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Identification: A.F. 40-year-old, white, non-Hispanic female.

Subjective

Chief Complaint: “I have some milk coming out of my breasts”.

History of Present Illness: Patient is a 40-year-old woman with past medical history of hypertension and diabetes, who presents to the office for yearly follow up. Patient reports that she has noticed a whitish discharge from both breasts for the last 2 months, but she did not seek medical advice because the secretion was present in a small amount and it was intermittent and only visible when she expressed her nipples. No other complaints reported.

Current Medications: Lisinopril 10 mg daily, HCTZ 10 mg daily, Metformin 500 mg twice a day, Nexium 40 mg daily, Glimepiride 5 mg daily, Aspirin 81 mg daily.

Past Medical History: HTN, DM type 2, GERD, overweight, hypercholesterolemia. Patient denies history of respiratory or renal disease.

Surgical History: Denies surgeries.

Allergies: No known drug or food allergies.

Immunizations: Received flu vaccine this season.

Social History: Patient lives with her boyfriend, and also has the social support of friends and neighbors. She is a current smoker (10 cigarettes per day). She consumes 2 drinks of alcohol daily and has a sedentary lifestyle.

Family History: Mother, deceased: Hypertension and breast cancer. Father, deceased: HTN, MI. Sister, 32, alive: Hypothyroidism.

Review of Symptoms

Skin/Hair/Nails: Denies any new complaints at this time. No rashes, moles or nail changes.

Head and Neck: Denies pain, immobility or any growths.

Eyes: Denies tearing, visual changes or discharge. No glasses.

Ears: Denies changes in hearing, sensitivity to noise or pain.

Nose/Sinuses: Denies discharge, pain or dryness.

Mouth/Throat: Denies sore throat, difficulty eating or swallowing.

Breast: Denies masses, pain, tenderness or surgery to the breasts. Reports performing breast self-exam very frequently, sometimes daily, because she is afraid of her mother history of breast cancer. Patient reports bilateral, scarce, whitish, thick, liquid discharge from both breasts when she presses her nipples.

Cardiovascular: Denies palpitations, chest pain or legs swelling. She usually measures the arterial blood pressure every other day and she denies recent elevated results.

Chest/Lungs: Denies pain, SOB or wheezing. Denies history of asthma or pneumonia.

Endocrine: Patient self-report well control over the Diabetes and thyroid problems. Denies changes to hair, polydipsia, polyuria or weight loss. Denies tiredness or sleeping disturbances. Patient reports that her blood sugar has been under control for the last year.

Hematological: Denies bleeding, anemia or easy bruising.

Lymphatic: Denies enlargement, pain or tenderness.

GI: Denies decreased appetite, constipation, and blood in stools or emesis.

GU: Denies pain, frequency, blood or discomfort on urination. LMP: 1 month ago.Denies vaginal itching or discharge, urinary problems, lesions or history of pelvic surgery. Gravida 2/Para 2/Ab 0. Gynecology checkups yearly; last Pap test 6 months ago.

Musculoskeletal: Denies muscle or joint pain or difficulty with gait.

Neuro: Denies headaches, dizziness, seizures, weakness or tremors, mental status changes or memory problems.

Mental/Psychiatric: Denies depression, anxiety or suicidal thoughts.

Subjective Analysis

This case is about a 39-year-old lady with apparently well-controlled diabetes, HTN. The chief complaint of the patient during this visit is the above described nonspontaneous bilateral whitish nipple discharge. Taking into consideration the symptoms reported and her past medical history, the first diagnosis could be galactorrhea.

Galactorrhea is a discharge of milk or a milk-like secretion from the breast in the absence of parturition or beyond six months’ postpartum in a non-breastfeeding woman. It is stated that the cause of galactorrhea can be attributed to either physiological or pathological causes. Risk factors associated with galactorrhea are frequent (daily) breast self-exam, stress, or wearing clothing that irate the nipples such wool or tight-fitting bra (Leung & Pacaud, 2004). Based on the description provided, it is evident that this patient exhibited symptoms and risk factors that support the diagnosis of galactorrhea. Anyhow, other diagnoses that present with nipple discharge must be ruled out after a detailed physical examination.

Objective

Physical exam: Well-developed and overweight. Current weight: 146 lbs., BMI- 27.6. Alert, cooperative, expresses appropriate concerns. Vitals: T: 97.9(O), BP: 123/82 P: 74 R: 17

HEENT: Head freely moveable with no lesions. PERRLA. No nystagmus. Sclera white. No conjunctival exudates. Tympanic Membrane landmarks not obscured, pearly grey with cone of light present, no discharge or pain noted. Nose: moist, smooth and pink mucosal membrane, with no redness, drainage or inflammation noted. Pharynx mucosa moist, smooth and pink, uvula midline, no mouth vesicles. Tonsils normal.

