WEEK 8 NR 509 ADVANCED HEALTH
ASSESSMENT FINAL EXAMS WITH
RATIONALES
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? - ANSWER-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
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? - ANSWER-"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 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? -
ANSWER-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 answer 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? -
ANSWER-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
ASSESSMENT FINAL EXAMS WITH
RATIONALES
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? - ANSWER-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
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? - ANSWER-"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 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? -
ANSWER-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 answer 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? -
ANSWER-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
