A 16-year-old female with nipple discharge.
K.Y. is a 16-year-old Caucasian female presenting to the clinic with a staff member from a local short-term group home facility. The group home houses children and adolescents who have behavioral problems as a result of mental illness, defiance, school/home issues, or jail/youth detention incarceration. K.Y. was brought in because she complained of "stuff coming from both breasts for about a month."
History of Present Illness
K.Y. reported that she stopped taking birth control pills when she noticed "stuff coming from both her breasts" a month ago. She reported having this for a short time about a year ago and was told it was normal. K.Y. stated: "I haven't noticed it since that time until last month." She stated that she missed her menstrual cycle last month and has not had one yet this month.
Past Medical History
This is K.Y.'s third visit to the office. She has a history of attention deficit hyperactivity disorder, gastroesophageal reflux disease, and depression. She has also had some discipline problems at home and school. K.Y. takes Adderall XR[R] daily, Prilosec[R] prn, Celexa[R] daily, and Risperdal[R] daily. Her immunizations are up to date, and she had a negative (0 mm) PPD two months ago. K.Y. denies use of illicit drugs or alcohol, any known pregnancies, and has no known food, drug, or environmental allergies. She reported using tobacco products and being sexually active when not in the group home. This patient is followed routinely by her pediatrician when she is living at home in her county of residence. She has counseling services through the group home and is followed by mental health professionals when transitioning back to her home.
Developmental and Growth History
Maternal and patient birth history are unknown. K.Y. has had a menstrual cycle for approximately five years. It has been fairly regular with the exception of missing last month and not having one yet this month.
Family and Social History
K.Y. states there is a family history of diabetes (maternal aunt), high blood pressure (person unknown), stroke (person unknown), and kidney disease (person unknown). She resides with her aunt and attends public school when not in the group home. The group home provides home schooling for the residents. K.Y. experienced the death of a close friend about two-and-a-half months ago.
K.Y. reports her appetite is good, and she eats meats, fruits, vegetables, and breads, and drinks milk. Her diet includes foods that are high in iron. K.Y. does not take any over-the-counter vitamin supplements. She admits to gaining weight over the last two months as evidenced by her clothes fitting tighter and not being able to button some of her pants.
Physical Assessment Findings
General appearance: K.Y. is well groomed and alert, and responds appropriately throughout the examination.
Vital signs: Temp: 99.0 (tympanic), Weight: 138.6 lbs (63 kg), Height: 58 1/8 in, BP: 118/72, BMI: 28.9.
HEENT: Head normocephalic. Eyes: PERRLA and red reflex noted bilaterally. Ears: TMs noted with normal light reflex and landmarks visible. Nose: no nasal septal deviation. No drainage. Throat: No exudate or erythema. Tonsils 1+. Mouth: Moist mucous membranes. Gums without swelling, masses, ulcerations, or bleeding. Neck: Supple. Trachea midline. Thyroid non-palpable.
Integumentary: Skin warm and dry. No lesions or rashes noted.
Respiratory: Lungs clear anterior and posterior bilaterally. Breathing non-labored.
Cardiovascular: Regular rate and rhythm with no murmurs, thrills, or heaves.
Breast: Moderate amount of thin, milky-appearing discharge manually expressed from the left breast. No discharge expressed from the right breast. Both breasts without palpable nodules or masses. No dimpling. No discolorations. No palpable axillary nodes. Tanner V.
Abdomen: Supple. No hepatosplenomegaly. No uterine enlargement. Bowel sounds present in all 4 quadrants.
Neurological: Speech intact. Oriented to person, place, and time.
Genitalia: No discharge, erythema, or lesions noted.
Lab results: Serum pregnancy test negative. Quantitative HCG less than 1.00 MIU/ML (normal). Prolactin 39.0 (high). Luteinizing hormone 3.5 (normal). FSH 2.0 (normal). An MRI of the brain and pituitary was ordered after the lab results were obtained.
MRI brain and pituitary: On the dynamic images in the posterior left side of the pituitary gland is a subtle hypointense 5x3 mm area of diminished enhancement.
K.Y. is a 16-year-old female presenting to the clinic with a complaint of discharge coming from both breasts for about one month. She is fully aware of her surroundings and responds appropriately throughout the conversation.
Medication-induced galactorrhea. Even though there are numerous reasons why galactorrhea may occur, one of the most common causes, beyond the infancy period, is medication-related. Medications may cause galactorrhea by blocking dopamine receptors, depleting dopamine, inhibiting dopamine release, blocking histamine receptors, or stimulating lactotrophs. Medications such as Reglan[R], Risperdal[R], tricyclic antidepressants, and selective serotonin reuptake inhibitors block dopamine receptors; Aldomet[R] and Serpasil* deplete dopamine; morphine, codeine, and heroin inhibit the release of dopamine; Tagamet[R], Pepcid[R], and Zantac[R] block histamine receptors; and Calan[R], birth control pills, and Depo Provera[R] stimulate lactotrophs (Pena & Rosenfeld, 2001).
