Nursing homework help

Abnormal milky nipple discharge

31-year-old Hispanic female who c/o milky nipple discharge for the past two weeks accompanied by headache and occasional episodes of dizziness. Both breasts are affected, patient denies menstrual irregularities or any history of substance abuse. LMP was three weeks ago.

None

Menstrual History: LMP three weeks ago, age of Menarche 13

OB history: 0

Gynecological history:

Last Pap smear: 2 years ago

Last MMG: Never

No history of miscarriages

General History: None

Surgical History: Denies surgical history

G0P0A0

Mother lives, Hypertension. Father lives, suffers from Addison’s disease and Diabetes Mellitus Type 2.

Patient denies chest pain/distress, palpitations, dyspnea, orthopnea, edema, hypertension, previous myocardial infarction, past electrocardiogram or cardiac arrest, murmurs, leg edema, capillary refill, varicose veins, distal pulses (radial, brachial, popliteal, posterior tibial, dorsalis pedis) 2 +.

Patient denies rash or eruptions, itching, pigmentation or texture changes, excessive sweating, unusual nail or hair growth, scars, bruises, rashes, masses, lumps, sores

Patient denies pain related to respiration, dyspnea, cyanosis, wheezing, cough, sputum (color/quantity/smell), hemoptysis, night sweats, exposure to tuberculosis, clubbing of fingers, clear to auscultation, clear to percussion, rales, rhonchi

Denies blurred or double vision, vision change, flashing lights, eye discharge, eye pain, irritation, denies corrective lens use.

Denies abdominal pain, nausea, heartburn, blood in stool, and change in bowel habits. Denies diarrhea, constipation, and change in stool.

Denies hearing change, ear discharge, denies tinnitus and or vertigo.

Patient denies dysuria, flank/suprapubic pain, urgency, frequency, nocturia, hematuria, polyuria, hesitancy, dribbling, loss of force of stream, passage of stone, edema of face, stress incontinence, hernias, sexually transmitted diseases. Denies vaginal discharge or bleeding.

Denies nasal discharge or congestion. Patient denies hoarseness, change in voice, frequent sore throats, bleeding or swelling of gums, recent tooth abscesses or extractions, soreness of tongue/buccal mucosa, ulcers, disturbance of taste, posterior pharyngeal wall has exudate

Denies limited joint mobility, muscle pain, stiffness, neck pain, back pain, trouble reaching above head. Denies weakness, joint pain, difficulty walking.

Abnormal milky discharge (bilateral). Breast Self-Examination monthly, denies pain, or masses

Occasional episodes of headache, bitemporal. Denies seizure, dizziness upon standing, denies short-term memory problems and or long-term memory problems, speech changes. Denies numbness/tingling in extremities, loss of conciseness, and trouble with coordination or balance problems

Denies anemia or history other blood cell disorder. Patient denies thyroid enlargement or tenderness, heat/cold intolerance, changes in weight, polydipsia, polyuria, changes in facial/body hair, skin striate

Denies anxiety, nervousness, depression, sadness. Denies any mood changes, hallucinations, or suicidal thoughts.

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31 years-old, female, Hispanic. Patient is alert and oriented, seated upright on the examination table, she is well-nourished, well-developed, and dressed appropriately with good hygiene. Maintain eyes contact during interview and answer all the questions appropriately

Head is normocephalic and atraumatic. Bilateral eyes with equal hair distribution, no lesions, no ptosis, no edema, conjunctiva clear and no injected. Pupils are equal, round, and reactive to light bilaterally. Ear shape equal bilaterally. External canals without inflammation bilaterally. Septum is midline, nasal mucosa is pink bilaterally. Moist buccal mucosa, no sores noted. Adequate dental hygiene. Throat: posterior pharyngeal wall is moist, glistening, non/reddened, without exudate, Tonsils are 1+

Heart rate and rhythm regular, no murmurs, no jugular vein distention, no peripheral edema, S1 and S2 identified, pedal pulse exam performed

Respiratory effort unremarkable, rate and pattern normal, lungs clear to auscultation bilaterally. Symmetric chest lift, no wheezes, rales on auscultation.

Bowel sounds are normoactive in all four quadrants. Abdomen soft, non-tender Tympanic throughout to percussion. No organomegaly noted.

Medium sized breast, pendulous, nipples symmetrical. No skin changes, retraction, lesions, masses, or tenderness appreciated on exam. Mild/bilateral Milky nipple discharge noted. No lymphadenopathy in axillary region bilaterally.

No inguinal hernia, No CVA, no dysuria, pain or discomfort, no bleeding present. No urethral or vaginal discharge noted upon examination

External genitalia

Mons pubis-no lesions, pubis hair in normal distribution.

Vulva/Labia Majora-no rashes, lesion, irritation, or piercings.

Bartholin Glands-no masses, inflammation, or discharge.

Skene glands- no masses, inflammation, or discharge.

Urethra-No prolapsed, discharge, non-tender.

Bladder-Unappreciated on exam

Vagina-no lesions, no discharge or blood, strong muscular

tone.

Cervix-Squamocolumnar junction identified on exam. No erythema, discharge, or lesions appreciated on exam.

Uterus-Small, midline, firm, mobile, non-tender with movement. Uterus was found to be midline, freely mobile, smooth, non-tender, no adnexal masses, or tenderness. Procedure did not detect any palpable masses or tenderness on examination.

