©THESTAR 2025 ALL RIGHTS RESERVED
AQUIFER FAMILY MEDICINE END OF
CASE EXAM QUESTIONS AND
ANSWERS 100% PASS
A 34-year-old woman who has no past medical problems nor is currently taking any
medications comes into your office because she noticed a tender lump in her left breast
starting approximately one month ago. She is worried because she has an aunt who had breast
cancer that was BRCA positive, though her mother is BRCA negative. Her periods have been
regular since they started at the age of 13 and occur every 32 days. She is currently
menstruating. She has three children aged 12, 9, and 4. On exam, her BMI is 32, up from 28
three years ago and her other vital signs are stable. On breast exam, you note a mobile rubbery
mass of approximately 1 x 1cm and with regular borders that is tender to palpation. You
appreciate no axillary adenopathy. The rest of her physical exam is unremarkable. Of the
information provided, which of the following places this patient at increased risk for breast
cancer?
A. Age
B. Weight
C. Parity - ANS The correct answer is B.
With a BMI of 32, obesity is the one risk factor for this patient based on the information given.
Other risk factors for breast cancer include family history of breast cancer in a first degree
relative (mother or sister - not aunt), prolonged estrogen exposure (menarche before age 12,
menopause after 45, advanced age at first pregnancy), genetic predisposition (BRCA 1 or 2
mutation), advanced age (breast cancer risk increases with age, and this patient is relatively
young), female sex, increased breast density and certain exposures (diethylstilbestrol, hormone
or radiation therapy, heavy smoking).
, ©THESTAR 2025 ALL RIGHTS RESERVED
A 64-year-old woman who is overweight with well-controlled hypertension comes to your office
complaining of a lump in her breast that she noticed while showering. She denies any pain,
tenderness, or skin changes. A pertinent review of systems is negative. Menarche began at the
age of 10. Her first child was born when she was 31 and she had her second and last child at the
age of 33. She experienced menopause at the age of 44. Her mother died of colon cancer when
she was 65 and her father passed away from metastatic prostate cancer at the age of 70. She
has no history of tobacco use ever and occasionally drinks a glass of wine with dinner. Her BMI
is 34. Which of the information provided thus far puts the patient at decreased risk for breast
cancer?
A. Age
B. Weight
C. Age at first birth
D. Age at menarche
E. Age at menopause - ANS The correct answer is E.
The patient experienced menopause at the age of 44, which shortens her time of estrogen
exposure, a known risk factor for the development of breast cancer. Factors associated with
decreased breast cancer risk include pregnancy at an early age, late menarche, early
menopause, high parity and medications such as selective estrogen receptor modulators along
with NSAIDs and aspirin. Risk factors for breast cancer include family history of breast cancer in
a first degree relative (mother or sister), prolonged estrogen exposure (menarche before age
12, menopause after 55, advanced age at pregnancy, obesity after menopause), female sex,
genetic predisposition (BRCA 1 or 2 mutation), advanced age (breast cancer risk increases with
age), increased breast density and exposures (diethylstilbestrol, hormone or radiation therapy,
smoking).
A 63-year old woman comes into your office for her annual preventive exam. She has
hypertension and type 2 diabetes. She is not sexually active. Her blood pressure is 125/80 and
her physical exam otherwise is within normal limits. You recommend influenza and zoster
vaccination. Her last colonoscopy was eight years ago and her last mammogram one year ago
was normal. She has never had an abnormal Pap smear. At the age of 45 she had a total
hysterectomy for fibroids. You tell her she does not require a Pap smear today because:
, ©THESTAR 2025 ALL RIGHTS RESERVED
A. She has never had an abnormal Pap smear
B. She is not sexually active
C. She had a total hysterectomy for fibroids
D. She is 63 years old
E. She experienced menopause more than 10 years ago - ANS The correct answer is C.
The patient described above underwent a total hysterectomy (total removal of the uterus and
cervix with or without oophorectomy) for benign reasons (fibroids). USPSTF guidelines
recommend against continued cervical cancer screening in patients whose uterus has been
removed for benign disease and evidence showed cytologic screening to be very low yield and
poor evidence that screening to detect vaginal cancers improves health outcomes in women
after hysterectomy for benign disease. Cervical cancer screening should begin at the age of 21
and women between the ages of 65 and 70 who have had three or more normal Pap tests in
the past ten years may choose to stop cervical cancer screening. Not being sexually active; age
63; only having had normal PAP smears and years since menopause are not reasons to stop
screening for cervical cancer.
