Okay, let's tackle this question. The patient is a 60-year-old woman with blood-stained nipple discharge and a family history of breast cancer. The next best step is the key here. First, I need to recall the standard approach to such cases.

Nipple discharge can be caused by various things, but when it's blood-stained and there's a family history of breast cancer, it raises red flags. The immediate thought is to rule out breast cancer. The options probably include imaging studies like mammography, ultrasound, or MRI. Maybe a biopsy is an option too.

The core concept here is the workup for a suspicious breast lesion. The next step after presenting with these symptoms would be to perform imaging to assess the breast tissue. Mammography is often the first line for women over 40, especially with a family history. If there's a mass or microcalcifications, then a biopsy would be necessary. But the initial step is imaging.

Wait, the options aren't provided, but the correct answer is likely mammography. Let me check why other options would be incorrect. For example, if an option says "ultrasound first," that's not typically the first step in this age group. MRI is more sensitive but not the first line. Clinical exam alone isn't enough. So the correct answer is mammography.

Clinical pearl: Remember that mammography is the standard for evaluating breast cancer risk in this demographic. Family history increases the risk, so imaging is crucial. Also, blood-stained discharge is a red flag symptom for ductal carcinoma in situ or invasive cancer.

**Core Concept**
Nipple discharge with blood and a family history of breast cancer necessitates imaging to rule out ductal carcinoma in situ (DCIS) or invasive breast cancer. Mammography is the first-line diagnostic tool for evaluating suspicious breast lesions in postmenopausal women.

**Why the Correct Answer is Right**
Mammography (digital or 3D tomosynthesis) detects microcalcifications and architectural distortions often associated with DCIS or early invasive cancer. It is non-invasive, widely available, and standard for women over 40 with risk factors. Blood-stained discharge is a classic "red flag" for intraductal malignancy, requiring imaging before biopsy.

**Why Each Wrong Option is Incorrect**
**Option A:** "Clinical breast exam only" – Insufficient; imaging is mandatory for high-risk patients.
**Option B:** "Ultrasound first" – Ultrasound is secondary for characterizing masses, not initial screening in this age group.
**Option D:** "MRI" – MRI lacks specificity for calcifications and is reserved for high-risk screening or post-biopsy staging.

**Clinical Pearl / High-Yield Fact**
**Remember:** Blood-stained discharge in postmenopausal women is a red flag for breast cancer. Mammography is the gold standard for initial evaluation, not ultrasound or MRI. Never skip imaging in high-risk patients.

**Correct Answer: B. Mammography**

✓ Correct Answer: D. MRI