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NCAPA 31st Annual Recertification Exam Review Conference
Pre-Test
1. A 31-year-old male with a traumatic left sided hydrocele is found to have a solid testicular
mass. Routine evaluation of the mass is positive for malignancy. Serum alpha fetoprotein,
LDH and serum human chorionic gonadotropin levels are normal. Which of the following
is the most likely diagnosis?
a. testicular teratoma
b. nonseminomatous germ cell tumor
c. leydig cell testicular tumor
d. seminomatous germ cell tumor
2. Which of the following is not a risk factor for priapism?
a. Hepatitis C
b. Sickle cell disease
c. Cocaine use
d. PDE5 medications
3. Urinary tract infections are considered complicated in all but which of the following?
a. Nephrolithiasis
b. Male patients
c. Sexually active female
d. Diabetic patient
4. 65-year-old patient with scalp tenderness and jaw claudication develops ischemic optic
neuropathy. What is the best test to confirm the suspected diagnosis?
a. MRI of the brain with contrast
b. temporal artery biopsy
c. tonometry
d. erythrocyte sedimentation rate
e. CBC
5. What is the proper treatment for a Weber B bimalleolar ankle fracture with medial
mortise widening in a healthy 35 year old?
a. Open reduction internal fixation (ORIF)
b. Closed reduction, then weight bearing as tolerated in walking boot
c. Non weight bearing for 6 weeks, then resume activity
d. 50% partial weight bearing in a plaster cast
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NCAPA 31st Annual Recertification Exam Review Conference
Pre-Test
6. Tina Tanner is a 62 year old female with gradual loss of hearing in her right ear for more
than a year. Associated symptoms include right sided tinnitus and imbalance. After
performing a proper history and physical exam, you astutely decide to order an
audiogram. The audiogram reveals an asymmetric sensorineural hearing loss on the right
side. What is the next appropriate intervention?
a. Order a contrasted MRI of the internal auditory canals
b. Place the patient on a 12 day course of prednisone
c. Order a non-contrasted CT of the temporal bone
d. Start Meclizine 25mg TID for her imbalance
e. Advise the patient to utilize a right-sided hearing aid
7. An 82 year-old female presents with fatigue, poor appetite and signs of dementia.
Physical examination reveals her to be thin with normal vital signs. Her tongue is smooth
& red, and she has ataxia. Complete blood count shows anemia with an MCV of 109.
What is the most appropriate treatment for her condition?
a. Vitamin B12
b. Ferrous sulfate
c. Vitamin C
d. Folic acid
e. Vitamin D
8. An 80 year old female presents w/ R eye pain and injection she states began after “a rash
came up on my forehead.” Exam w/ fluorescein and Wood’s lamp reveals a dendriticappearing corneal lesion. What class of medications would be contraindicated in TX’ing
this condition?
a. Antivirals
b. Beta blockers
c. Steroids
d. Carbonic anhydrase inhibitors
e. NSAIDs
9. A 65 year-old male presents with fatigue worsening back and rib pain over the past few
months. A complete blood count shows anemia, and a chemistry panel reveals
hypercalcemia and an elevated creatinine. Plain films show lytic lesions in the ribs and
spine. What is the most appropriate diagnostic test to confirm the suspected diagnosis?
a. Lumbar puncture
b. Bone marrow biopsy
c. Ionized calcium level
d. MRI of the spine
e. 24-hour urine protein
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NCAPA 31st Annual Recertification Exam Review Conference
Pre-Test
10. Aspirin is acceptable for stroke prophylaxis in patients who have AF with CHADS Vasc
Score of three. T or F?
a. True
b. False
11. A 14-year-old boy with Marfan syndrome has the sudden onset of severe, tearing chest
pain. Thirty minutes later, blood pressure 60/40 mm Hg, pulse 140/min/regular. Which
of the following abnormalities on echocardiography is most suggestive of pericardial
tamponade?