A 47-year-old woman comes into your office for a health care maintenance exam. She has
hypertension and type 2 diabetes. She is not sexually active and has not yet experienced
menopause. There is no family history of cancer. Her blood pressure is 118/78, her BMI is 34
and the remainder of her physical exam is within normal limits. Her vaccinations are up-to-date,
she has a PAP smear today and will have labs drawn. According to USPSTF, which of the
following is the best recommendation to give her concerning mammography?
A. Should have started at age 40 and every year thereafter
B. Should have started at age 40 and every 2 years thereafter
C. Start at age 50 and every year thereafter
D. Start at age 50 and every 2 years thereafter
E. Should have started at age 45 and every year thereafter - ANS The correct answer is D.
, ©THESTAR 2025 ALL RIGHTS RESERVED
Mammography has a sensitivity of 60% to 90% for detecting breast cancer and decreases breast
cancer mortality. According to the most recent USPSTF guidelines, routine mammography is not
indicated for women younger than 50 years old except as based on patient context (history)
and beliefs about risks/benefits. The USPSTF recommends biennial testing for women between
the ages of 50 and 74. There is insufficient evidence to assess the benefits versus risk of
screenings in women after the age of 75. Other groups such as the American Cancer Society
(ACS) and American College of Obstetricians and Gynecologists (ACOG) recommend yearly
mammograms starting at age 40, continuing as long as the woman is in good health.
A 27-year-old woman comes into your office because she heard from her friend about a
vaccination against cervical cancer and would like one. She has no medical problems and has
had a Mirena IUD for three years. She has an allergy to latex and penicillin. She began having
sex at the age of 18 and is currently sexually active with one partner. She occasionally uses
condoms. She smokes half a pack of cigarettes per day. Her mother had endometrial cancer
several years ago and had a total hysterectomy. Why is the patient not an ideal candidate for
the Gardasil vaccination?
A. Age
B. Sexual activity
C. Mirena IUD
D. Allergy to penicillin
E. Tobacco use - ANS The correct answer is A.
Gardasil9 is a vaccination against 9 HPV types and is approved for females ages 9 to 26. While
the recommendation is to end at age 26, that does not mean it is dangerous; it just hasn't been
studied and will not likely be covered by insurance. Activity (B) is not a contraindication to
Gardasil vaccination. The other choices are not contraindications to vaccinations.
Which of the following is correct regarding breast self-examination? Choose the single best
answer.
A. Most women regularly perform breast self-examination.
AQUIFER FAMILY MEDICINE END OF
CASE EXAM QUESTIONS AND
ANSWERS 100% PASS
A 34-year-old woman who has no past medical problems nor is currently taking any
medications comes into your office because she noticed a tender lump in her left breast
starting approximately one month ago. She is worried because she has an aunt who had breast
cancer that was BRCA positive, though her mother is BRCA negative. Her periods have been
regular since they started at the age of 13 and occur every 32 days. She is currently
menstruating. She has three children aged 12, 9, and 4. On exam, her BMI is 32, up from 28
three years ago and her other vital signs are stable. On breast exam, you note a mobile rubbery
mass of approximately 1 x 1cm and with regular borders that is tender to palpation. You
appreciate no axillary adenopathy. The rest of her physical exam is unremarkable. Of the
information provided, which of the following places this patient at increased risk for breast
cancer?
A. Age
B. Weight
C. Parity - ANS The correct answer is B.
With a BMI of 32, obesity is the one risk factor for this patient based on the information given.
Other risk factors for breast cancer include family history of breast cancer in a first degree
relative (mother or sister - not aunt), prolonged estrogen exposure (menarche before age 12,
menopause after 45, advanced age at first pregnancy), genetic predisposition (BRCA 1 or 2
mutation), advanced age (breast cancer risk increases with age, and this patient is relatively
young), female sex, increased breast density and certain exposures (diethylstilbestrol, hormone
or radiation therapy, heavy smoking).
, ©THESTAR 2025 ALL RIGHTS RESERVED
A 64-year-old woman who is overweight with well-controlled hypertension comes to your office
complaining of a lump in her breast that she noticed while showering. She denies any pain,
tenderness, or skin changes. A pertinent review of systems is negative. Menarche began at the
age of 10. Her first child was born when she was 31 and she had her second and last child at the
age of 33. She experienced menopause at the age of 44. Her mother died of colon cancer when
she was 65 and her father passed away from metastatic prostate cancer at the age of 70. She
has no history of tobacco use ever and occasionally drinks a glass of wine with dinner. Her BMI
is 34. Which of the information provided thus far puts the patient at decreased risk for breast
cancer?
