History of Present Illness
Review of Systems
Past Medical History
Physical Examination
Essential Differential Diagnosis
Relevant Testing
Test Results 1
Relevant Next Steps
Test Results 2
Diagnosis
Treatment Orders
Question 1
Question 2
Question 3
About the Case
Nipple discharge in a 31 yo female
Review of Systems
General
: Gradually increasing lethargy over the past 2 months. 3 kg unintentional weight gain in the past 6 months.
Skin
: No rash or history of excessive facial hair or acne.
HEENT
: No rhinorrhea, tinnitus, vertigo, or change in hearing.
Pulmonary
: Noncontributory
Cardiovascular
: Noncontributory
Gastrointestinal
: Noncontributory
Genitourinary
: Noncontributory
Gynecologic
: Decreased libido. Vaginal dryness during sexual intercourse. She has been trying to conceive for the last 2 years. One full-term, uncomplicated pregnancy 5 years ago.
Musculoskeletal
: Noncontributory
Neurologic
: 6-month history of dull frontal and occasionally retro-orbital headaches that are increasing in frequency and that now occur almost daily and affect her work performance. There are no associated neurologic symptoms, including disturbances of vision, strength, balance, or gait. She denies nausea, photophobia, or phonophobia. Until 1 month ago, the headaches would resolve completely with nonsteroidal antiinflammatory drugs, but for the last month taking simple analgesia does not suffice. She denies history of headaches prior to 6 months ago.
Psychiatric
: She is mildly depressed recently, which she attributes to the frequent headaches. No suicidal ideation.
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