Nipple discharge in a 31 yo female

Physical Examination

  • General appearance: Comfortable-appearing female who generally looks well and appears her stated age.

  • Vital signs:
  • BMI: 22 kg/m2
  • Temperature: 36.6° C
  • Pulse: 80 beats/minute and regular
  • Respirations: 18/min
  • BP: 135/74 mm Hg

  • Skin: Normal color, no rash, hirsutism, or acne.

  • HEENT: Pupils equal and reactive to light and accommodation. Normal visual fields to confrontation. Visual acuity 20/20 in both eyes. Fundi normal bilaterally. No thyroid enlargement or nodules.

  • Pulmonary: Equal air entry and chest is clear on auscultation. No crackles or wheezes.

  • Cardiovascular: Regular rate and rhythm with normal heart sounds. No murmurs. Normal peripheral pulses and capillary refill.

  • GYN: No breast masses or skin changes. No axillary lymphadenopathy. Mild diffuse breast tenderness on palpation. Milky nipple discharge elicited bilaterally with pressure around areolae.

  • Gastrointestinal: Abdomen soft, nontender, and nondistended. No organomegaly, and bowel sounds are normal.

  • Genitourinary: Unremarkable

  • Musculoskeletal: Unremarkable

  • Neurologic: Normal and symmetric motor strength and reflexes on extremities. Sensation grossly intact to light touch. Cranial nerves 2 through 12 intact. Gait and balance normal.

  • Mental status: Alert, oriented to person, place, and time. Affect seems slightly depressed.