Download Zhejiang University Clerkship Examination

Zhejiang University Clerkship Examination
Examination Pattern: closed book
Examination Date: 2012-3-30
Examination Time: 10:00 Am-11:00pm
Student Name: _____________________
Student ID: ________________
Multiple choice questions
There are 50 questions in this section. Each question is followed by some choices marked A), B), C),
D) and E). You should decide on the best choice, and then mark the corresponding letter and
necessary information on Answer Sheet
(Item 1 and 2)
A 70-year-old man has undergone anterior resection for carcinoma of the rectum. He is extubated in the operating
room (OR). In the recovery room, he is found to be restless with an HR of 136 bpm and a BP of 144/80 mmHg.
ABG analysis on room air reveals ph. 7.24; PCO2, 60mm Hg; PO2, 54mmHg; HCO3, 25mEq/L; and SaO2, 90%.
1. The physiologic status can best be described as which of the following?
A. Respiratory alkalosis
B. Respiratory acidosis
C. Metabolic acidosis
D. Metabolic alkalosis
E. Combined respiratory and metabolic acidosis
2. Appropriate management for this patient should be which of the following?
A. To administer 40% oxygen by mask
B. Morphine, 2 mg IV
C. Ringer’s lactate, 250ml over 1 hour
D. Intubation and ventilatory support
E. Deep breathing and coughing
3.
A 65-year-old woman undergoes a lumpectomy and sentinel lymph node biopsy and is found to have a 5-mm
tubular cancer ER and PR positive and a negative sentinel lymph node. What adjuvant treatment should be
recommended?
A. Chemotherapy and radiation
B. Radiation treatment only
C. Hormonal therapy only
D. Radiotherapy and hormonal therapy
E. Partial breast irradiation
4.
After undergoing a left thyroid operation, a 42-year-old opera singer notes no change in speech, but she has
difficulty in singing high-pitched notes. Which nerve is most likely to be injured?
A. Recurrent laryngeal
B. Internal laryngeal
C. External laryngeal
D. Pharyngeal branch of vagus
E. Phrenic
5.
A 2-cm ulcer on the greater curvature of the stomach is diagnosed in a 70-year-old woman by a barium study.
Gastric analysis to maximal acid stimulation shows achlorhydria. What is the nest step in management?
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A. Antacids, H2 blockers, and repeat barium study in 6 to 8 weeks
B. Proton pump inhibitor (PPI) (e.g., omeprazole) and repeat barium study in 6 to 8 weeks
C. Prostoglandin E (misoprostol) and repeat barium study in 6 to 8 weeks
D. Immediate elective surgery
E. Upper endoscopy with multiple biopsies (at least 8 or 9) for the ulcer
6.
A 36-year-old man presents with weight loss and a large palpable tumor in the upper abdomen. Endoscopy
reveals an intact gastric mucosa without signs of carcinoma. Multiple biopsies show normal gastric mucosa. A
UGI study shows a mass in the stomach. At surgery, a 3-kg mass is removed. It is necessary to remove the left
side of the transverse colon. What is the most likely diagnosis?
A. Gastric cancer
B. Gastrointestinal stromal tumor (GIST)
C. Choledochoduodenal fistula
D. Eosinophilic gastroenteritis
E. Linitis plastic
7. In repair of a femoral hernia, the structure most vulnerable to major injury lies:
A. Medially
B. Laterally
C. Anteriorly
D. Posteriorly
E. Superficially
8.
A 13-year-old boy is brought to the emergency department at midnight with a 4-hour history of right scrotal
pain that was sudden in onset and associated with nausea and one episode of vomiting. On examination, he is
in obvious distress. He has mild right lower abdominal tenderness, and high-riding, tender right testes. CBC
and urinalysis are normal. Which of the following is the most appropriate next step in management?
(A) Admit the patient to the hospital and place him on bed rest
(B) Analgesics and a scrotal support
(C) Antibiotic therapy
(D) Schedule a testicular isotope scan
(E) Urgent surgical exploration
(Item 9 and 10)
A 39-year-old woman presents to the physician’s office for evaluation of a palpable nodule in the neck of 2 years’
duration. Her past history is pertinent for Hashimoto’s disease diagnosed 5 years ago, for which she takes thyroid
hormone. She has a history of low-dose chest irradiation for an enlarged thymus gland during infancy. On
examination, a 2.5-cm nodule is palpable in the left lobe of the thyroid and is firm and nontender.