Physiologic galactorrhea in pregnancy. According to Pena and Rosenfeld (2001), galactorrhea may be considered physiologic in pregnancy. Pregnant women may lactate as early as the second trimester, and some continue to produce milk for up to two years after cessation of breastfeeding. It has been determined that during the first few weeks of pregnancy, global hyperplasia starts to occur in the pituitary gland. By the time a female has reached the immediate postpartum period, the gland will have expanded almost 1.2 cm in diameter. As the gland expands, there is a simultaneous increase in the size and population of lactotroph cells and a progressive increase in serum prolactin (Imran, Ur, & Clarke, 2007).
Galactorrhea secondary to prolactin secreting pituitary microadenomas. Microadenomas, tumors less than 10 mm in diameter, may or may not be associated with hormone secretion. Most frequently, they are not problematic, and many of them may be found incidentally when other problems are being investigated. Although tumors are most often clinically insignificant, it is important to rule out secretory tumors as a causal agent when patients present with symptoms such as hyperprolactinemia (Corenblum, 2013). Even though microadenomas may occur in any ethnic group and present at any age, prolactinomas, the most commonly occurring secretory microadenomas, tend to be discovered more often in women than men. This is thought to be the case because women present with the most distinguished features, which are amenorrhea and/or galactorrhea (Corenblum, 2013). Pituitary microadenomas can cause Cushing's disease, acromegaly, hyperthyroidism, and rarely, symptoms related to decreased secretion from the pituitary gland. Symptoms of a pituitary microadenoma may include tiredness, headaches, vomiting, dizziness, vision problems, and menstrual or breast changes (Barrow Neurological Institute, n.d.). Unlike nonsecretory microadenomas that do not require intervention, secretory microadenomas must have either a surgical or pharmacologic intervention.
The Management Plan
K.Y. was diagnosed with a left posterior pituitary microadenoma. Her time at the group home was ending; therefore, she was referred to an endocrinologist in her home town. K.Y. was also referred back to her primary care provider for routine follow up. The treatment included a long-acting dopamine receptor agonist, cabergoline. Her prescription included cabergoline 0.5 mg twice a week for a month then decreased to once a week due to side effects K.Y. experienced. She will continue follow up in her hometown, and if at any point she returns to the group home, she will be followed by this office.
Barrow Neurological Institute, (n.d.). Microadenoma. Retrieved from http://www. thebarrow.org/NeurologicaLServices/ Pituitary_Center/220146
Corenblum, B.C. (2013). Pituitary microadenomas. Retrieved from http://emedi cine.medscape.com/article/126702overview
Imran, S.A., Ur, E., & Clarke, D.B. (2007). Managing prolactin-secreting adenomas during pregnancy. Canadian Family Physician, 53(4), 653-658. Retrieved from http://www.cfp.ca/content/ 53/4/653.full
Pena, K.S., & Rosenfeld, J.A. (2001). Evaluation and treatment of galactorrhea. American Family Physician, 63(9), 1763-1771. Retrieved from http://www. aafp.org/afp/2001/0501 /p1763.html
Ferri, F.F. (2014). Ferri's clinical advisor 5 books in 1. Philadelphia: Elsevier.
Molitch, M.E., (2012). Management of incidentally found nonfunctional pituitary tumors. Neurosurgical Clinics of North America, 23(4), 543-553. doi:10.1016/ j.nec.2012.06.003
Schuiling, K.D., & Likis, F.E. (2013). Women's gynecologic health (2nd ed.). Burlington, MA: Bartlett and Jones.
Critical Thinking Case Studies is designed to test your problem-solving and decision-making abilities. Instructions: Read the symptom(s) above. Then, outline how you would assess and manage the problem. Finally, compare your rationale and decision to that listed in the shaded area.
If you are interested in author guidelines for this column or would like to submit material, contact: Tedra S. Smith, DNP, CRNP,
PNP-PC; Pediatric Nursing; East Holly Avenue/Box 56; Pitman, NJ 08071-0056; firstname.lastname@example.org
Avis Johnson-Smith, DNP, CPNP-PC, FNPBC, CNS, is a Clinical Professor and FNP Track Coordinator, the Department of Nursing, Angelo State University, San Angelo, TX, and is a Nurse Practitioner and CoOwner, Healthy Kids and Families Wellness Center LLC, Albany, GA.
Linda W. Omondi, DNP, M.Ed., FNP-BC, is an Assistant Clinical Professor, Southern Illinois University Edwardsville (SIUE), Edwardsville, IL, and is the Clinical Coordinator, SIUE WE CARE Clinic, School of Nursing at SIUE Campus, East St. Louis, IL.
Denotra Gaillard, DNP, APRN, FNP-C, is an Assistant Professor, Georgia Regents University, Columbus State University Campus, and a Nurse Practitioner, Unite Here Wellness Clinic, Columbus, GA.
Aubrey Smith, MA, BS, BBA, RT, is a Practice Administrator and Co-Owner, Healthy Kids and Families Wellness Center, LLC, Albany, GA.
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|Title Annotation:||Critical Thinking Case Studies|
|Author:||Johnson-Smith, Avis; Omondi, Linda W.; Gaillard, Denotra; Smith, Aubrey|
|Article Type:||Clinical report|
|Date:||Jan 1, 2015|
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