NR 509 - Final Exam Bate's Interactive Questions and Answers

NR 509 - Final Exam Bate's Interactive
Questions and Answers
A44-year-
oldfemalemathematicianpresentstoclinicwithacomplaintofamassintherightbreast.Herpart
nernoticedthismass2daysago,andthepatientfeelsguiltybecauseshehasonlyhadonemamm
ogramanddoesnotengageinbreastself-
examination(BSE)onanyregularbasis.Shehasnofamilyhistoryofbreastcancer,andherprior
mammogramwasorderedasaroutinescreeningtestatage43yearsafterabriefdiscussionwith
herprimarycareprovider.Afterathoroughinvestigationrevealsabenigncyst,whatadviceshou
ldbegiventothispatientaboutscreeningforbreastcancerinheragegroup?

a.BSEiswellevidenced,andallrecommendingagenciesagreethatitshouldbetaughtandreinf
orced.
b.Clinicalbreastexamination(CBE)issuperiortoBSEandshouldbearoutinepartofannualexa
minationsstartingatage30years.
c.ThispatientwasincompliancewiththeU.S.PreventiveServicesTaskF-
CORRECTANSWER-
c.ThispatientwasincompliancewiththeU.S.PreventiveServicesTaskForce(USPSTF)reco
mmendationsforheragegroupandriskfactorspriortohercurrentcomplaint.

A42-year-
oldfemalewebsitedeveloperpresentsforanannualpreventiveexaminationwithquestionsabo
utbreastcancerscreening.Sheisconcernedabouttheradiationexposureassociatedwithma
mmographyandisinterestedinmagneticresonanceimaging(MRI)asapossiblealternativeforr
outinescreening.Sheisotherwisehealthywithnofamilyhistoryofbreast,ovarian,orcoloncanc
er.WhichofthefollowingistrueaboutMRIasascreeningmodalityforbreastcancerinthegeneral
population?

a.BreastcancerscreeningbyMRIhasbeenwellstudiedinthegeneralpopulation.
b.SensitivityofscreeningforbreastcancerincreaseswithbreastMRIattheexpenseofspecificit
y.
c.ThispatientisanidealcandidateforscreeningviabreastMRIbasedoncurrentevidence.
d.Womenatlowlifetimeriskofbreastcancer(<20%)arerecommendedtoundergoscreeningM
RI.
e.KnownBRCA1orBRCA2mutationisinsufficientc-CORRECTANSWER-
b.SensitivityofscreeningforbreastcancerincreaseswithbreastMRIattheexpenseofspecificit
y.

A35-year-
oldG0P0womanpresentstoclinicwithacomplaintofbilateralnippledischarge.Thisdischarges
tartedseveralweeksagoandhasoccurredatirregularintervalssincethattime.Shedoesnotco
mplainoflocaltenderness,redness,fever,oranyothersystemicsymptomsasidefromslightlyirr
egularperiodsoverthelastfewmonths.Onexamination,sheisabletoexpressasmallamountof

,discharge,whichissenttothelaboratoryandfoundtobeconsistentwithbreastmilkbutwithouta
nysignsofbloodorpus.Screeninglaboratoriesarealsosent,whichrevealanormalbloodcount,
metabolicpanel,thyroid-
stimulatinghormone,andhumanchorionicgonadotropin(HCG)level.Furtherlaboratoriesare
stillpending.Whichofthefollowingisthemostlikelydiagnosis?

a.Mastitis
b.Ductalcarcinomainsitu
c.Pagetdiseaseofthebreast
d.Occultpregnancy
e.Prolactinoma-CORRECTANSWER-e.Prolactinoma

A22-year-
oldG0P0undergraduatestudentpresentstoclinicafterfindingabreastmassonbreastself-
examination(BSE)athome.Themassisnontenderwithoutskinchanges,erythema,oroverlyin
gswelling.Shehasheardthatmostbreastcancersarefoundbypatientsthemselves,andsheisv
eryconcernedthatshemayhavebreastcancer.WhichofthefollowingistrueaboutBSEandself-
detectionofbreastcancer?

a.Mostmassesthatwomenfindathomeandbringtoaprovider'sattentionturnouttobemalignan
t.
b.Thispatientismorelikelytofindafibroadenomathanacanceronself-examination.
c.Themostlikelybreastmassthispatientislikelytofindinherselfisanabscesscomplicatingund
erlyingmastitis.
d.Becauseofthispatient'sage,breastmassesshouldnotbepursuedwithimaginganddiagnosi
sbecausetheriskofcancerissolow.
e.BSEisuniversallyrecommendedbecauseofveryhighsensitivity-CORRECTANSWER-
b.Thispatientismorelikelytofindafibroadenomathanacanceronself-examination.