9. Which of the following portions of her history increases the risk for thyroid cancer?
(A) Age group of 20–40 years
(B) Female gender
(C) low-dose irradiation during infancy
(D) Chronicity of the nodule
(E) Past history of Hashimoto’s disease
10. Which of the following is the most appropriate next step in her management?
(A) Ultrasound of the neck
(B) Thyroid scintiscan
(C) MRI of the neck
(D) CT scan of the neck and chest
(E) FNA of the nodule
(Item 11-13)
A 30-year-old man presents to the emergency department with sudden onset of severe epigastric pain and vomiting
3 hours ago. He reports a 6-month history of chronic epigastric pain occurring nearly every day and relieved by
antacids. On examination, he appears sweaty and avoids movement. Vital signs reveal a temperature of 100°F, BP
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of 100/60mmHg, pulse rate of 110/min, and respiratory rate of 12/min. The remainder of his examination reveals
diminished bowel sounds and a markedly tender and rigid abdomen. A chest x-ray and abdominal films reveal
pneumoperitoneum.
11. Which of the following is the most likely diagnosis?
(A) small-bowel obstruction
(B) Dead bowel
(C) Perforated colon carcinoma
(D) Perforated duodenal ulcer
(E) Perforated gastric ulcer
12. Which of the following is the most appropriate next diagnostic test?
(A) CT scan
(B) UGI water-soluble contrast study
(C) Lower GI water-soluble contrast study
(D) Abdominal ultrasound
(E) None of the above
13. Which of the following is the most appropriate next step in management?
(A) Immediate laparotomy
(B) nonoperative management with NG decompression and antibiotics
(C) Fluid resuscitation
(D) Administration of H2 blockers
(E) Placement of a central venous line
(Item 14-16)
A 65-year-old man presents to the physician’s office for his yearly examination. His past history is pertinent for a
40 pack-year smoking history and colon cancer 3 years ago for which he underwent a sigmoid colectomy. The most
recent colonoscopy follow-up 3 months ago was negative. His physical examination is normal. Laboratory results
show a normal CBC and electrolytes, markedly elevated cholesterol, and a CEA of 12 compared to values of less
than 5 obtained every 6 months since colectomy. A repeat CEA four weeks later was 15, and liver function tests
revealed a minimally elevated alkaline phosphatase, with normal transaminases and bilirubin.
14. Which of the following is the most appropriate diagnostic test in this patient?
(A) positron emission tomography (PET) scan
(B) Radionuclide liver scan
(C) Ultrasound
(D) CT scan
(E) MRI scan
15. The imaging studies demonstrate three lesions in the right hepatic lobe suspicious for metastatic disease, each
measuring 3–4 cm in diameter. There was no evidence of extrahepatic disease. Which of the following is the
most appropriate next step in management?
(A) Systemic chemotherapy
(B) Intra-arterial chemotherapy through the hepatic artery
(C) Surgical resection
(D) Radiation therapy to the liver
(E) Repeat imaging studies in 3 months to determine the growth rate of the disease
16. A 75-year-old woman is admitted to the hospital from a nursing home for abdominal pain and pneumonia. She
was noted to be short of breath with increasing cough for 2 days before admission. Treatment, consisting of
supplemental oxygen, IV antibiotics, and pulmonary toilet, is instituted, with improvement within 2 days. On
the third hospital day, her abdominal pain worsens. Examination reveals a mildly distended abdomen with
bowel sounds but no signs of peritonitis. Remainder of examination reveals a tender bulge in the medial left
thigh below the inguinal ligament. Gentle pressure causes more pain but does not change the size or shape of
the bulge. Abdominal films show a nonspecific bowel gas pattern. Laboratory analysis shows a WBC of
13,000, decreased from 18,000 at the time of admission. Which of the following is the most likely diagnosis?
(A) Incarcerated direct inguinal hernia
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(B) Lymph node with abscess
(C) Femoral artery aneurysm
(D) Incarcerated indirect inguinal hernia
(E) Incarcerated femoral hernia
17. A 45-year-old man complains of burning epigastric pain that wakes him up at night. The pain is relieved by
eating or using over-the-counter antacids and H2 blockers. Diagnosis is best confirmed by which of the
following?