A. Age
B. Weight
C. Age at first birth
D. Age at menarche
E. Age at menopause - ANS The correct answer is E.
The patient experienced menopause at the age of 44, which shortens her time of estrogen
exposure, a known risk factor for the development of breast cancer. Factors associated with
decreased breast cancer risk include pregnancy at an early age, late menarche, early
menopause, high parity and medications such as selective estrogen receptor modulators along
with NSAIDs and aspirin. Risk factors for breast cancer include family history of breast cancer in
a first degree relative (mother or sister), prolonged estrogen exposure (menarche before age
12, menopause after 55, advanced age at pregnancy, obesity after menopause), female sex,
genetic predisposition (BRCA 1 or 2 mutation), advanced age (breast cancer risk increases with
age), increased breast density and exposures (diethylstilbestrol, hormone or radiation therapy,
smoking).
A 63-year old woman comes into your office for her annual preventive exam. She has
hypertension and type 2 diabetes. She is not sexually active. Her blood pressure is 125/80 and
her physical exam otherwise is within normal limits. You recommend influenza and zoster
vaccination. Her last colonoscopy was eight years ago and her last mammogram one year ago
was normal. She has never had an abnormal Pap smear. At the age of 45 she had a total
hysterectomy for fibroids. You tell her she does not require a Pap smear today because:
, ©THESTAR 2025 ALL RIGHTS RESERVED
A. She has never had an abnormal Pap smear
B. She is not sexually active
C. She had a total hysterectomy for fibroids
D. She is 63 years old
E. She experienced menopause more than 10 years ago - ANS The correct answer is C.
The patient described above underwent a total hysterectomy (total removal of the uterus and
cervix with or without oophorectomy) for benign reasons (fibroids). USPSTF guidelines
recommend against continued cervical cancer screening in patients whose uterus has been
removed for benign disease and evidence showed cytologic screening to be very low yield and
poor evidence that screening to detect vaginal cancers improves health outcomes in women
after hysterectomy for benign disease. Cervical cancer screening should begin at the age of 21
and women between the ages of 65 and 70 who have had three or more normal Pap tests in
the past ten years may choose to stop cervical cancer screening. Not being sexually active; age
63; only having had normal PAP smears and years since menopause are not reasons to stop
screening for cervical cancer.
A 47-year-old woman comes into your office for a health care maintenance exam. She has
hypertension and type 2 diabetes. She is not sexually active and has not yet experienced
menopause. There is no family history of cancer. Her blood pressure is 118/78, her BMI is 34
and the remainder of her physical exam is within normal limits. Her vaccinations are up-to-date,
she has a PAP smear today and will have labs drawn. According to USPSTF, which of the
following is the best recommendation to give her concerning mammography?
A. Should have started at age 40 and every year thereafter
B. Should have started at age 40 and every 2 years thereafter
C. Start at age 50 and every year thereafter
D. Start at age 50 and every 2 years thereafter
E. Should have started at age 45 and every year thereafter - ANS The correct answer is D.
, ©THESTAR 2025 ALL RIGHTS RESERVED
Mammography has a sensitivity of 60% to 90% for detecting breast cancer and decreases breast
cancer mortality. According to the most recent USPSTF guidelines, routine mammography is not
indicated for women younger than 50 years old except as based on patient context (history)
and beliefs about risks/benefits. The USPSTF recommends biennial testing for women between
the ages of 50 and 74. There is insufficient evidence to assess the benefits versus risk of
screenings in women after the age of 75. Other groups such as the American Cancer Society
(ACS) and American College of Obstetricians and Gynecologists (ACOG) recommend yearly
mammograms starting at age 40, continuing as long as the woman is in good health.
A 27-year-old woman comes into your office because she heard from her friend about a
vaccination against cervical cancer and would like one. She has no medical problems and has
had a Mirena IUD for three years. She has an allergy to latex and penicillin. She began having
sex at the age of 18 and is currently sexually active with one partner. She occasionally uses
condoms. She smokes half a pack of cigarettes per day. Her mother had endometrial cancer
several years ago and had a total hysterectomy. Why is the patient not an ideal candidate for
the Gardasil vaccination?
A. Age
B. Sexual activity
C. Mirena IUD
D. Allergy to penicillin
E. Tobacco use - ANS The correct answer is A.
Gardasil9 is a vaccination against 9 HPV types and is approved for females ages 9 to 26. While
the recommendation is to end at age 26, that does not mean it is dangerous; it just hasn't been
studied and will not likely be covered by insurance. Activity (B) is not a contraindication to
Gardasil vaccination. The other choices are not contraindications to vaccinations.
Which of the following is correct regarding breast self-examination? Choose the single best
answer.
A. Most women regularly perform breast self-examination.
