NR-509 Final Exam Study
Guide
1. 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: 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.
Rationale: The USPSTF recommends biennial screening
mammography for women aged 50 to 74 years. For women aged 40
to 49 years, the decision to start screening should be individualized.
This patient had a mammogram at age 43 after a discussion with
her provider, which is consistent with shared decision-making. She
has no family history and no other risk factors, so she was in
compliance with recommendations.
2. 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.
Rationale: Breast MRI is highly sensitive but has lower specificity
than mammography, leading to more false-positive results and
unnecessary biopsies. It is not recommended for routine screening
1
,in the general population, especially in women at average risk. It is
reserved for high-risk women (e.g., BRCA mutation carriers).
3. A 35-year-old GOPO 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: Bilateral nipple discharge that is consistent with breast
milk (galactorrhea) in a non-pregnant woman suggests
hyperprolactinemia. Prolactinoma is the most common cause of
galactorrhea. Other causes include medications, hypothyroidism,
and renal failure, but these have been ruled out by normal TSH and
metabolic panel. Irregular periods are also consistent with
hyperprolactinemia.
4. A 22-year-old GOPO undergraduate student presents to
clinic after finding a breast mass on breast self-examination
(BSE) at home. The mass is nontender without skin changes.
(Question incomplete in source)
Ans: [Incomplete in source]
Rationale: [Incomplete in source]
5. A 48-year-old female psychologist presents to clinic with
concerns about her breast cancer risk after an age-matched
cousin was recently diagnosed with this disease. This cousin
is the third family member on her father's side in as many
years to be diagnosed with breast cancer, including the
patient's own father, who had surgery and subsequent
2
,treatment 3 years ago for breast cancer. The patient has
little other knowledge of her family history, only that her
grandparents independently arrived from Eastern Europe
near the end of World War II and were among very few
members of their family that survived the war. The patient
has read about testing for the breast cancer genes (BRCA1
and BRCA2) and desires further information about whether
this would be appropriate for her. Which of the following is
true about this patient's indications for BRCA testing?
Ans: This patient carries several risk factors that together justify
BRCA testing.
Rationale: This patient has a strong family history of breast cancer,
including a father with breast cancer and multiple paternal relatives
affected. Male breast cancer and multiple affected family members
on the same side are red flags for hereditary breast and ovarian
cancer syndrome. BRCA testing is indicated when there is a
significant family history suggestive of a hereditary syndrome.
6. A 68-year-old former paleontologist presents to clinic with
concerns about her breast cancer risk. Her mother
developed the disease in her 50s and died from it in her 60s.
A younger cousin developed the disease a few years ago
before the age of 50 years, but this individual was not
tested for the BRCA1 and BRCA2 genes. In addition, the
patient suffered from lymphoma in her 20s and had
radiation to the chest. She did take hormone replacement
therapy for a few years before data emerged that this may
contribute to breast cancer risk. She has had several
abnormal mammograms in her 50s for persistently dense
breasts with subtle findings, but follow-up biopsies never
showed any malignant pathology. Which of the following is
true regarding magnetic resonance imaging (MRI) screening
of this patient?
Ans: Regardless of recommendations, the high sensitivity of breast
MRI comes at the expense of markedly decreased specificity (i.e.,
the ability to rule out disease in healthy breasts).
Rationale: Breast MRI is highly sensitive but has low specificity,
leading to many false positives. This patient has multiple risk factors
(family history, chest radiation, dense breasts), but MRI screening
must be balanced against the risk of unnecessary biopsies and
anxiety from false-positive results.
3
, 7. A 66-year-old female museum curator presents for a
routine annual examination. On examination, a notably
enlarged supraclavicular lymph node is appreciated on the
right side. The lymph node is nontender and feels firm and
rubbery. She denies any localized or systemic symptoms
such as breast lumps, fevers, or night sweats. She has been
taking conjugated estrogen tablets for 9 years since
menopause, though she has not taken progestin compounds
since she had a hysterectomy for heavy bleeding at age 45
years. Which of the following is true about this presentation
of lymphadenopathy?
Ans: Metastatic breast cancer cells may spread directly into the
infraclavicular and then supraclavicular nodes without first causing
notable changes in the axillary nodes.
Rationale: Breast cancer can spread via lymphatic channels to the
infraclavicular and supraclavicular nodes without involving the
axillary nodes first. A firm, nontender supraclavicular node in an
older woman is highly suspicious for malignancy, and breast cancer
is a common primary.
8. 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 fibroadenoma. 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"
Rationale: Breast masses are described using clock-face positions
relative to the nipple. The 10:30 position corresponds to the upper
outer quadrant of the right breast, which is the most common
location for fibroadenomas. This standardized description facilitates
communication and documentation.
9. A 54-year-old female dietician presents for a routine
annual examination. On review of systems, she reports that
she has had many breast findings over several years,
including one biopsy with normal pathology. She feels that
her breasts have become far less lumpy since she
4
Guide
1. 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: 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.
