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Unfolding Case Scenario 2-1 for Bloody nipple discharge in a lactating patient

Learning Objectives

  1. Describe the pathophysiology of bloody nipple discharge in a lactating patient
  2. Differentiate between normal and concerning breast/chest assessment findings in a lactating patient with bloody nipple discharge
  3. Differentiate between a normal and concerning clinical presentation of nipple discharge in a lactating patient

Question 1

A 27-year-old first time mother presents on day 6 postpartum with a history of bilateral, blood-tinged breast milk collected while using her breast pump. The patient had a spontaneous, vaginal delivery at 39 weeks and 3 days to a baby girl weighing 7 pounds, 10 ounces. Pregnancy, labor, delivery, and postnatal course were uncomplicated. The patient breastfed within the first hour of life and her milk came in by 72 hours postpartum. Because breastfeeding was painful for her, she started pumping on day 3 and giving her baby breast milk by bottle. The breastfeeding pain resolved on day 5 and she has not used the breast pump in the last 24 hours. At the infant’s pediatric visit on day 5 of life, the newborn was at 3% below birth weight. The mother’s grandmother died of breast cancer in her 80s. The patient is a non-smoker and reports no alcohol or drug use. She lives with her boyfriend, the father of the baby in an apartment and plans to stay home with the baby and not return to work.

When obtaining this patient’s medical history, which of the following is the most important in evaluating the chief complaint?  

 

Question 2

A 27-year-old first time mother presents on day 6 postpartum with a history of bilateral, blood-tinged breast milk collected while using her breast pump. The patient had a spontaneous, vaginal delivery at 39 weeks and 3 days to a baby girl weighing 7 pounds, 10 ounces. Pregnancy, labor, delivery, and postnatal course were uncomplicated. The patient breastfed within the first hour of life and her milk came in by 72 hours postpartum. Because breastfeeding was painful for her, she started pumping on day 3 and giving her baby breast milk by bottle. The breastfeeding pain resolved on day 5 and she has not used the breast pump in the last 24 hours. At the infant’s pediatric visit on day 5 of life, the newborn was at 3% below birth weight. The mother’s grandmother died of breast cancer in her 80s. The patient is a non-smoker and reports no alcohol or drug use. She lives with her boyfriend, the father of the baby in an apartment and plans to stay home with the baby and not return to work.

When performing a breast/chest assessment for this patient, which of the following would be most concerning for an underlying malignancy?

 

Question 3

A 27-year-old first time mother presents on day 6 postpartum with a history of bilateral, blood-tinged breast milk collected while using her breast pump. The patient had a spontaneous, vaginal delivery at 39 weeks and 3 days to a baby girl weighing 7 pounds, 10 ounces. Pregnancy, labor, delivery, and postnatal course were uncomplicated. The patient breastfed within the first hour of life and her milk came in by 72 hours postpartum. Because breastfeeding was painful for her, she started pumping on day 3 and giving her baby breast milk by bottle. The breastfeeding pain resolved on day 5 and she has not used the breast pump in the last 24 hours. At the infant’s pediatric visit on day 5 of life, the newborn was at 3% below birth weight. The mother’s grandmother died of breast cancer in her 80s. The patient is a non-smoker and reports no alcohol or drug use. She lives with her boyfriend, the father of the baby in an apartment and plans to stay home with the baby and not return to work.

If during a breast/chest assessment you were able to elicit discharge from the nipple of this patient, which of the following images of nipple discharge would be most concerning for an underlying breast malignancy?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Question 4

A 27-year-old first time mother presents on day 6 postpartum with a history of bilateral, blood-tinged breast milk collected while using her breast pump. The patient had a spontaneous, vaginal delivery at 39 weeks and 3 days to a baby girl weighing 7 pounds, 10 ounces. Pregnancy, labor, delivery, and postnatal course were uncomplicated. The patient breastfed within the first hour of life and her milk came in by 72 hours postpartum. Because breastfeeding was painful for her, she started pumping on day 3 and giving her baby breast milk by bottle. The breastfeeding pain resolved on day 5 and she has not used the breast pump in the last 24 hours. At the infant’s pediatric visit on day 5 of life, the newborn was at 3% below birth weight. The mother’s grandmother died of breast cancer in her 80s. The patient is a non-smoker and reports no alcohol or drug use. She lives with her boyfriend, the father of the baby in an apartment and plans to stay home with the baby and not return to work.

Which of the following breast changes would be considered normal in a lactating woman during the first few weeks postpartum?

 

Question 5

A 27-year-old first time mother presents on day 6 postpartum with a history of bilateral, blood-tinged breast milk collected while using her breast pump. The patient had a spontaneous, vaginal delivery at 39 weeks and 3 days to a baby girl weighing 7 pounds, 10 ounces. Pregnancy, labor, delivery, and postnatal course were uncomplicated. The patient breastfed within the first hour of life and her milk came in by 72 hours postpartum. Because breastfeeding was painful for her, she started pumping on day 3 and giving her baby breast milk by bottle. The breastfeeding pain resolved on day 5 and she has not used the breast pump in the last 24 hours. At the infant’s pediatric visit on day 5 of life, the newborn was at 3% below birth weight. The mother’s grandmother died of breast cancer in her 80s. The patient is a non-smoker and reports no alcohol or drug use. She lives with her boyfriend, the father of the baby in an apartment and plans to stay home with the baby and not return to work.

Which of the following biological processes is most likely involved in the clinical presentation of the patient presented in this case? 

Unfolding Case Scenario 2-2 for Bloody nipple discharge in a lactating patient

Learning Objectives

  1. Identify the concerning clinical and physical exam findings in a lactating patient with bloody nipple discharge
  2. Describe the principle components of a focused breast examination for concerns of breast malignancy
  3. Formulate a management plan for a lactating patient with bloody nipple discharge suspicious for malignancy

Question 1

A 42 year-old Caucasian woman is concerned because yesterday she noticed a red-brown stain on her nursing bra on the right side. She is afraid that she may have breast cancer.  Which of the following pieces of the patient’s history would make you most concerned for an underlying malignancy?

Question 2

A 42 year-old Caucasian woman is concerned because yesterday she noticed a red-brown stain on her nursing bra on the right side. She is afraid that she may have breast cancer.

When asked about her breastfeeding experience, she says she has had a good breastfeeding experience with her two month old “milk monster.” Since her mother died from breast cancer last year, she’s been worried about developing breast cancer herself. Which of the following components of the patient’s clinical presentation and history puts her at the greatest risk for developing breast cancer?

Question 3

A 42 year-old Caucasian woman is concerned because yesterday she noticed a red-brown stain on her nursing bra on the right side. She is afraid that she may have breast cancer.

When asked about her breastfeeding experience, she says she has had a good breastfeeding experience with her three-week old “milk monster.” Since her mother died from breast cancer last year, she’s been worried about developing breast cancer herself.

When you asked about whether the patient has noticed any skin changes or masses in her breasts, she responds that she has an itchy rash on her breast for which she used hydrocortisone. She also notes that she thinks one breast appears larger than the other, and her nipples are inverted. If confirmed on a physical exam, which of these reported findings would prompt you to refer this patient to a specialist?

Question 4

The patient doesn’t know if the discharge occurs from one nipple pore or multiple. If you could only see this patient remotely via telehealth, how would you ask her to elicit nipple discharge?

Question 5

The patient saw milky discharge from both breasts after you taught her how to elicit discharge. She also felt a pea-sized lump a centimeter away from the base of the right nipple. She had never noticed it before because this was the first time she manually expressed milk. What would you recommend to this patient?