A48-year-
oldfemalepsychologistpresentstoclinicwithconcernsaboutherbreastcancerriskafteranage-
matchedcousinwasrecentlydiagnosedwiththisdisease.Thiscousinisthethirdfamilymember
onherfather'ssideinasmanyyearstobediagnosedwithbreastcancer,includingthepatient'so
wnfather,whohadsurgeryandsubsequenttreatment3yearsagoforbreastcancer.Thepatient
haslittleotherknowledgeofherfamilyhistory,onlythathergrandparentsindependentlyarrivedf
romEasternEuropeneartheendofWorldWarIIandwereamongveryfewmembersoftheirfamil
ythatsurvivedthewar.Thepatienthasreadabouttestingforthebreastcancergenes(BRCA1an
dBRCA2)anddesiresfurtherinformationaboutwhetherthiswouldbeappropriateforher.Whic
hofthefollowingistrueaboutthispatient'sindicationsforBRCAtesting?

a.HerfamiliallineageisirrelevanttoherriskofBRCAgenesand-CORRECTANSWER-
d.ThispatientcarriesseveralriskfactorsthattogetherjustifyBRCAtesting.

A68-year-
oldformerpaleontologistpresentstoclinicwithconcernsaboutherbreastcancerrisk.Hermoth
erdevelopedthediseaseinher50sanddiedfromitinher60s.Ayoungercousindevelopedthedis

,easeafewyearsagobeforetheageof50years,butthisindividualwasnottestedfortheBRCA1an
dBRCA2genes.Inaddition,thepatientsufferedfromlymphomainher20sandhadradiationtoth
echest.Shedidtakehormonereplacementtherapyforafewyearsbeforedataemergedthatthis
maycontributetobreastcancerrisk.Shehashadseveralabnormalmammogramsinher50sfor
persistentlydensebreastswithsubtlefindings,butfollow-
upbiopsiesnevershowedanymalignantpathology.Whichofthefollowingistrueregardingmag
neticresonanceimaging(MRI)screeningofthispatient?

a.NoagencyrecommendsbreastMRIforapatientsuchasthisone,whohasmoderatelybutnote
xtraordinaryriskfactorsforb-CORRECTANSWER-
c.Regardlessofrecommendations,thehighsensitivityofbreastMRIcomesattheexpenseofm
arkedlydecreasedspecificity(i.e.,theabilitytoruleoutdiseaseinhealthybreasts).

A66-year-
oldfemalemuseumcuratorpresentsforaroutineannualexamination.Onexamination,anotabl
yenlargedsupraclavicularlymphnodeisappreciatedontherightside.Thelymphnodeisnonten
derandfeelsfirmandrubbery.Shedeniesanylocalizedorsystemicsymptomssuchasbreastlu
mps,fevers,ornightsweats.Shehasbeentakingconjugatedestrogentabletsfor9yearssincem
enopause,thoughshehasnottakenprogestincompoundssinceshehadahysterectomyforhe
avybleedingatage45years.Whichofthefollowingistrueaboutthispresentationoflymphadeno
pathy?

a.Breastcanceralwayspresentswithaxillarylymphadenopathybecausethelymphaticsofthe
breastuniformlydrainintotheaxilla.
b.Supraclavicularnodesaregenerallyconsideredbenignandrequirenofurtherevaluationorfo
llow-up.
c.Supraclavicularnodesarefoundalongtheanterioredgeofthetrapeziusmuscleintheneck.
d.Firm,-CORRECTANSWER-
e.Metastaticbreastcancercellsmayspreaddirectlyintotheinfraclavicularandthensupraclavi
cularnodeswithoutfirstcausingnotablechangesintheaxillarynodes.

