A 54-year-old post-menopausal woman presents with right nipple discharge. Key history factors to obtain include when the discharge started, its characteristics, associated symptoms, past breast issues or surgeries, and family history of breast disease. On examination, both breasts and axillae should be palpated for lumps or lymph nodes, and the nipple examined for discharge amount and color. Differentials to consider and rule out include intraductal papilloma, duct ectasia, fibrocystic disease, and intraductal carcinoma, which can be distinguished through ductography, cytology of discharge, and mammography if a lump is present.

1. CDM
SURGERY

2. A 54 year old post-menopausal woman presents to the OPD with right nipple
discharge.
a. What are the history and examination findings you would look for?
b. What are the differentials you will consider? How will you rule out each?

3. In History
– History of presenting complaint When did start? How did it start? How did
the patient notice? Type of discharge(serous/ blood stained/ blackish or
greenish)? Amount of discharge( scanty or excessive), Any associated symptoms
like ( presence of lump, fever ,tenderness, nipple retraction), previous similar
complaints (if yes tx done for those complaints)
– Past surgical history of breast lump (if yes , its prognosis , tx and if any
complications)
– Family history Any breast diseases in family (if yes first/ second or third
degree)
– Past Obstetrical and gynecological history

4. On examination
We should look for
1. Palpation of both breasts (affected and non affected)
2. Palpation for any lumps (if yes describe as a swelling)
3. Palpation of the nipple , surrounding skin, look for cracked nipples, eczema
,nipple areolar complex, look at discharge color, consistency and amount.
4. Palpate the axilla for any lymph nodes

5. Characteristic Features
– Solitary Intraductal Papilloma Single Breast having Clear or bloody discharge
;sometimes a small lump may be present behind or near the nipple, this lump may
be tender sometimes.
– Duct Ectasia of Breast/Mammary Duct Ectasia Usually has greenish coloured
/blackish cloured discharge; sometimes can occur as a syndrome non puerperal
mastitis + nipple inversion + nipple discharge.
– Fibrocystic Disease of breast These rarely present with clear discharge, usual
presentation of these are smooth defined edges with fibrous texture and lumpy
nature. Usual complaint of these patinets is presence of lump.
– Ductal Carcinoma Insitu usually they don’t have any symptoms found on
screening mammogram, they might present with bloody discharge with nipple
retraction lump or thickening near the breast.

6. Differentials and rule out
– Solitary Intra-ductal Papilloma
– Duct ectasia
– Fibrocystic disease of Breast
– Intraductal Carcinoma

7. – Breast ductography is an established diagnostic technique that is sometimes useful for
women who present with nipple discharges. Ductography (also called galactography or
ductogalactography) basically involves injecting a ‘contrast enhancing’ die or substance
directly into the breast ducts and then performing an X-Ray. This allows the physician to follow
the course of fluids through the ducts and determine if and where there is any blockage (or
cell block).A simple, solitary papilloma will be elicited with wart like growth , ductal ectasia
may quite easily appear as a ‘blocked duct’.
– Cytology of the discharge may also reveal presence of what type of cells, normal physiological
cells (in case of fibrocystic disease )or cancerous cells(in case of DCIS)
– Diagnostic Mammogram is rarely useful in cases of nipple discharge, mammorgram is only
useful if you have an underlying breast lump and that would justify the nipple discharge (in
case of fibrocystic disease of breast)

8. References
– Bailey and love (26th edition )
– Emedince.medscape.com
– A clinical manual of surgery , S.das