NECK: Neck Supple, No masses. No lymphadenopathy. Trachea midline, no thyroid enlargement noted.

Chest/Lungs: Chest expansion symmetric, without use of accessory muscles. No respiratory distress. No adventitious breath sounds noted.

Breasts: Breast symmetrical, saggy. Skin smooth with even color and no rash or lesion. Arm movement shows no dimpling or retractions. Bilateral, thick, whitish discharge expressed from both nipples. No blood or smell noticed.

Cardiovascular: Regular rate and rhythm. No murmur or extra heart sounds noted. Strong peripheral pulses 2+, palpable in 4 extremities. Capillary refill less than 3 seconds.

Abdomen: Abdomen soft, non-tender, no rebound tenderness. Bowel sounds present in 4 quadrants. No organomegaly.

Genital/Rectal: Exam deferred at this visit.

Urinary: No costo-vertebral angle (CVA) tenderness to palpation or percussion. No bruits auscultated.

Musculoskeletal: Full range of motion in all extremities, no clubbing present, extremities non-tender. No edema noted.

Neurological: CN II-XII intact. Mental status is normal for patient’s age. No motor or sensory deficits. Deep tendon reflexes normal.

Psych: AAO x 3. Appropriate mood and affect. Cooperative.

Objective Analysis

The second step in the evaluation of a nipple discharge is to determine whether the discharge is pathologic or physiologic. Nipple discharges are classified as pathologic if they are spontaneous, bloody or associated with a mass. Pathologic discharges are usually unilateral and confined to one duct. Physiologic discharges are characterized by discharge only with compression and by multiple duct involvement. These discharges are frequently bilateral. With either type, the discharge fluid may be clear, yellow, white or dark green (Morrow, 2000).

After completing a detailed physical examination on this patient, the positive findings on the breasts were limited to the presence of the non-spontaneous, bilateral discharge, with no lumps, dimpling or retractions, decreasing the possibility of breast cancer. In addition, the rest of the exam did not reveal any other positive findings that lead to the possibility of pathologic underlying conditions. For example, this client has a diagnosis of hypothyroidism, which could be a cause of nipple secretion; however, her disease seems to be under control since there no bradycardia or coarse hair were identified, just to mention two of the signs.

At this point, the characteristics of the discharge described by the client, and the findings during the physical assessment, along with the exacerbating factor of the repetitive stimulation of the breasts match what has been reported in the literature, making physiologic galactorrhea the most likely diagnosis for this patient.

Assessment Analysis

Following a thorough history and physical, the initial diagnosis suggested for this patient is:

1. Galactorrhea: This condition may be caused by prolonged, intensive breast stimulation, such as from suckling, self-manipulation, or stimulation during sexual activity. Galactorrhea caused by breast stimulation is more common in parous women but has been reported in virgins, postmenopausal women, and men (Leung & Pacaud, 2004). The above-described factors are present in this patient.

2. Essential hypertension.

3. Diabetes Mellitus type 2.

4. GERD.

5. Overweight.

The subsequent differential diagnosis must be ruled out:

1. Pituitary tumors: Prolactinomas are the most common type of pituitary tumor and are associated with galactorrhea, amenorrhea, and marked hyperprolactinemia. These tumors are associated more often with visual field defects, headache, neurologic deficits, and loss of anterior pituitary hormones (Leung & Pacaud, 2004). These signs and symptoms are not present in this patient.

2. Thyroid disorders: Primary hypothyroidism is a rare cause of galactorrhea in adults. In patients with primary hypothyroidism, there is increased production of thyrotropin-releasing hormone, which may stimulate prolactin release (Leung & Pacaud, 2004). Despite this patient has a diagnosed hypothyroidism; this condition, clinically seems to be under control and client reports good adherence to her thyroid medications. Nevertheless, the level of thyroid hormones will help to discard this cause.

3. Chronic renal failure: Approximately 30 percent of patients with chronic renal failure have elevated prolactin levels, possibly because of decreased renal clearance of prolactin. Although galactorrhea in these patients is rare, it can result from the elevated prolactin levels (Leung & Pacaud, 2004). In addition to the negative personal history of renal problems, this patient examination does not show any signs of chronic kidney disease. Anyhow, determination of eGFR and a complete renal panel would help to rule out this possible diagnosis.