a. Pericardial effusion
b. Diastolic collapse of right ventricle
c. Dilated right atrium
d. Calcification of aortic root
12. A 24-year-old female presents to your ER w/ complaints of R flank pain, anorexia,
vomiting and fever. UPT is negative, urine dip has leuks w/ numerous skin cells but no
blood/nitrites or organisms on gram stain. Labs are otherwise notable for leukocytosis of
19. She endorses pain when you hyperextend her R leg at the hip. What is the most likely
cause of her symptoms?
a. Pyelonephritis
b. Acute cholecystitis
c. Infected kidney stone
d. Retrocecal appendicitis
e. Gastroenteritis
13. A patient presents to the emergency department with acute onset of bilateral lower
extremity weakness, numbness in the perineal area, and incontinence of the bowels and
bladder. They have normal vital signs and are otherwise healthy. What is the most likely
diagnosis?
a. Herniated nucleus pulposus
b. Cauda equina syndrome
c. Spondylolisthesis
d. Sacroiliitis
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NCAPA 31st Annual Recertification Exam Review Conference
Pre-Test
14. A 18 year old female presents with 2-day history of unilateral, throbbing headache with
associated phonophobia and intermittant nausea. The patient says these types of
headaches have occurred in the past during her menstrual period. Your first-line
treatment of this patient’s current symptoms may include all of the following except:
a. NSAIDs
b. Beta-blockers
c. Triptan medication
d. Dihydroergotamine
15. A 54-year-old woman has been receiving intravenous antibiotics for 10 days in treatment
of pneumonia. She now has sharp anterior chest pain. EKG shows diffuse ST segment
elevation. White blood count is 33,000/microL with left shift. Which of the following is
the most likely diagnosis?
a. Pericarditis due to enterovirus
b. Aortic dissection
c. Purulent (bacterial) pericarditis
d. Acute myocardial infarction
16. The heart rate associated with a junctional rhythm is 40-60. T or F?
a. True
b. False
17. A 22 year-old male presents with a one-month history of fatigue, cough and night sweats.
Upon examination, you note a non-tender 2 cm right supraclavicular lymph node and
clear lung sounds bilaterally. Chest x-ray shows a widened mediastinum and no lung
infiltrates. Which of the following is most likely seen on lymph node biopsy results?
a. Plasma cells
b. Smudge cells
c. Reed-Sternberg cells
d. Granulomatous cells
e. Adenocarcinoma cells
18. A 13 year old male is failing the 8th grade. His teachers describe his as fidgety and
impulsive. He sometimes skips school and has been known throw desks when he is angry.
He has multiple suspensions for fighting, bringing a weapon to school, and stealing. What
is the most appropriate diagnosis?
a. Antisocial Personality Disorder
b. ADHD
c. Autism Spectrum Disorder
d. Conduct Disorder
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NCAPA 31st Annual Recertification Exam Review Conference
Pre-Test
19. A 57-year-old male complains of severe L eye pain after going into a movie theater. Visual
acuity is 20/35 OD & 20/100 OS. Associated symptoms include headache, N/V. The L eye
is injected, the cornea is steamy and the pupil is fixed & dilated. What finding would you
anticipate on exam?
a. Homonymous hemianopsia
b. Papilledema
c. Tonometry reading of 50 mmHg
d. Restricted downward gaze E. Retinal pallor with a cherry red spot
20. A 40 year old male rarely leaves his home and reports difficulty interacting with others.
He is scanning the room while talking and endorses command auditory hallucinations and
past visual hallucinations of aliens. He describes anxiety about his medication being
poisoned. He admits to problems being compliant with meds and in the past experienced
side effects while on Haldol. What would be the next appropriate treatment?
a. SSRI
b. Older generation antipsychotic
c. Atypical antipsychotic
d. Clozaril
21. A heart block means an artery is “blocked”. T or F?
a. True
b. False
22. The normal QRS complex should be below .20 seconds in width. T or F?
a. True
b. False
23. Which of the following types of involuntary movements is most suggestive of Parkinson’s
Disease?
a. Unilateral resting tremor
b. Bilateral action tremor
c. Clonic jerking movements
d. Choreiform movements
24. Identify the symptom that is least associated with bladder neck obstruction?
a. Hesitancy
b. Frequency
c. Strains to void
d. Double voiding
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NCAPA 31st Annual Recertification Exam Review Conference
Pre-Test
25. A 4 year old presents to the clinic with a fever to 104, sore throat, low appetite and
difficulty breathing. The family recently immigrated to the United States. He was
apparently fine yesterday. Mom says that she left him in his playroom for a few minutes
this morning and he seemed fine but over the last few hours, his condition has worsened.
