WEEK 8 NR 509 ADVANCED HEALTH ASSESSMENT
FINAL EXAMS WITH RATIONALES
A 24-year-old graphic designer presents to clinic with a concern for a breast mass. A
rubbery, mobile, nontender mass is palpated in the right breast as described by the
patient, which is consistent with a firbroadenoma. In describing the location of the mass,
the examiner notes that it is 3 cm proximal to and 3 cm to the left of the nipple. Which
of the following would be the most appropriate way to report this finding? - -ANS☑️☑️-
-"Rubbery, mobile, nontender mass located in right breast, in the 10:30 position from the
nipple"
Breast findings can be described by quadrant or by position on a clock face, with 12
o'clock at the superior edge of the breast and the nipple at the center of the clock. The
10:30 position meets this patient's description of a mass in the right breast that is
proximal and to the left of the nipple. "Rubbery, mobile, nontender mass located in right
breast, in the lower outer quadrant" is incorrect. Though description by quadrant is
common, this mass would be found in the upper outer quadrant. "Rubbery, mobile,
nontender mass located in right breast, in the upper inner quadrant" is incorrect as
above. "Rubbery, mobile, nontender mass located in the left breast, upper outer
quadrant" is incorrect. This mass is in the right, not left, breast—just a reminder that
precision is key in record keeping. "Rubbery, mobile, nontender mass located in right
breast, in the 1:30 position from the nipple" is incorrect. The 1:30 position describes a
mass that is 3 cm proximal and 3 cm to the right of the nipple, rather than 3 cm
proximal and 3 cm to the left to the nipple.
CHAPTER 18: Breasts and Axillae
A 22-year-old G0P0 undergraduate student presents to clinic after finding a breast mass
on breast self-examination (BSE) at home. The mass is nontender without skin changes,
erythema, or overlying swelling. She has heard that most breast cancers are found by
,patients themselves, and she is very concerned that she may have breast cancer. Which of
the following is true about BSE and self-detection of breast cancer? - -ANS☑️☑️--a. Most
masses that women find at home and bring to a provider's attention turn out to be
malignant.
Rationale: This patient is more likely to find a fibroadenoma than a cancer on self-
examination. In this patient's age range (15-25 years), palpable masses are most likely to
be benign fibroadenomas. Most masses that women find at home and bring to a
provider's attention turn out to be malignant is incorrect. About 11% of complaints of
breast masses turn out to be malignant, leaving the vast majority (89%) noncancerous.
The most likely breast mass this patient is likely to find in herself is an abscess
complicating underlying mastitis is incorrect. This patient has neither the symptoms of
mastitis (localized swelling/erythema/tenderness with generalized fever) nor the risk
factors for this condition (pregnancy and/or breastfeeding), making mastitis a very
unlikely diagnosis. Because of this patient's age, breast masses should not be pursued with
imaging and diagnosis because the risk of cancer is so low is incorrect. Though the risk of
cancer in this patient is low, the consequence of missing a cancer diagnosis is quite high;
for that reason, definitive diagnosis should be pursued for almost all breast masses.
Because of this patient's age, breast masses should not be pursued with imaging and
diagnosis because the risk of cancer is so low is incorrect. BSE suffers from notoriously
low sensitivity and specificity, making it a very controversial recommendation as it tends
to overestimate disease in healthy breasts and miss cancer in breasts with subtle disease.
CHAPTER 18: Breasts and Axillae
CHAPTER 18: Breasts and Axillae
A 35-year-old G0P0 woman presents to clinic with a complaint of bilateral nipple
discharge. This discharge started several weeks ago and has occurred at irregular intervals
since that time. She does not complain of local tenderness, redness, fever, or any other
systemic symptoms aside from slightly irregular periods over the last few months. On
examination, she is able to express a small amount of discharge, which is sent to the
laboratory and found to be consistent with breast milk but without any signs of blood or
,pus. Screening laboratories are also sent, which reveal a normal blood count, metabolic
panel, thyroid-stimulating hormone, and human chorionic gonadotropin (HCG) level.
Further laboratories are still pending. Which of the following is the most likely diagnosis?