4. Neurogenic causes: Neurogenic stimulation may repress the secretion of hypothalamic prolactin inhibitory factor, which results in hyperprolactinemia and galactorrhea. Neurogenic causes of galactorrhea include chest surgery, burns, and herpes zoster that affect the chest wall (Leung & Pacaud, 2004), which do not form part of the history of this client.

5. Breast cancer: The most common cause of pathologic nipple discharge is intraductal papilloma, followed by duct ectasia. If a palpable mass is present in association with a discharge, the likelihood of cancer is greatly increased (Morrow, 2000). Breast examination of this patient did not reveal any tumor or mass; nevertheless, a mammogram would help to discriminate this diagnosis.

6. Idiopathic causes: Idiopathic galactorrhea is a diagnosis of exclusion. Galactorrhea is considered idiopathic if no cause is found after a thorough history, physical examination, and laboratory evaluation. The patient’s breast tissue may have increased sensitivity to normal circulating prolactin levels (Leung & Pacaud, 2004).

Plan

The plan for this patient includes:

1. Decrease excessive stimulation of breasts.

2. Laboratory work up including thyroid hormones, renal studies, prolactin levels and pregnancy test.

3. Occult blood exam and culture with sensitivity of the breast discharge.

4. Schedule a mammogram to rule out breast masses (benign cyst or breast cancer).

5. MRI to eliminate the possibility of pituitary tumors.

6. Continue with current medication regimen.

7. Smoking cessation encouraged.

8. Decrease in alcohol intake and began a well balance diet in addition to practice exercises frequently, avoid inactivity.

1. Instruct client to return to clinic before the scheduled follow up if symptoms worsen.

Plan Analysis

In regards to the case of this lady, it was in essence a palpable diagnosis. According to Leung and Pacaud (2004), a thorough history and physical examination can provide important clinical clues in the evaluation of patients with galactorrhea. As a result of the symptoms that the patient described, the first step on the plan for the suspected diagnosis of physiologic galactorrhea included client education. Patient education was provided in two ways, verbally and in the form of leaflets concerning galactorrhea and its management. Ms. F was instructed on avoiding any activities that would produce nipple stimulation, such as the daily breast examination. This measure would help to reduce the incidence of nipple discharge. However, patient was instructed to continue performing monthly breast self-exams as an effective screening method for breast cancer.

Morrow (2000) stated that a careful history usually identifies a physiologic discharge. Anyhow, coexisting abnormalities should be excluded with mammography, especially in women more than 35 years of age, MRI for further evaluation for possible brain tumor and an extensive blood work. If the work-up is negative, reassurance is most likely the only therapy that is needed. In order to identify possible non-physiologic causes, the appropriate tests were ordered to this patient.

Follow up visits were arranged to evaluate test results of the thyroid hormones, renal studies, prolactin levels, MRI, and to assess effectiveness of avoiding activities that would increase breast stimulation. Patient understands that this initial diagnosis is given based only on clinical findings, and that she needs to return to the clinic for follow up on test results, or visit an urgent care center if symptoms worsen or any there is any other concern.

Theoretical Integration

A nursing model that guided my care to this specific patient is the theory of self-efficacy. It is stated that the theory of self-efficacy is based on the belief of that what people think, believe, and feel affects how they behave. Awareness of an individual’s determinants to incorporate good health behaviors is essential in finding ways to promote effective health-promoting behaviors. The theory of self-efficacy evaluates the past experiences in completing a particular task in order to assist the patient in completing present tasks (Peterson and Bredow, 2008). As evidenced by this case, this patient used to perform daily breast exams because of the negative experience with her mother suffering from breast cancer. This theory supports my actions as a healthcare provider, since based on it, I may enhance perceived self-efficacy by diminishing emotional arousals such as the fear felt by this client, which might be associated with negative behaviors toward her own health.

APN Competencies

Concerning the case of A.F., I served as the clinician, educator and collaborator of her care. As the role of secondary care provider/clinician, I determined the diagnosis and additional differential diagnosis, based on the symptoms that the patient presented and the findings during the physical examination. I determined what laboratories and diagnostic exams were necessary. I also provided the patient with educational pamphlets concerning galactorrhea, benign cyst, and breast cancer. I assisted the preceptor in filling out the necessary referrals to schedule the MRI and the mammogram.

References

Leung, A., & Pacaud, D. (2004). Diagnosis and management of galactorrhea. American Family Physician, 70(3), 543-543-50, 437-9, [553-4] passim.

Morrow, M. (2000). The evaluation of common breast problems. American Family Physician, 61(8), 2371-2371-8, 2385, 2317-20 passim.

Peterson, J. S. & Bredow, S. B. (2008). Essentials Middle Range Theories of Family (5th ed.). Philadelphia: Lippincott Williams and Wilkins.