Adnexa-small, no masses, non-tender bilaterally. Rectal patient deferred rectal exam at this time

Full ROM all extremities. No joint effusions noted. Steady gate, no limping or musculoskeletal deformities

No pre/post-auricular, ant/posterior cervical chain, occipital, sub-mandibular, sub-mental, supraclavicular, infraclavicular, axillary, inguinal node lymphadenopathy

Normal sensory exam, deep tendon reflexes symmetrical and equal bilaterally, Sensory foot exam performed.

She is very cooperative, no anxiety or suicidal ideation noted.

Galactorrhea (O92.6, ICD-10): Galactorrhea has several causes including physiological as in pregnancy, lactation, stress, or it can be pathological, or drug induced. This condition is characterized by inappropriate discharge of milk containing fluids from the breast, it is a relatively common condition experienced by about 20 to 25 percent of women at some point in their life (Patrascu et al, 2015). Main s/s of concern for the visit bilateral milky nipple discharge.

Differential Diagnosis:

Pituitary adenoma (D35.2, ICD-10): Prolactin secreting adenomas are the most frequent type among pituitary tumors. Patients often present endocrinological symptoms such as galactorrhea, resulting from hyperprolactinemia, and less commonly, visual defects due to compression of optic chiasm (Cristina et al, 2015).

Hyperprolactinemia. (E22.1-ICD-10) Hyperprolactinemia can occur when the pituitary gland overproduces prolactin. The excess of prolactin can cause symptoms that vary depending on a person’s sex. t’s normal to have this condition during pregnancy or when producing milk for breastfeeding. pituitary tumors may be the cause of almost 50 percent of hyperprolactinemia. A prolactinoma is a tumor that forms in the pituitary gland. These tumors are typically noncancerous. Other causes of hyperprolactinemia include acid H2 blockers, antihypertensive medications, such as verapamil, estrogen, antidepressant drugs amount others. Will review labs and test results. In this case patient is not taking any medication that can precipitate this sign and symptoms.

Ductal carcinoma in situ (C50.919, ICD-10): The incidence of ductal carcinoma in situ has increased drastically in the United States. Currently, more than 14 % of breast cancers diagnosed in the United States are ductal carcinoma in situ (DCIS). About one in every 1300 screening mammographic examination will lead to the diagnosis of DCIS (Baxter et al, 2004). Breast examination normal, mammogram will be ordered.

Plan and Education:

Diagnostic labs & studies: Orders placed for Pap smear screening, vaginal culture. Patient scheduled for mammogram on two weeks. Finding the cause of galactorrhea is complex since there are multiple possible causes. It is imperative to conduct a comprehensive medical history review, physical exam, analysis of fluid discharged from the nipples, and blood test including CBC, TSH. A pregnancy test is important, as well as mammographic studies, and US. MRI of the brain to check for a tumor or other abnormalities of the pituitary gland (Patrascu et al, 2015).

2.Treatment Medications: The treatment focuses on resolving the underlying cause. Example stop taking a medication which can cause abnormal milky nipple discharge. In this case is Unknown cause, medication to lower prolactin levels: Bromocriptine, 2.5 mg to 15 mg orally daily, side effects (dizziness, nausea, confusion, involuntary movements). Pituitary adenoma, use of a medication to shrink the tumor or have surgery to remove it upon results and recommendations.

3. Discussed lifestyle changes such as do not stimulates your nipples during sexual activity, avoid frequent manipulation of your nipples, wear a bra that fits well and wear clothing that minimizes friction between the fabric and your nipples. Some medications to treat depression, birth control pills or high blood pressure can cause galactorrhea.

4.Follow up: one month: will review laboratory results, mammogram, and Pap smear results. Patient is to call office with any pelvic pain, irregular bleeding, discharge or other issues or concerns. Patient advised if severe pain or significant bleeding go to emergency department. Referral to Gynecologist and Endocrinologist.

Health promotion education

Patient advised that environmental health is an essential component of physical health. Water, sanitation, hygiene, waste management, pollution control, and prevention of disease transmission are essential to maintain one person healthy.

Patient advised to keep herself active and practice regular exercises.

Patient advised to follow a healthy diet, high in fiber contents, drink at least 2 liters of water per day; moderate the sodium intake, low in fat and cholesterol, and to avoid sugar and sodas as much as possible.

Patient advised to use sunscreen when going outdoors to prevent skin cancer.

Patient educated on substance abuse problems, and to avoid smoking, drinking alcohol or illicit drugs use. Also advised to avoid secondhand smoking.

Patient advised to get at least 8 hrs. of sleep daily.

Patient advised to visit the dentist and get a vision examination at least once a year.

Patient educated on the importance of immunizations to keep one person healthy

Patient educated on the importance of immunizations to keep one person healthy

Patient educated on Diabetes Mellitus and High blood pressure risk factors since parents suffer from those diseases.

Patient advised on COVID-19 disease’s transmission and symptoms; and to practice social distancing, wear a face mask, and practice frequent hand hygiene/sanitizing to avoid COVID-19 Disease.

Patient was instructed in routine Breast self-exam performance to early detect any breast anomalies

The beginning for Pap smear testing is recommend at age 21 and the frequency is every three years for women ages 21 to 65. Women age 30 and older could consider Pap testing every five years if the procedure is combined with testing for HPV or they might consider HPV testing instead of the Pap test.