STUDY - Technical - New Dacian's Medicine
Nipple
discharge (Classical / Allopathic Medicine)
Nipple discharge
can occur spontaneously, or it can be elicited by nipple
stimulation. It's characterized by duration (intermittent or
constant), extent (unilateral or bilateral), color,
consistency, and composition. Its incidence increases with age
and parity. This sign rarely occurs in men and in nulligravid,
regularly menstruating women, where it's more likely to be
pathologic. However, it's relatively common in middle-aged,
parous women, who can often elicit a thick, grayish discharge
- benign epithelial debris from inactive ducts. Colostrum (a
thin, yellowish, or milky discharge) is common in the last
weeks of pregnancy.
Nipple discharge
can signal serious underlying disease, particularly when
accompanied by other breast changes. Significant causes
include endocrine disorders, cancer, certain drugs, and
blocked lactiferous ducts.
HISTORY:
Ask the patient when she first noticed the discharge, and ask her its duration, quantity, color, and consistency. Is the discharge spontaneous, or does it have to be expressed? Is it bloody?
Ask the patient if she has noticed other nipple and breast changes, such as pain, tenderness, itching, warmth, changes in contour, or lumps. If she reports a lump, question her about its onset, location, size, and consistency.
Review the patient's complete gynecologic history.
Ask the patient about her normal menstrual cycle and the date of her last menses. Does she experience breast swelling and tenderness, bloating, irritability, headaches, abdominal cramping, nausea, or diarrhea before or during menses?
Obtain a pregnancy history, noting the outcome of each as well as pregnancy-related complications. If she breastfed, note the approximate time of her last lactation.
Review the patient's medical history for risk factors of breast cancer, including previous or current malignancies, nulliparity or first pregnancy after age 30, early menarche, and late menopause. Also, ask the patient if there's a family history of breast cancer.
Obtain a drug history, including prescription and over-the-counter drugs, herbal remedies, and recreational drugs. Also, ask the patient about alcohol intake.
Ask the patient when she first noticed the discharge, and ask her its duration, quantity, color, and consistency. Is the discharge spontaneous, or does it have to be expressed? Is it bloody?
Ask the patient if she has noticed other nipple and breast changes, such as pain, tenderness, itching, warmth, changes in contour, or lumps. If she reports a lump, question her about its onset, location, size, and consistency.
Review the patient's complete gynecologic history.
Ask the patient about her normal menstrual cycle and the date of her last menses. Does she experience breast swelling and tenderness, bloating, irritability, headaches, abdominal cramping, nausea, or diarrhea before or during menses?
Obtain a pregnancy history, noting the outcome of each as well as pregnancy-related complications. If she breastfed, note the approximate time of her last lactation.
Review the patient's medical history for risk factors of breast cancer, including previous or current malignancies, nulliparity or first pregnancy after age 30, early menarche, and late menopause. Also, ask the patient if there's a family history of breast cancer.
Obtain a drug history, including prescription and over-the-counter drugs, herbal remedies, and recreational drugs. Also, ask the patient about alcohol intake.
Eliciting nipple
discharge
If the patient has a history or evidence of nipple discharge, you can attempt to elicit it during your examination. Help the patient into a supine position, and then gently squeeze her nipple between your thumb and index finger, noting discharge from the nipple. Then place your fingers on the areola, as shown, and palpate the entire areolar surface, watching for discharge from areolar ducts.
PHYSICAL ASSESSMENT:
Elicit discharge, if possible, and note its color, consistency, amount, and odor. (See Eliciting nipple discharge.)
Examine the nipples and breasts with the patient in four different positions: sitting with her arms at her sides, sitting with her arms overhead, sitting with her hands pressing on her hips, and leaning forward so her breasts are suspended. Check for nipple deviation, flattening, retraction, redness, asymmetry, thickening, excoriation, erosion, and cracking. Inspect her breasts for asymmetry, irregular contours, dimpling, erythema, and peau d'orange.
With the patient in a supine position, palpate the breasts and axillae for lumps, giving special attention to the areolae. Note the size, location, delineation, consistency, and mobility of any lump you find.
If the patient has a history or evidence of nipple discharge, you can attempt to elicit it during your examination. Help the patient into a supine position, and then gently squeeze her nipple between your thumb and index finger, noting discharge from the nipple. Then place your fingers on the areola, as shown, and palpate the entire areolar surface, watching for discharge from areolar ducts.
PHYSICAL ASSESSMENT:
Elicit discharge, if possible, and note its color, consistency, amount, and odor. (See Eliciting nipple discharge.)
Examine the nipples and breasts with the patient in four different positions: sitting with her arms at her sides, sitting with her arms overhead, sitting with her hands pressing on her hips, and leaning forward so her breasts are suspended. Check for nipple deviation, flattening, retraction, redness, asymmetry, thickening, excoriation, erosion, and cracking. Inspect her breasts for asymmetry, irregular contours, dimpling, erythema, and peau d'orange.
With the patient in a supine position, palpate the breasts and axillae for lumps, giving special attention to the areolae. Note the size, location, delineation, consistency, and mobility of any lump you find.
SPECIAL
CONSIDERATIONS:
Nipple discharge
can be caused by psychotropic agents, particularly
phenothiazines and tricyclic antidepressants; some
antihypertensives; hormonal contraceptives; cimetidine;
metoclopramide; and verapamil.
PEDIATRIC
POINTERS:
Nipple discharge in children and adolescents is rare. When it does occur, it's almost always nonpathologic, as in the bloody discharge that sometimes accompanies the onset of menarche.
Infants of both sexes may experience a milky breast discharge beginning 3 days after birth and lasting up to 2 weeks.
Nipple discharge in children and adolescents is rare. When it does occur, it's almost always nonpathologic, as in the bloody discharge that sometimes accompanies the onset of menarche.
Infants of both sexes may experience a milky breast discharge beginning 3 days after birth and lasting up to 2 weeks.
AGING ISSUES:
In postmenopausal women, breast changes are considered malignant until proven otherwise.
In postmenopausal women, breast changes are considered malignant until proven otherwise.
PATIENT
COUNSELING:
Advise the patient to wear a breast binder, which may reduce discharge by eliminating nipple stimulation.
Advise the patient to wear a breast binder, which may reduce discharge by eliminating nipple stimulation.
Bibliography:
1. Rapid Assessment, A
Flowchart Guide to Evaluating Signs & Symptoms, Lippincott
Williams & Wilkins, 2004.
2. Professional Guide to
Signs and symptoms, Edition V, Lippincott
Williams & Wilkins, 2007.
3. Guide to common symptoms,
Edition V, McGraw - Hill, 2002.