Nipple discharge - serous, serosanguinous, bloody

Nipple discharge - serous, serosanguinous, bloody

ibrocystic breast disease
mammary duct ectasia
intraductal papilloma
epithelial hyperplasia
epithelial hyperplasia of pregnancy
cancer or benign breast tumors

Background

A serous or yellowish discharge is fairly common if patients have fibrocystic changes of the breast. Any blood-tinged (serosanguineous) or bloody discharge often indicates an intraductal papilloma or a malignancy of the breast. While very worrisome for malignancy, bloody nipple discharge is actually most likely to be due to a benign process.


Goals

After a thorough exam, a mammogram should be included to rule out underlying malignancy that is undetectable by physical exam. Any bloody nipple discharge needs surgical investigation even if the exam and the mammogram are negative.

Mrs. Grey is a friend from church who confides in you about a problem she has with leaking of urine. She is 65 years old and has 4 children, married and living nearby. Her husband died last year and she put off seeing a physician because of medical care duties involving her husband. The urine leakage problem has been present for over 5 years and is worse with any lifting, coughing or sneezing. She gets an urge to go to urinate and often leaks urine before she gets to the toilet.
Her medical health is good except for long standing diabetes (15 years) which is under control with oral pills. She has not taken estrogen replacement therapy because she didn't have any hot flashes when she underwent menopause.

In order to cure or improve the urine loss it must be determined what is the cause of her problem. Which of the following statements is correct about the diagnosis of urinary incontinence?

bladder spasms (detrusor instability) can be diagnosed by symptoms alone
interstitial cystitis is a cause of stress incontinence
mixed incontinence decreases as age increases
stress incontinence is diagnosed by observing urinary leakage with straining
a urinalysis is used to diagnose overflow incontinence

CORECT

Stress incontinence is diagnosed by observing urine leakage with coughing or straining. It is almost always associated with urethrovesical neck hypermobility (bladder/urethra dropping). This is visually confirmed by a Q-tip test in which a sterile Q-tip is placed inside the urethra and as a woman strains, the end of the Q-tip rises more than 30 degrees. If this is present, surgery is often needed (bladder 'tack') if pelvic muscle exercises fail to cure the loss. If hypermobility is not present, different treatment is necessary. There may be an intrinsic weakness of the urethral sphincter muscle.

A 33-year-old man is referred to you for an examination for medical clearance for an elective cholecystectomy. He has a history of non-insulin-dependent diabetes mellitus and suffered three fractured ribs in a motor vehicle accident 5 years ago. He is a smoker with a 15-pack/year history. He has a mild nonproductive cough and otherwise is asymptomatic. His physical examination is essentially normal. A preoperative chest radiograph reveals a left lower lung zone solitary nodule measuring approximately 1.5 cm in diameter.
Your next step in managing this patient should be

a. Sputum examination for cytology
b. Elective resection of the nodule
c. Review previous chest radiographs
d. Fiberoptic bronchoscopy
e. Computerized tomography (CT) scan of the chest

C

1. review with old x-ray(most important)
   no change in last 2years-benign, chest x-ray F/U
   new or growing lesion- Bx. resection
   2. if no old x-ray, no characteristic calcification
   nonsmoker,<35yo-chest x-ray F/U(q3months for 1year, and then per 1year)
   smoker,>35yo-Bx.(PCNA or open lung Bx.)
   
   SPN suggesting malignancy
   1.male,>45yo
   2.smoker
   3.size>2cm
   4.indistinct,spiculated margin or lobulated shape
   5.no calcification
   6.with chest sx. atelectasis,pneumonitis,adenopathy

compare the previous xray(s) with the current xray and see if there is any change in the size of the lesion.If it has not changed then proceed with the surgery.The lesion is probably benign.