- -ANS☑️☑️--Prolactinoma
Rationale: Prolactinomas are pituitary tumors that secrete prolactin, which causes the
production of breast milk and can suppress menstruation. Mastitis is incorrect. Mastitis is
a breast infection that is typically painful and characterized by a focal area of redness and
tenderness in one breast. Ductal carcinoma in situ is incorrect. While nipple discharge
should raise suspicion for breast cancer, in this case the discharge is neither bloody nor
purulent, and it is notably bilateral. A prudent provider may still order a mammogram
and/or ultrasound, but the -ANS☑️☑️- is unlikely to be breast cancer. Paget disease of
the breast is incorrect. This condition may present with nipple discharge, but it is usually
bloody. Occult pregnancy is incorrect. This patient has a negative HCG test, which is the
standard hormonal laboratory examination used to determine pregnancy in both urine
and serum tests.
CHAPTER 18: Breasts and Axillae
A 42-year-old female website developer presents for an annual preventive examination
with questions about breast cancer screening. She is concerned about the radiation
exposure associated with mammography and is interested in magnetic resonance imaging
(MRI) as a possible alternative for routine screening. She is otherwise healthy with no
family history of breast, ovarian, or colon cancer. Which of the following is true about
MRI as a screening modality for breast cancer in the general population? - -ANS☑️☑️--
Sensitivity of screening for breast cancer increases with breast MRI at the expense of
specificity.
Sensitivity of screening for breast cancer increases with breast MRI at the expense of
specificity. Increased sensitivity (in this case, higher-resolution imaging to pick up subtler
disease) is often traded for reduced specificity (in the form of discovering many small
items of no pathological significance). This is a core concept in designing screening tests—
very sensitive tests often pick up false positives, while very specific tests often rule out
disease effectively by missing many actual cases. Balance must be sought between these
two when setting thresholds for positive and negative screens. Breast cancer screening by
MRI has been well studied in the general population is incorrect. This screening modality
, has only been studied in high-risk populations. This patient is an ideal candidate for
screening via breast MRI based on current evidence is incorrect. This patient meets no
known criteria for screening with breast MRI (known BRCA mutation, history of chest
radiation, etc.). Women at low lifetime risk of breast cancer (<20%) are recommended
to undergo screening MRI is incorrect. Only women at high lifetime risk (>20%) are
current recommended to utilize breast MRI as a screening tool. Known BRCA1 or BRCA2
mutation is insufficient criteria to justify screening with breast MRI is incorrect. The
BRCA1 or BRCA2 mutation confers a risk >20% of breast cancer over a lifetime, which is
considered sufficient criteria for screening with MRI rather than mammogram.
CHAPTER 18: Breasts and Axillae
A 44-year-old female mathematician presents to clinic with a complaint of a mass in the
right breast. Her partner noticed this mass 2 days ago, and the patient feels guilty
because she has only had one mammogram and does not engage in breast self-
examination (BSE) on any regular basis. She has no family history of breast cancer, and
her prior mammogram was ordered as a routine screening test at age 43 years after a
brief discussion with her primary care provider. After a thorough investigation reveals a
benign cyst, what advice should be given to this patient about screening for breast cancer
in her age group? - -ANS☑️☑️--c. This patient was in compliance with the U.S.
Preventive Services Task Force (USPSTF) recommendations for her age group and risk
factors prior to her current complaint.