On physical exam, the patient appears ill, is cyanotic, tachypneic and sitting upright with
his neck extended. He is drooling. His lung exam reveals wheezing and retractions. What
is the first step in the management of this patient?
a. Perform on oral exam and visualize the foreign body he swallowed
b. Immediate intubation and protection of his airway (Acute epiglottitis)
c. IV antibiotics
d. X-ray of the neck
26. A “delta wave” is associated with Brugadas Syndrome and is high risk? T or F?
a. True
b. False
27. All of the following are common injuries associated with an anterior shoulder dislocation
except:
a. AC joint separation
b. Bankart lesion
c. Hill Sachs lesion
d. Rotator cuff tear
28. In which skin disease is direct immunofluorescence helpful in making the diagnosis?
a. Vitiligo
b. Pyoderma gangrenosum
c. Bullous impetigo
d. Syphilis
e. Bullous pemphigoid
29. A 27 year old former swimmer presents to clinic with right shoulder pain that has
increased over several months after increasing upper body strengthening workouts. She
feels occasional clicking when she does certain movements and says the shoulder feels
“loose”. She has 5/5 strength and a positive O’Brien’s test. What is the likely diagnosis?
a. Rotator cuff tear
b. Adhesive capsulitis
c. Labral tear
d. proximal humerus stress fracture
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NCAPA 31st Annual Recertification Exam Review Conference
Pre-Test
30. Which of the following statements about conditions of the wrist and hand is inaccurate?
a. Heberden’s nodes and Bouchard’s nodes can both be symptoms of OA.
b. Certain scaphoid fractures may require up to 16 weeks of casting for adequate
healing.
c. The most common type of distal radius fracture is a Colles’ fracture.
d. Most metacarpal shaft fractures with malrotation can be treated nonoperatively.
31. Which is the most common skin cancer?
a. Basal cell carcinoma
b. Superficial spreading melanoma
c. Squamous cell carcinoma
d. Merkel cell carcinoma
e. Verrucous carcinoma
32. A 72-year-old female presents w/ difficulty swallowing solids - daughter reports foul odor
to her breath along with stating that she “coughs up bits of food sometimes.” She also has
a history of recent hospital admit for aspiration PNA. What underlying condition is likely
causing her dysphagia?
a. Achalasia
b. CVA w/ resultant neuromuscular dysfunction
c. ETOH’ism
d. Zenker’s diverticulum
e. Schatzki’s ring
33. A 23-year-old male, no PMH, presents to the emergency department with the sudden
onset of moderate to severe right-sided chest pain and shortness of breath. No trauma or
accident. His vital signs are normal. Physical exam reveals diminished breath sounds on
the right and hyper resonance. CXR reveals a loss of markings along the right lung
margins, involving about 10% of the lung space. The mediastinum has not shifted. What
is the most appropriate management plan?
a. Decompression of the chest by insertion of a large-bore intravenous catheter
into the right second intercostal space at the midclavicular line
b. Oxygen supplementation and close observation with bed rest
c. Pleurodesis
d. Wedge resection
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NCAPA 31st Annual Recertification Exam Review Conference
Pre-Test
34. A 24 year old sexually-active male presents w/ rapidly worsening injection and discharge
to both eyes failing outpatient conjunctivitis TX. Exam is notable for copious, thick
purulent discharge. A gram stain of the discharge might reveal what finding to help
confirm the expected pathogen?
a. Gram-negative diploccoci
b. Gram-positive cocci in clusters
c. Gram-negative rods
d. Nothing - this is likely chlamydia
e. Nothing - this is likely adenovirus
35. Which of the following tests should always be included in the initial evaluation of a
reproductive-aged patient with a history of abnormal uterine bleeding?
