1. Nipple Discharge R/O Mechanical Stimulation R/O Medication Cause: Phenothiazine Reserpine Estrogen Opiates Check Prolactin Level Check TSH AbnormalNormal Primary Care Physician to treat Reassure Surgery Referral Recheck 1 Month: If Unchanged or Resolved Bloody (<5% associated with malignancy) Non-Bloody Bilateral Breast Exam Consider Single Duct (may be cancer) vs. Multiple Duct (not as worrisome) Bilateral (not as worrisome) vs. Unilateral (may be cancer) Ductograms do not R/O pathology and should not be ordered Age > 35: Diagnostic Mammogram -- Unless negative mammogram within past 6 months.

2. Breast Pain Occurs in 70% of Premenopausal Females Cyclic Pain Non-Cyclic Pain Mild to Moderate Moderate to Severe Non-Hormonal Therapy for 4-6 Months: Reassurance Supportive & Well- Fitting Bra NSAIDS Caffeine Decrease Oil of Primrose: 1500-3000 mg daily (contains gamolenic acid) Vitamin E 800u daily Primary MD for possible hormone therapy: Premenopausal-- BCP Perimenopausal-- consider low dose BCP Postmenopausal-- Decrease or stop Estrogen Primary MD Assessment for: Breast Disorder Chest Wall Disorder --Bone --Muscle --Joint Pleural Disease Cardiac Disease GI Disease Bilateral Breast Exam Assess currency with screening mammograms (see Breast Cancer Screening Guidelines) PositiveNegative Refer to Breast Lump Algorithm

3. Infection/Mastitis (Non-Breastfeeding Female) *Inflammatory carcinoma should always be considered. Redness, Warmth, Swelling, Purulent Discharge, Draining Wound Warm Packs, NSAIDS, Antibiotics Cephalexin--500 mg po QID x 10 days Dicloxacillin--500 mg po QID x 10 days E-mycin--333 mg. TID x 10 days if allergic to penicillin Recheck within 7-10 days or sooner if new or increasing symptoms Signs and Symptoms Alleviated Signs and Symptoms Unchanged or Increased Instruct: Screening Mammogram per Age Guidelines Surgery Referral If breastfeeding, treat with antibiotics, as above. Continue breastfeeding. If patient has implants, consider longer course of antibiotics or referral to Plastic Surgery. Bilateral Breast Exam