concerning symptom for patients, as it may indicate underlying breast pathology. In this case, we have a 28-year-old female patient named Marcia, who presents with nipple drainage. This assignment will address various aspects of nipple discharge, including classification, diagnostic approaches, and potential causes. We will also discuss the importance of obtaining a complete medical history and physical examination to guide further evaluation and management. Through this assignment, medical students will gain a better understanding of the evaluation and management of patients presenting with nipple discharge.
Answers:
1. The three classifications of nipple discharge are physiological, pathological, and iatrogenic.
2. Based on the description provided, the nipple discharge in Marcia’s case fits into the pathological classification.
3. Aside from the concerns mentioned, this woman may be experiencing breast pain, breast swelling, and changes in breast texture.
4. Women with a strong family history of breast cancer may be candidates for genetic testing for BRCA1 and BRCA2 mutations.
5. When performing a thorough breast examination on a patient with nipple drainage, two important components include inspection of the breast for any masses or skin changes and palpation of the breast tissue to assess for any lumps or abnormalities.
6. When obtaining a complete medical history on this patient, four important parts of the examination are assessing for any history of hormonal imbalances, previous breast surgeries, use of hormonal medications, and any history of exposure to chemicals or medications that can affect breast tissue. These factors may help identify potential causes of the nipple discharge.
7. Five chemical agents that can cause nipple discharge and galactorrhea include antipsychotic medications (e.g., risperidone), antidepressants (e.g., selective serotonin reuptake inhibitors), antihypertensive medications (e.g., methyldopa), hormonal medications (e.g., oral contraceptives), and illicit drugs (e.g., marijuana).
8. The nipple discharge should be tested for cytologic examination, microbiological cultures, and assessment of hormone levels, specifically prolactin.
9. Cytologic studies are not recommended for nipple discharge evaluation as they have limited sensitivity and specificity.
10. Diagnostic mammography should be performed in patients with pathological nipple discharge to evaluate for any underlying breast abnormalities or masses.
11. Following diagnostic mammography, an imaging study that might be performed is breast ultrasound. This is helpful in further evaluating any suspicious findings identified on mammography and distinguishing between solid and cystic lesions.
12. Two important lab tests to obtain in this case are hormonal assays, including prolactin levels, and thyroid function tests. These tests help assess for potential endocrine abnormalities that may contribute to the nipple discharge.
13. An MRI of the brain would be indicated if there are neurological symptoms or signs, such as headaches or visual disturbances, that suggest a possible pituitary tumor causing elevated prolactin levels.
14. Three possible diagnoses for this patient with nipple drainage include intraductal papilloma, ductal carcinoma in situ, and fibrocystic changes.
15. If galactorrhea is suspected as a result of a chemical origin, the causative chemical agent must be identified and eliminated from exposure.
16. Galactorrhea is more common in premenopausal women compared to postmenopausal women.
17. All patients with spontaneous or unilateral nipple discharge regardless of color should be referred for surgical evaluation.
18. Patients should be educated that most causes of breast discharge are not malignant. Malignancy accounts for a small proportion of cases, and the majority of cases are due to benign causes such as hormonal imbalances.
19. In women with galactorrhea, where the prolactin level is normal and menses are normal, women should be informed of the normal physiologic association with nipple stimulation.
20. Nipple discharge is concerning to most women because it is often associated with breast cancer. It is important to reassure patients and provide appropriate evaluation to identify the underlying cause of the discharge and guide further management.
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