a. Endometrial sampling
b. Pelvic ultrasound
c. Thyroid stimulating hormone
d. Human chorionic gonadotropin
36. Alice Cooperton is a 35 year old with Type 1 diabetes mellitus. He has had multiple sets of
pressure equalization tubes in the past. He presents for an evaluation of chronic ear
drainage. He has been on multiple oral and topical antibiotics without improvement. His
physical exam reveals an inflamed retraction pocket in the pars flaccida with granulation
and keratinous debris. The most likely diagnosis is:
a. Malignant otitis externa
b. Chronic otitis media with a TM perforation
c. Chronic fungal otitis externa
d. Pars flaccida cholesteatoma
e. Bullous Myringitis
37. A 62-year-old man has the sudden onset of a cold, painful right arm. BP 112/64 mm Hg;
pulse 130/min/irregularly irregular. The right forearm and hand are pallid and cold. No
pulses are felt in the right arm or wrist. Which of the following is the most likely
diagnosis?
a. Brachial artery embolus
b. Subclavian steal syndrome
c. Polyarteritis nodosa
d. Sympathetic neurodystrophy
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NCAPA 31st Annual Recertification Exam Review Conference
Pre-Test
38. A 72-year old patient presents with complaints of “the worst headache of my life.” Review
of systems is positive for nausea. Physical exam is remarkable for elevated blood pressure
and lethargy. What is the most likely diagnosis?
a. Transient ischemic attack
b. Acute ischemic stroke
c. Intracerebral hemorrhage
d. Subarachnoid hemorrhage
39. What is the most common cause of recurrent erythema multiforme?
a. Syphilis
b. Varicella zoster
c. Herpes simplex
d. Tinea
e. Staphylococcal impetigo
40. A 4-year-old boy faints while running. Upon awakening, vital signs are normal. The
patient is alert and pink. Cardiac and neurologic exams are normal. Which of the
following is the most likely diagnosis?
a. Hypertrophic obstructive cardiomyopathy
b. 3rd degree atrioventricular block
c. Vasovagal syncope
d. Long QT interval syndrome
e. Congenital aortic valve stenosis
41. A 34 year old man with HIV has a CD4 count of 122. He goes swimming in a public pool,
and then subsequently develops a diarrheal illness. For what organism are you most
suspicious?
a. Legionella
b. Rotavirus
c. Cryptosporidium
d. Schistosoma
e. Trichinella
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NCAPA 31st Annual Recertification Exam Review Conference
Pre-Test
42. A 65-year-old woman complains of a 3-week history of pain and sense of weakness in her
neck, shoulders, and hip. She has a low-grade fever. Otherwise, she feels well and has no
other symptoms. Her eyelids and hands appear normal; she has no rashes. Her neck,
shoulder, and hips have full range of motion, and she has normal strength. Her
sedimentation rate is markedly elevated, but her creatine phosphokinase (CPK) is normal.
The following best matches her clinical syndrome or disease:
a. Takayasu’s arteritis
b. Polymyalgia rheumatica (PMR)
c. Wegener’s granulomatosis (WG)
d. Henoch-Shönlein purpura (HSP)
e. Behçet’s syndrome
43. A 44 year old woman presents to clinic with a two week history of a maculopapular rash
on the torso, arms and legs, including the palms and soles. The patient also complains of
joint pain. Generalized lymphadenopathy is found on physical exam. Which test will help
you rule out the disease for which you should be most concerned, given this scenario?
a. anti-nuclear antibody
b. fluorescent treponemal antibody
c. nucleic acid test for gonorrhea
d. complete blood count
e. acid fast staining
44. A 64-year old female with a recent diagnosis of light chain dominant multiple myeloma is
admitted for a confirmed pulmonary embolism as seen on CT scan of the chest with IV
contrast. The day after admission, her serum BUN is 22mg/dL and creatinine is 1.3mg/dL
(which increased from the admission labs of BUN of 19mg/dL and creatinine level of
0.6mg/dL. The fractional excretion of sodium is calculated at >3.2%. Besides a mild
proteinuria, which of the following would most likely be seen on urinalysis?