This patient was in compliance with the USPSTF recommendations for her age group and
risk factors prior to her current complaint. The USPSTF recommends that women age
<50 years discuss risks and benefits with their provider and decide on appropriate
screening for their individual preferences and needs. These recommendations are
controversial and likely to change again over time, but they are underpinned by one key
issue: Mammograms have low sensitivity and specificity in younger women with higher
levels of estrogen, which keeps breast tissue dense and obscures lesions. This patient
should be reassured that her decision not to screen further was well reasoned and did
not lead to morbidity in her case. BSE is well evidenced, and all recommending agencies
agree that it should be taught and reinforced is incorrect. BSE is also extremely
controversial and may lead to high rates of invasive testing for finding that are not
malignant. Recommending agencies disagree greatly on this particular screening
modality. CBE is superior to self breast examination and should be a routine part of
FINAL EXAMS WITH RATIONALES
A 24-year-old graphic designer presents to clinic with a concern for a breast mass. A
rubbery, mobile, nontender mass is palpated in the right breast as described by the
patient, which is consistent with a firbroadenoma. In describing the location of the mass,
the examiner notes that it is 3 cm proximal to and 3 cm to the left of the nipple. Which
of the following would be the most appropriate way to report this finding? - -ANS☑️☑️-
-"Rubbery, mobile, nontender mass located in right breast, in the 10:30 position from the
nipple"
Breast findings can be described by quadrant or by position on a clock face, with 12
o'clock at the superior edge of the breast and the nipple at the center of the clock. The
10:30 position meets this patient's description of a mass in the right breast that is
proximal and to the left of the nipple. "Rubbery, mobile, nontender mass located in right
breast, in the lower outer quadrant" is incorrect. Though description by quadrant is
common, this mass would be found in the upper outer quadrant. "Rubbery, mobile,
nontender mass located in right breast, in the upper inner quadrant" is incorrect as
above. "Rubbery, mobile, nontender mass located in the left breast, upper outer
quadrant" is incorrect. This mass is in the right, not left, breast—just a reminder that
precision is key in record keeping. "Rubbery, mobile, nontender mass located in right
breast, in the 1:30 position from the nipple" is incorrect. The 1:30 position describes a
mass that is 3 cm proximal and 3 cm to the right of the nipple, rather than 3 cm
proximal and 3 cm to the left to the nipple.
CHAPTER 18: Breasts and Axillae
A 22-year-old G0P0 undergraduate student presents to clinic after finding a breast mass
on breast self-examination (BSE) at home. The mass is nontender without skin changes,
erythema, or overlying swelling. She has heard that most breast cancers are found by
,patients themselves, and she is very concerned that she may have breast cancer. Which of
the following is true about BSE and self-detection of breast cancer? - -ANS☑️☑️--a. Most
masses that women find at home and bring to a provider's attention turn out to be
malignant.
Rationale: This patient is more likely to find a fibroadenoma than a cancer on self-
examination. In this patient's age range (15-25 years), palpable masses are most likely to
be benign fibroadenomas. Most masses that women find at home and bring to a
provider's attention turn out to be malignant is incorrect. About 11% of complaints of
breast masses turn out to be malignant, leaving the vast majority (89%) noncancerous.
The most likely breast mass this patient is likely to find in herself is an abscess
complicating underlying mastitis is incorrect. This patient has neither the symptoms of
mastitis (localized swelling/erythema/tenderness with generalized fever) nor the risk
factors for this condition (pregnancy and/or breastfeeding), making mastitis a very
unlikely diagnosis. Because of this patient's age, breast masses should not be pursued with
imaging and diagnosis because the risk of cancer is so low is incorrect. Though the risk of
cancer in this patient is low, the consequence of missing a cancer diagnosis is quite high;
for that reason, definitive diagnosis should be pursued for almost all breast masses.
Because of this patient's age, breast masses should not be pursued with imaging and
diagnosis because the risk of cancer is so low is incorrect. BSE suffers from notoriously
low sensitivity and specificity, making it a very controversial recommendation as it tends
to overestimate disease in healthy breasts and miss cancer in breasts with subtle disease.
CHAPTER 18: Breasts and Axillae
CHAPTER 18: Breasts and Axillae
A 35-year-old G0P0 woman presents to clinic with a complaint of bilateral nipple
discharge. This discharge started several weeks ago and has occurred at irregular intervals
since that time. She does not complain of local tenderness, redness, fever, or any other
systemic symptoms aside from slightly irregular periods over the last few months. On
examination, she is able to express a small amount of discharge, which is sent to the
laboratory and found to be consistent with breast milk but without any signs of blood or
,pus. Screening laboratories are also sent, which reveal a normal blood count, metabolic
panel, thyroid-stimulating hormone, and human chorionic gonadotropin (HCG) level.
Further laboratories are still pending. Which of the following is the most likely diagnosis?
