Question

A 49-year old man reports feeling fullness in his right armpit and nipple discharge at his right areola. He denies other symptoms, significant medical history, or allergies.

• Discuss what questions you would ask the patient, what physical exam elements you would include, and what further testing you would want to have performed.
• In SOAP format, list:
  • Pertinent positive and negative information
  • Differential and working diagnosis
  • Treatment plan, including: pharmacotherapy with complementary and OTC therapy, diagnostics (labs and testing), health education and lifestyle changes, age-appropriate preventive care, and follow-up to this visit.

Answer 1

Any fluid that leaks from one or both nipples of a non-pregnant and non-breastfeeding breast is referred to as nipple discharge.

Causes of Physiologic Nipple Discharge

1. Pregnancy, Lactation,Postpartum galactorrhea which may last up to two years after delivery,After spontaneous or intentional termination of pregnancy

Causes of Pathologic Nipple Discharge

1. Infection (periductal mastitis)
2. Breast abscess
3. Neoplastic process of the breasts (e.g., intraductal carcinoma, Paget disease of breast)
4. Pituitary tumor/prolactinoma
5. Thoracic/breast trauma
6. Systemic disease/endocrinopathies that elevate prolactin level (e.g., hypothyroidism, disorders of the pituitary gland or

Diagnosis

Finding the underlying cause of galactorrhea can be a complex task because there are so many possibilities.

Testing may involve:

• A physical exam, during which your doctor may try to express some of the fluid from your nipple by gently examining the area around your nipple. Your doctor may also check for breast lumps or other suspicious areas of thickened breast tissue.
• Analysis of fluid discharged from the nipple, to see if fat droplets are present in the fluid, which can help confirm the diagnosis of galactorrhea.
• A blood test, to check the level of prolactin in your system. If your prolactin level is elevated, your doctor will most likely check your thyroid-stimulating hormone (TSH) level, too.
• A pregnancy test, to exclude pregnancy as a possible cause of nipple discharge.
• Mammography, ultrasound or both, to obtain images of your breast tissue if your doctor finds a breast lump or observes other suspicious breast or nipple changes during your physical exam.
• Magnetic resonance imaging (MRI) of the brain, to check for a tumor or other abnormality of your pituitary gland.

Treatment:Try a medication, such as bromocriptine (Cycloset) or cabergoline, to lower your prolactin level and minimize or stop milky nipple discharge.