a. dysmorphic red blood cells with some red blood cell casts
b. positive white blood cell casts
c. bland urine sediment with a high specific gravity
d. epithelial cell casts with a low specific gravity
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NCAPA 31st Annual Recertification Exam Review Conference
Pre-Test
45. Tyler Swift is a 22 year old male who experienced right ear pain after a flight to California.
He had a cold a few days before. Now the patient says he cannot hear in his right ear. On
exam, you note a blue/dull tympanic membrane on the right. What is the patient’s most
likely diagnosis?
a. Right sensorineural hearing loss
b. Left sensorineural hearing loss
c. Right conductive hearing loss
d. Left conductive hearing loss
e. Tympanic membrane perforation
46. A 28-year-old G2P2 SVD x two presents to the office with a three month history of “heavy
bleeding.” She states her menses will last 5-7 days, and describes the bleeding as heavy
enough to have to change tampons every hour during the first 2-3 days of her cycle. She
denies postcoital bleeding, dyspareunia, or pelvic pain. The patient does not currently use
any contraception. She takes no medication on a regular basis. Her PMH is
noncontributory. Her physical exam is unremarkable. Serum pregnancy test is negative,
and transvaginal ultrasound shows no structural abnormalities and a normal endometrial
thickness. Which of the following is the best choice for initial management?
a. Endometrial ablation
b. Intrauterine tamponade
c. Levonorgesterol-containing intrauterine system
d. Conjugated equine estrogen
47. A 50 year old male comes to you with complaints of severe headaches for the past two
years. He also mentions that his feet and hands are larger in size and his wedding ring no
longer fits. This patient is most likely to also complain of which of the following?
a. Constipation
b. Arthralgias and myalgias
c. Dry skin
d. Chest palpitations
48. A 12-year-old girl has anterior chest pressure radiating into her neck when playing soccer.
Symptoms end with 5 min of rest. Vital signs are normal. An apical lift and 3/6 ejection
murmur medial to the apex are noted. Which of the following is the most likely diagnosis?
a. Hypertrophic obstr. Cardiomyopathy
b. Mitral valve prolapse
c. Pre-excitation syndrome
d. Long QT interval syndrome
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NCAPA 31st Annual Recertification Exam Review Conference
Pre-Test
49. Gareth Brooks is a 54 year old man who presents for an evaluation of vertigo. Every few
weeks, the patient will experience severe vertigo associated with ringing in the left ear and
decreased hearing. What is the most appropriate first treatment for this condition?
a. Epley maneuvers
b. Meclizine 25mg three times a day
c. CT brain with contrast
d. Initiate a low salt diet
e. Start the patient on amlodipine 10mg daily
50. Dresslers syndrome is a form of coronary artery disease. T or F?
a. True
b. False
51. Pat Benicar is a 75 year old female who presents with momentary room-spinning vertigo
which occurs whenever she looks up or rolls over in bed. She denies hearing loss, tinnitus,
and ear fullness. What is the appropriate treatment?
a. Low salt diet, 1500-2000mg per day.
b. Meclizine 25mg TID
c. Prednisone, high dose x 12 days
d. Epley Maneuvers
e. Amoxicillin 500mg TID
52. Which of the following medications below is typically not included as a part of either triple
or quadruple therapy for peptic ulcer disease?
a. Amoxicillin
b. Lansoprazole
c. Carafate
d. Bismuth subsalicylate
e. Clarithromycin
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NCAPA 31st Annual Recertification Exam Review Conference
Pre-Test
53. A 65-year-old female, PMH of HTN, OA, and GERD presents to your clinic for hospital
follow up 1 week after her discharge following elective knee surgery. She is complaining of
cough and shortness of breath. Her post-surgical course required a 1 day stay in the ICU
due to a difficult extubation, but she quickly improved. Her total stay was 5 days and there
were no further complications. Today, she reports 2 days ago of temperature to 39.1°C
(102.4°F), a cough with sputum production, and shortness of breath. Her vital signs reveal
mild tachycardia and fever, but normal blood pressure. A CXR in your office reveals a LLL
infiltrate. What is the most likely cause of this patient’s symptoms?