- -ANS☑️☑️--Prolactinoma
Rationale: Prolactinomas are pituitary tumors that secrete prolactin, which causes the
production of breast milk and can suppress menstruation. Mastitis is incorrect. Mastitis is
a breast infection that is typically painful and characterized by a focal area of redness and
tenderness in one breast. Ductal carcinoma in situ is incorrect. While nipple discharge
should raise suspicion for breast cancer, in this case the discharge is neither bloody nor
purulent, and it is notably bilateral. A prudent provider may still order a mammogram
and/or ultrasound, but the -ANS☑️☑️- is unlikely to be breast cancer. Paget disease of
the breast is incorrect. This condition may present with nipple discharge, but it is usually
bloody. Occult pregnancy is incorrect. This patient has a negative HCG test, which is the
standard hormonal laboratory examination used to determine pregnancy in both urine
and serum tests.
CHAPTER 18: Breasts and Axillae
A 42-year-old female website developer presents for an annual preventive examination
with questions about breast cancer screening. She is concerned about the radiation
exposure associated with mammography and is interested in magnetic resonance imaging
(MRI) as a possible alternative for routine screening. She is otherwise healthy with no
family history of breast, ovarian, or colon cancer. Which of the following is true about
MRI as a screening modality for breast cancer in the general population? - -ANS☑️☑️--
Sensitivity of screening for breast cancer increases with breast MRI at the expense of
specificity.
Sensitivity of screening for breast cancer increases with breast MRI at the expense of
specificity. Increased sensitivity (in this case, higher-resolution imaging to pick up subtler
disease) is often traded for reduced specificity (in the form of discovering many small
items of no pathological significance). This is a core concept in designing screening tests—
very sensitive tests often pick up false positives, while very specific tests often rule out
disease effectively by missing many actual cases. Balance must be sought between these
two when setting thresholds for positive and negative screens. Breast cancer screening by
MRI has been well studied in the general population is incorrect. This screening modality
, has only been studied in high-risk populations. This patient is an ideal candidate for
screening via breast MRI based on current evidence is incorrect. This patient meets no
known criteria for screening with breast MRI (known BRCA mutation, history of chest
radiation, etc.). Women at low lifetime risk of breast cancer (<20%) are recommended
to undergo screening MRI is incorrect. Only women at high lifetime risk (>20%) are
current recommended to utilize breast MRI as a screening tool. Known BRCA1 or BRCA2
mutation is insufficient criteria to justify screening with breast MRI is incorrect. The
BRCA1 or BRCA2 mutation confers a risk >20% of breast cancer over a lifetime, which is
considered sufficient criteria for screening with MRI rather than mammogram.
CHAPTER 18: Breasts and Axillae
A 44-year-old female mathematician presents to clinic with a complaint of a mass in the
right breast. Her partner noticed this mass 2 days ago, and the patient feels guilty
because she has only had one mammogram and does not engage in breast self-
examination (BSE) on any regular basis. She has no family history of breast cancer, and
her prior mammogram was ordered as a routine screening test at age 43 years after a
brief discussion with her primary care provider. After a thorough investigation reveals a
benign cyst, what advice should be given to this patient about screening for breast cancer
in her age group? - -ANS☑️☑️--c. This patient was in compliance with the U.S.
Preventive Services Task Force (USPSTF) recommendations for her age group and risk
factors prior to her current complaint.
This patient was in compliance with the USPSTF recommendations for her age group and
risk factors prior to her current complaint. The USPSTF recommends that women age
<50 years discuss risks and benefits with their provider and decide on appropriate
screening for their individual preferences and needs. These recommendations are
controversial and likely to change again over time, but they are underpinned by one key
issue: Mammograms have low sensitivity and specificity in younger women with higher
levels of estrogen, which keeps breast tissue dense and obscures lesions. This patient
should be reassured that her decision not to screen further was well reasoned and did
not lead to morbidity in her case. BSE is well evidenced, and all recommending agencies
agree that it should be taught and reinforced is incorrect. BSE is also extremely
controversial and may lead to high rates of invasive testing for finding that are not
malignant. Recommending agencies disagree greatly on this particular screening
modality. CBE is superior to self breast examination and should be a routine part of
