A 67-year-old woman comes to the physician for a 3-month history gradually worsening pain in her left knee. She describes the pain as dull and aching, worse in the evenings after a day of activity, and improves somewhat with rest. She has difficulty climbing stairs and reports stiffness in the morning that usually resolves within 15 minutes. There are no recent traumas or illness. On examination, her knee show bony enlargement and crepitus with movement. There is no significant warmth, erythema, or effusion noted. The joint range of motion is mildly reduced, particularly with flexion. Her hands show bony nodules at the distal and proximal interphalangeal joints. Radiographs reveal joint space narrowing and osteophyte formation. Which of the following is most likely to have prevented this patient’s condition?

A) Blood pressure management
B) Elimination of intense exercises
C) No specific preventive measures
D) Smoking cessation
E) Weight loss

A 54-year-old woman comes to the physician for a 7-month history of progressively worsening pain in her left hip. The pain is worse when she walks around the grocery store and the shopping street nearby her home. Otherwise she spends most of the day at home watching TV, and there’s less pain during this time. She has been smoking one pack of cigarettes daily for 30 years. She drinks two glasses of wine with dinner every evening. She is 5’2″ (162 cm) and 180 pounds (80 kg). HbA1c is 7.0%. Physical examination shows 5/5 strength in all four extremities, with slight pain elicited in the left hip on passive and active motion. She uses acetaminophen and ibuprofen to manage the pain, where the combination works to a moderate degree. Vitals are: temp 98.6 F, HR 80, RR 16, BP 150/90. Which of the following is most likely to have prevented this patient’s condition?

A) Alcohol cessation
B) Blood pressure management
C) Glycemic control
D) Reduced calorie diet
E) Smoking cessation

A 30-year-old  woman comes to the physician for a 1-day history of sharp left-sided chest pain. She describes the pain as increasing slightly with deep inspiration. One week ago she had mild coryza without fever. Physical examination shows no marked pain with palpation. Reaching behind the back and over the head does not worsen the pain. Serum creatine kinase is mildly elevated. She has no past medical history. Which of the following is the most likely explanation for this patient’s findings?

A) Costochondritis
B) Fibromyalgia
C) Mitral valve prolapse syndrome
D) Pleurodynia
E) Viral pleurisy

A 23-year-old man is brought to emergency following a fall from his motorbike in the woods. A radiograph of the left arm is shown.

A decrease in which of the following is most likely to be seen in this patient?

A) 5th finger flexion
B) Interosseous muscle movement
C) Thumb adduction
D) Thumb opposition
E) Wrist extension

A 12-year-old boy is brought to the physician by his mother for a 3-month history of increasingly awkward walking and intermittent hip pain. Physical examination shows an antalgic gait. He is 6’0″ and 190 pounds.

Which of the following is most likely to be seen in this patient?

A) Idiopathic avascular osteonecrosis
B) Increased unmineralized osteoid
C) Inflammation of the synovium
D) Poorly developed acetabulum
E) Posteroinferior displacement of the epiphysis

A 54-year-old man comes to the physician for a 6-month history of progressively worsening shortness of breath on exertion. Around 6 months ago, he began feeling extra “winded” while doing errands and walking around a local mall. The past few months, he feels fatigued walking up two flights of stairs in his house. There is no chest pain. He has no symptoms at rest. He takes no medications. He has been smoking one-half pack of cigarettes daily for 36 years. His HbA1c is 5.6%. Blood pressure is 128/75. An baseline ECG shows no abnormalities. A resting echocardiogram shows an ejection fraction of 55%. Which of the following is the next best step in management?

A) Ambulatory ECG monitor
B) Carotid duplex ultrasonography
C) Exercise ECG stress test
D) Exercise echo stress test
E) Measure serum troponins

A 17-year-old male comes to the clinic because of a 2-month history of aching pain in the front of his right knee. He says the pain worsens when she sits for long periods, such as during car rides, and when she goes up or down stairs. The pain is also triggered during squatting, especially while powerlifting. He denies any trauma, instability, swelling, locking, or catching of the knee. On physical examination, there is no effusion, erythema, or deformity. The knee has full range of motion. There is mild peripatellar tenderness and pain with patellar compression, but no tenderness over the tibial tuberosity or medial knee. Strength and neurovascular exams are normal. Which of the following is the most likely diagnosis?

A) Osgood-Schlatter disease
B) Patellar tendonitis
C) Patellar tendon rupture
D) Patellofemoral pain syndrome
E) Pes anserine bursitis

A 73-year-old woman comes to the physician because of several episodes of dizziness and near-syncope over the past week. She reports no chest pain but says she occasionally feels like she’s about to faint when getting up too quickly. Blood pressure is 120/85mm Hg. An ECG is shown. Which of the following is the most likely diagnosis and treatment?

A) First-degree block; observe
B) First-degree block; pacemaker
C) Mobitz type I (Wenckebach); observe
D) Mobitz type I (Wenckebach); pacemaker
E) Mobitz type II; observe
F) Mobitz type II; pacemaker
G) Third-degree block; observe
H) Third-degree block; pacemaker
I) Wolff-Parkinson-White; observe
J) Wolff-Parkinson-White; pacemaker

A 67-year-old man comes to the physician for a routine health maintenance visit. He has a history of well-controlled type II diabetes and hypertension. He’s a non-smoker. He received an influenza vaccine last fall and the Tdap booster 6 years ago. Physical exam and labs are unremarkable. Vitals are normal. The physician recommends vaccination as part of age-based preventive care. Which of the following is the most appropriate next step in management?

A) Influenza vaccine
B) PCV13 alone
C) PCV15 followed by PCV20 in 1 year
D) PCV20 or 21 alone
E) PPSV23 alone

A 60-year-old man comes to the physician for a health maintenance examination. He feels well and has no current complaints. He has a history of hypertension and mild hyperlipidemia, both of which are well-controlled with medication. He has no known history of cancer and is up to date on vaccinations. He reports smoking a pack of cigarettes daily from age 18 until now. He has not had any recent cough, weight loss, or hemoptysis. His last colonoscopy was at age 52 and was normal. He has no family history of colon, lung, or prostate cancer. BMI is 24. BP is 130/80. Which of the following is the most appropriate next step in preventive care for this patient?

A) Abdominal ultrasound
B) Colonoscopy
C) Fasting glucose testing
D) Low-dose CT of the chest
E) PSA testing