a. C. pneumoniae
b. M. catarrhalis
c. Legionella species
d. P. aeruginosa
54. Which of the following is not classically associated with primary hyperaldosteronism?
a. Hypertension
b. Hyperkalemia
c. metabolic alkalosis
d. increased aldosterone to renin ratio >20
55. A 58-year-old male with a history of hypertension being treated with a thiazide diuretic
has sudden onset late one evening of severe pain in his left great toe. The pain is
accompanied by edema and redness, but there is no skin ulceration. There is no history of
trauma. A joint aspiration reveals numerous neutrophils. Over the next several weeks, he
has two more similar episodes. Which of the following laboratory test findings is most
characteristic for his underlying disease process?
a. elevated rheumatoid factor titer
b. hypercalcemia
c. hyperuricemia
d. positive antinuclear antibody (ANA)
56. A 67-year-old female presents with postmenopausal bleeding. Which of the following is
the most important condition to be considered in the differential diagnosis?
a. Endometriosis
b. Ovarian cancer
c. Endometrial cancer
d. Uterine leiomyoma
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NCAPA 31st Annual Recertification Exam Review Conference
Pre-Test
57. A 24 year old female reports decreased interest in hanging out with friends and difficulty
getting out of her bed. Her appetite has decreased and she struggles to stay focused at
work. Her symptoms worsened after her boyfriend left 8 months ago. She is sad, has
contemplated suicide, and has been cutting on her arm. Which diagnosis is most
appropriate?
a. Adjustment Disorder
b. Major Depressive Disorder
c. Persistent Depressive Disorder (Dysthymic Disorder)
d. Borderline Personality Disorder
58. A 12 year old girl presents to clinic with her mom, who wants her treated for "warts". On
physical exam, you see a small cluster of four lesions of the right forearm. The lesions are
round and smooth with a central depression. There appears to be a slight vascular
component to the papules. Which infecting agent do you suspect?
a. Varicella virus
b. Smallpox virus
c. Human papilloma virus
d. Coxsackie virus
e. Molluscum contagiosum virus
59. A 27 year old women comes to you with severe palpitations, 19 pounds (8.6 kg) weight loss
over the past two months, heat intolerance, irritability and nervousness. On physical
exam, she is found with a homogeneous large thyroid gland measuring 4 X 7 cm, mild
proptosis of the eyes, and no lid lag. Her vitals are as follow: HR 128 beats/minute, RR
24, BP 150/82. Which of the following labs will confirm your diagnosis?
a. TSH, free T4, and thyroglobulin level
b. TSH, Free T4, and Thyroid stimulating immunoglobulin (TSI)
c. TSH, Thyroid peroxidase antibody, and thyroglobulin antibody
d. TSH, free T4 and T4
60. An 11-year-old boy has coarctation of the aorta. An ejection click is heard at the apex.
Which of the following is the most likely cardiac diagnosis?
a. Mitral valve prolapse
b. Hypertrophic obstructive cardiomyopathy
c. Bicuspid aortic valve
d. Pulmonary valve stenosis
e. Ruptured chordae tendineae
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NCAPA 31st Annual Recertification Exam Review Conference
Pre-Test
61. The gold standard clinical exam special test for diagnosing an ACL tear is:
a. McMurray
b. Lachman
c. Posterior Drawer test
d. Valgus stress test at 0 degrees
62. You are seeing a 17 year old female for evaluation of irregular menstrual cycles. She also
complained of tiredness, fatigue, weight gain, dry skin and now constipation. Two
months ago she was diagnosed with attention deficit disorder and has been prescribed
Ritalin 10 mg daily to help her concentrate better in school. Of the following tests, which
will help you establish a diagnosis?
a. TSH, T3, and Thyroid peroxidase antibody levels
b. TSH, free T4, and thyroid peroxidase antibody levels
c. TSH, free T4 and thyroid stimulating immunoglobulin levels
d. TSH, free T4 and thyroglobulin levels
63. Johnny Beck is a 75 year old man who complains of hoarseness and ear pain for the past 3
months. Associated symptoms include pain when swallowing. What other finding would
you expect to find on examination?
a. Axillary lymphadenopathy
b. 25 pound weight gain compared with his last visit
c. Bulging right tympanic membrane
d. Normal laryngoscopy exam
e. Exophytic lesion on left true vocal cord
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