Rationale: The USPSTF recommends biennial screening
mammography for women aged 50 to 74 years. For women aged 40
to 49 years, the decision to start screening should be individualized.
This patient had a mammogram at age 43 after a discussion with
her provider, which is consistent with shared decision-making. She
has no family history and no other risk factors, so she was in
compliance with recommendations.
2. 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.
Rationale: Breast MRI is highly sensitive but has lower specificity
than mammography, leading to more false-positive results and
unnecessary biopsies. It is not recommended for routine screening
1
,in the general population, especially in women at average risk. It is
reserved for high-risk women (e.g., BRCA mutation carriers).
3. A 35-year-old GOPO 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: Bilateral nipple discharge that is consistent with breast
milk (galactorrhea) in a non-pregnant woman suggests
hyperprolactinemia. Prolactinoma is the most common cause of
galactorrhea. Other causes include medications, hypothyroidism,
and renal failure, but these have been ruled out by normal TSH and
metabolic panel. Irregular periods are also consistent with
hyperprolactinemia.
4. A 22-year-old GOPO undergraduate student presents to
clinic after finding a breast mass on breast self-examination
(BSE) at home. The mass is nontender without skin changes.
(Question incomplete in source)
Ans: [Incomplete in source]
Rationale: [Incomplete in source]
5. A 48-year-old female psychologist presents to clinic with
concerns about her breast cancer risk after an age-matched
cousin was recently diagnosed with this disease. This cousin
is the third family member on her father's side in as many
years to be diagnosed with breast cancer, including the
patient's own father, who had surgery and subsequent
2
,treatment 3 years ago for breast cancer. The patient has
little other knowledge of her family history, only that her
grandparents independently arrived from Eastern Europe
near the end of World War II and were among very few
members of their family that survived the war. The patient
has read about testing for the breast cancer genes (BRCA1
and BRCA2) and desires further information about whether
this would be appropriate for her. Which of the following is
true about this patient's indications for BRCA testing?
Ans: This patient carries several risk factors that together justify
BRCA testing.
Rationale: This patient has a strong family history of breast cancer,
including a father with breast cancer and multiple paternal relatives
affected. Male breast cancer and multiple affected family members
on the same side are red flags for hereditary breast and ovarian
cancer syndrome. BRCA testing is indicated when there is a
significant family history suggestive of a hereditary syndrome.
6. A 68-year-old former paleontologist presents to clinic with
concerns about her breast cancer risk. Her mother
developed the disease in her 50s and died from it in her 60s.
A younger cousin developed the disease a few years ago
before the age of 50 years, but this individual was not
tested for the BRCA1 and BRCA2 genes. In addition, the
patient suffered from lymphoma in her 20s and had
radiation to the chest. She did take hormone replacement
therapy for a few years before data emerged that this may
contribute to breast cancer risk. She has had several
abnormal mammograms in her 50s for persistently dense
breasts with subtle findings, but follow-up biopsies never
showed any malignant pathology. Which of the following is
true regarding magnetic resonance imaging (MRI) screening
of this patient?
Ans: Regardless of recommendations, the high sensitivity of breast
MRI comes at the expense of markedly decreased specificity (i.e.,
the ability to rule out disease in healthy breasts).
Rationale: Breast MRI is highly sensitive but has low specificity,
leading to many false positives. This patient has multiple risk factors
(family history, chest radiation, dense breasts), but MRI screening
must be balanced against the risk of unnecessary biopsies and
anxiety from false-positive results.
3
, 7. A 66-year-old female museum curator presents for a
routine annual examination. On examination, a notably
enlarged supraclavicular lymph node is appreciated on the
right side. The lymph node is nontender and feels firm and
rubbery. She denies any localized or systemic symptoms
such as breast lumps, fevers, or night sweats. She has been
taking conjugated estrogen tablets for 9 years since
menopause, though she has not taken progestin compounds
since she had a hysterectomy for heavy bleeding at age 45
years. Which of the following is true about this presentation
of lymphadenopathy?
Ans: Metastatic breast cancer cells may spread directly into the
infraclavicular and then supraclavicular nodes without first causing
notable changes in the axillary nodes.
Rationale: Breast cancer can spread via lymphatic channels to the
infraclavicular and supraclavicular nodes without involving the
axillary nodes first. A firm, nontender supraclavicular node in an
older woman is highly suspicious for malignancy, and breast cancer
is a common primary.
8. 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 fibroadenoma. 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"
Rationale: Breast masses are described using clock-face positions
relative to the nipple. The 10:30 position corresponds to the upper
outer quadrant of the right breast, which is the most common
location for fibroadenomas. This standardized description facilitates
communication and documentation.
9. A 54-year-old female dietician presents for a routine
annual examination. On review of systems, she reports that
she has had many breast findings over several years,
including one biopsy with normal pathology. She feels that
her breasts have become far less lumpy since she
4
