NR509 Final Exam| 88 Questions| With Complete Solutions
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?
a. BSE is well evidenced, and all recommending agencies agree that it should be taught
and reinforced.
b. Clinical breast examination (CBE) is superior to BSE and should be a routine part of
annual examinations starting at age 30 years.
c. This patient was in compliance with the U.S. Preventive Services Task Fo -
ANSWER-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.
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
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?
a. Breast cancer screening by MRI has been well studied in the general population.
b. Sensitivity of screening for breast cancer increases with breast MRI at the expense of
specificity.
c. This patient is an ideal candidate for screening via breast MRI based on current
evidence.
d. Women at low lifetime risk of breast cancer (<20%) are recommended to undergo
screening MRI.
e. Known BRCA1 or BRCA2 mutation is insufficient cr - ANSWER-b. Sensitivity of
screening for breast cancer increases with breast MRI at the expense of specificity.
Rationale: 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).
,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?
a. Mastitis
b. Ductal carcinoma in situ
c. Paget disease of the breast
d. Occult pregnancy
e. Prolactinoma - ANSWER-e. Prolactinoma
Rationale: Prolactinomas are pituitary tumors that secrete prolactin, which causes the
production of breast milk and can suppress menstruation.
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?
a. Most masses that women find at home and bring to a provider's attention turn out to
be malignant.
b. This patient is more likely to find a fibroadenoma than a cancer on self-examination.
c. The most likely breast mass this patient is likely to find in herself is an abscess
complicating underlying mastitis.
d. Because of this patient's age, breast masses should not be pursued with imaging and
diagnosis because the risk of cancer is so low.
e. BSE is universally recommended because of very high sensitivity - ANSWER-b. This
patient is more likely to find a fibroadenoma than a cancer on self-examination.
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.
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
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?
a. Her familial lineage is irrelevant to her risk of BRCA genes and - ANSWER-d. This
patient carries several risk factors that together justify BRCA testing.
Rationale: This patient has both a first-degree male relative with breast cancer and
several relatives in the same lineage with breast cancer. Both of these suggest risk for
the BRCA genes, but the BRCAPRO calculator can further refine the numerical risk and
help decide if screening might be helpful.
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?
a. No agency recommends breast MRI for a patient such as this one, who has
moderately but not extraordinary risk factors for br - ANSWER-c. 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: 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
health breasts). Sensitivity and specificity of screening test are almost always trade-offs;
that is, a test that picks up more true cases is also very likely to then pick up more false
positives, and vice versa.
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?
a. Breast cancer always presents with axillary lymphadenopathy because the
lymphatics of the breast uniformly drain into the axilla.
b. Supraclavicular nodes are generally considered benign and require no further
evaluation or follow-up.
c. Supraclavicular nodes are found along the anterior edge of the trapezius muscle in
the neck.
d. Firm, r - ANSWER-e. Metastatic breast cancer cells may spread directly into the
infraclavicular and then supraclavicular nodes without first causing notable changes in
the axillary nodes.
, Rationale: Metastatic breast cancer cells may spread directly into the infraclavicular and
then supraclavicular nodes without first causing notable changes in the axillary nodes.
Though axillary lymphadenopathy should be evaluated with age-appropriate imaging to
rule out breast cancer, cells that are metastasizing from the breasts can pass directly to
the infraclavicular, then supraclavicular nodes.
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?
a. "Rubbery, mobile, nontender mass located in right breast, in the 10:30 position from
the nipple"
b. "Rubbery, mobile, nontender mass located in right breast, in the lower outer
quadrant"
c. "Rubbery, mobile, nontender mass located in right breast, in the upper inner
quadrant"
d. "Rubbery, mobile, nontender mass located in the left breast, upper outer quadrant"
e. "Rubbery, mobile, nontender mass located in right breast, in the 1:30 position from
the nipple" - ANSWER-a. "Rubbery, mobile, nontender mass located in right breast, in
the 10:30 position from the nipple"
Rationale: 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.
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 underwent menopause 3 years ago. Which of the following is true
regarding changes in the breasts with menopause?
a. Transformation of breasts to primarily fatty tissue with menopause decreases the
sensitivity and specificity of mammograms.
b. Estrogen in hormone replacement therapy (HRT) has no effect on breast density after
menopause.
c. Glandular tissue of the breast atrophies with menopause, primarily due to decrease in
the number of lobules.
d. Breast density has no genetic component and is entirely due to estrogen dose from
endogenous and exogenous sources over the lifetime.
e. Mammography performs most poorly in the menopausal and postmenopau -
ANSWER-c. Glandular tissue of the breast atrophies with menopause, primarily due to
decrease in the number of lobules.
Rationale: Glandular tissue of the breast atrophies with menopause, primarily due to a
decrease in the number of lobules. The consequent decrease in breast density makes
mammograms ever more useful during the age when breast cancer incidence starts to
rise markedly.