A24-year-
oldgraphicdesignerpresentstoclinicwithaconcernforabreastmass.Arubbery,mobile,nonte
ndermassispalpatedintherightbreastasdescribedbythepatient,whichisconsistentwithafirbr
oadenoma.Indescribingthelocationofthemass,theexaminernotesthatitis3cmproximaltoan
d3cmtotheleftofthenipple.Whichofthefollowingwouldbethemostappropriatewaytoreportthi
sfinding?

a."Rubbery,mobile,nontendermasslocatedinrightbreast,inthe10:30positionfromthenipple"
b."Rubbery,mobile,nontendermasslocatedinrightbreast,inthelowerouterquadrant"
c."Rubbery,mobile,nontendermasslocatedinrightbreast,intheupperinnerquadrant"
d."Rubbery,mobile,nontendermasslocatedintheleftbreast,upperouterquadrant"
e."Rubbery,mobile,nontendermasslocatedinrightbreast,inthe1:30positionfromthenipple"-
CORRECTANSWER-
a."Rubbery,mobile,nontendermasslocatedinrightbreast,inthe10:30positionfromthenipple"

, A54-year-
oldfemaledieticianpresentsforaroutineannualexamination.Onreviewofsystems,shereport
sthatshehashadmanybreastfindingsoverseveralyears,includingonebiopsywithnormalpath
ology.Shefeelsthatherbreastshavebecomefarlesslumpysincesheunderwentmenopause3
yearsago.Whichofthefollowingistrueregardingchangesinthebreastswithmenopause?

a.Transformationofbreaststoprimarilyfattytissuewithmenopausedecreasesthesensitivitya
ndspecificityofmammograms.
b.Estrogeninhormonereplacementtherapy(HRT)hasnoeffectonbreastdensityaftermenopa
use.
c.Glandulartissueofthebreastatrophieswithmenopause,primarilyduetodecreaseinthenum
beroflobules.
d.Breastdensityhasnogeneticcomponentandisentirelyduetoestrogendosefromendogenou
sandexogenoussourcesoverthelifetime.
e.Mammographyperformsmostpoorlyinthemenopausalandpostmenopa-
CORRECTANSWER-
c.Glandulartissueofthebreastatrophieswithmenopause,primarilyduetodecreaseinthenum
beroflobules.

Anoverweight26-year-
oldpublicservantpresentstotheEmergencyDepartmentwith12hoursofintenseabdominalpai
n,light-
headedness,andafaintingepisodethatfinallypromptedhertoseekmedicalattention.Shehas
astrongfamilyhistoryofgallstonesandisconcernedaboutthispossibility.Shehasnothadanyv
omitingordiarrhea.Shehadanormalbowelmovementthismorning.Herβ-
humanchorionicgonadotropin(β-
hCG)ispositiveattriage.Shereportsthatherlastperiodwas10weeksago.Hervitalsignsattriag
earepulse,118;bloodpressure,86/68;respiratoryrate,20/min;oxygensaturation,99%;andte
mperature,37.3ºCorally.Theclinicianperformsanabdominalexampriortoherpelvicexamand
,onpalpationofherabdomen,findsinvoluntaryrigidityandreboundtenderness.Whatisthemos
tlikelydiagnosis?

a.Rupturedtubal(orectopic)pregnancy
b.Acutecholecystitis
c.Rupturedappendix
d.Per-CORRECTANSWER-a.Rupturedtubal(orectopic)pregnancy

A63-year-
oldjanitorwithahistoryofadenomatouscolonicpolypspresentsforawellvisit.Basiclabsareperf
ormedtoscreenfordiabetesmellitusanddyslipidemia.Electrolytesandliverenzymeswereals
omeasured.Hislabsareallnormalexpectformoderateelevationsofaspartateaminotransfera
se,alanineaminotransferase,γ-
glutamyltransferase,andalkalinephosphataseaswellasamildlyelevatedtotalbilirubin.Hepre
sentsforafollow-
upappointmentandtheclinicianperformsanabdominalexamtoassesshisliver.Whichofthefoll
owingfindingswouldbemostconsistentwithhepatomegaly?