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?
a. BSE is well evidenced, and all recommending agencies agree that it should be taught
and reinforced.
b. Clinical breast examination (CBE) is superior to BSE and should be a routine part of
annual examinations starting at age 30 years.
c. This patient was in compliance with the U.S. Preventive Services Task Fo -
ANSWER-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.
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
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?
a. Breast cancer screening by MRI has been well studied in the general population.
b. Sensitivity of screening for breast cancer increases with breast MRI at the expense of
specificity.
c. This patient is an ideal candidate for screening via breast MRI based on current
evidence.
d. Women at low lifetime risk of breast cancer (<20%) are recommended to undergo
screening MRI.
e. Known BRCA1 or BRCA2 mutation is insufficient cr - ANSWER-b. Sensitivity of
screening for breast cancer increases with breast MRI at the expense of specificity.
Rationale: 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).
,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?
a. Mastitis
b. Ductal carcinoma in situ
c. Paget disease of the breast
d. Occult pregnancy
e. Prolactinoma - ANSWER-e. Prolactinoma
Rationale: Prolactinomas are pituitary tumors that secrete prolactin, which causes the
production of breast milk and can suppress menstruation.
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?
a. Most masses that women find at home and bring to a provider's attention turn out to
be malignant.
b. This patient is more likely to find a fibroadenoma than a cancer on self-examination.
c. The most likely breast mass this patient is likely to find in herself is an abscess
complicating underlying mastitis.
d. Because of this patient's age, breast masses should not be pursued with imaging and
diagnosis because the risk of cancer is so low.
e. BSE is universally recommended because of very high sensitivity - ANSWER-b. This
patient is more likely to find a fibroadenoma than a cancer on self-examination.
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.
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
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?
a. Her familial lineage is irrelevant to her risk of BRCA genes and - ANSWER-d. This
patient carries several risk factors that together justify BRCA testing.
Rationale: This patient has both a first-degree male relative with breast cancer and
several relatives in the same lineage with breast cancer. Both of these suggest risk for
the BRCA genes, but the BRCAPRO calculator can further refine the numerical risk and
help decide if screening might be helpful.
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?
a. No agency recommends breast MRI for a patient such as this one, who has
moderately but not extraordinary risk factors for br - ANSWER-c. 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: 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
health breasts). Sensitivity and specificity of screening test are almost always trade-offs;
that is, a test that picks up more true cases is also very likely to then pick up more false
positives, and vice versa.
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?
a. Breast cancer always presents with axillary lymphadenopathy because the
lymphatics of the breast uniformly drain into the axilla.
b. Supraclavicular nodes are generally considered benign and require no further
evaluation or follow-up.
c. Supraclavicular nodes are found along the anterior edge of the trapezius muscle in
the neck.
d. Firm, r - ANSWER-e. Metastatic breast cancer cells may spread directly into the
infraclavicular and then supraclavicular nodes without first causing notable changes in
the axillary nodes.
, Rationale: Metastatic breast cancer cells may spread directly into the infraclavicular and
then supraclavicular nodes without first causing notable changes in the axillary nodes.
Though axillary lymphadenopathy should be evaluated with age-appropriate imaging to
rule out breast cancer, cells that are metastasizing from the breasts can pass directly to
the infraclavicular, then supraclavicular nodes.
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?
a. "Rubbery, mobile, nontender mass located in right breast, in the 10:30 position from
the nipple"
b. "Rubbery, mobile, nontender mass located in right breast, in the lower outer
quadrant"
c. "Rubbery, mobile, nontender mass located in right breast, in the upper inner
quadrant"
d. "Rubbery, mobile, nontender mass located in the left breast, upper outer quadrant"
e. "Rubbery, mobile, nontender mass located in right breast, in the 1:30 position from
the nipple" - ANSWER-a. "Rubbery, mobile, nontender mass located in right breast, in
the 10:30 position from the nipple"
Rationale: 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.
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 underwent menopause 3 years ago. Which of the following is true
regarding changes in the breasts with menopause?
a. Transformation of breasts to primarily fatty tissue with menopause decreases the
sensitivity and specificity of mammograms.
b. Estrogen in hormone replacement therapy (HRT) has no effect on breast density after
menopause.
c. Glandular tissue of the breast atrophies with menopause, primarily due to decrease in
the number of lobules.
d. Breast density has no genetic component and is entirely due to estrogen dose from
endogenous and exogenous sources over the lifetime.
e. Mammography performs most poorly in the menopausal and postmenopau -
ANSWER-c. Glandular tissue of the breast atrophies with menopause, primarily due to
decrease in the number of lobules.
Rationale: Glandular tissue of the breast atrophies with menopause, primarily due to a
decrease in the number of lobules. The consequent decrease in breast density makes
mammograms ever more useful during the age when breast cancer incidence starts to
rise markedly.