(A) Urea breath test
(B) Serum gastrin levels
(C) Barium meal examination
(D) Upper endoscopy
(E) Upper endoscopy and biopsy
18. A 42-year-old executive has refractory chronic duodenal ulcer disease. His physician has suggested several
surgical options. The patient has chosen a parietal (highly selective) vagotomy instead of a truncal vagotomy
and antrectomy because?
(A) It results in a lower incidence of ulcer recurrence
(B) It benefits patients with antral ulcers the most
(C) It reduces acid secretion to a greater extent
(D) The complication rate is lower
(E) It includes removal of the ulcer
19. A 60-year-old woman undergoes vagotomy and pyloroplasty for duodenal ulcer disease. Gallstones are noted
at the time of the original operation. Eight days following surgery, she develops abdominal pain and right
upperquadrant tenderness. To determine if the gallbladder is the cause of her symptoms, she should undergo
which study?
(A) Supine x-ray
(B) Hepatobiliary scan (HIDA)
(C) Ultrasound
(D) Erect x-ray
(E) Cholangiogram
20. A 35-year-old man has known ulcerative colitis. Which of the following is an indication for total
proctocolectomy?
(A) Occasional bouts of colic and diarrhea
(B) Sclerosing cholangitis
(C) Toxic megacolon
(D) Arthritides
(E) Iron deficiency anemia
21. Complication of diverticulitis includes:
(A) Carcinoma of the colon
(B) Extraintestinal manifestations such as arthritis, iritis, and skin rashes
(C) Fistulisation to adjacent organs such as the bladder, with insueing colovesical fistula
(D) Artheriovenous fistulae of the intestine
(E) Sclerosing cholangitis
22. An elderly nursing home patient is brought to the hospital with recent onset of colicky abdominal pain,
distension and obstipation on examination, the abdomen is markedly distended and tympanitic. There is no
marked tenderness. Plain abdominal x-ray shows a markedly distended loop located mainly in the right upper
quadrant. The likely diagnosis is:
(A) Small-bowel obstruction
(B) Large-bowel obstruction
(C) Gallstone ileus
(D) Mesenteric vascular occlusion
(E) Sigmoid volvulus
23. A 70-year-old man presents with pallor and breathlessness on exertion. He does not complain of abdominal
pain. He has microcytic, hypochromic anemia. What is the most probable cause?
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(A) Diverticulosis of the colon
(B) Peptic ulcer disease
(C) Crohn’s disease
(D) Ulcerative colitis
(E) Carcinoma if the right colon
24. A 45-year-old man with hepatitis C undergoes an uneventful percutaneous liver biopsy. About 6-weeks later,
he complains of RUQ pain, is clinically jaundiced, with hemoglobin, of 9.2mg/dl and is fecal occult blood
positive. Which diagnosis best explains this patient’s symptoms?
(A)Hepatocellular carcinoma
(B)Chronic hepatitis C
(C)Colon carcinoma with liver metastasis
(D)Hemobilia
(E)Symptomatic cholelithiasis
25. A 40-year-old female alcoholic is suspected of having a hepatic mass. Percutaneous ultrasound-guided liver
biopsy is contraindicated in which of the following?
(A)Hepatocellular carcinoma
(B)Metastatic carcinoma
(C)Cirrhosis
(D)Hepatitis C
(E)Hepatic adenoma
26. A 40-year-old man with a history of alcohol consumption of 25-year duration is admitted with a history of a
6-Ib weight loss and upper abdominal pain of 3-weeks duration. Examination reveals fullness in the
epigastrium. His temperature is 99ºF, and his WBC count is 10,000. Which is the most likely diagnosis?
(A)Pancreatic pseudocyst
(B)Subhepatic abscess
(C)Biliary pancreatitis
(D)Cirrhosis
(E)Splenic vein thrombosis
27. A 58-year-old man with a 30-year history of alcoholism, and pancreatitis is admitted to the hospital with an
elevated bilirubin level of 5 mg/dl, acholic stools, and an amylase level of 600 U. Obstructive jaundice in
chronic pancreatitis usually results from which of the following?
(A)Sclerosing cholangitis
(B)CBD compression caused by inflammation
(C)Alcoholic hepatitis
(D)Biliary dyskinesia
(E)Splenic vein thrombosis
28. Following a motor vehicle accident a truck driver complains of severe abdominal pain. Serum amylase level is
markedly increased to 800U.Grey Turner’s sign is seen in the flanks. Pancreatic trauma is suspected. Which
statement is true of pancreatic trauma?
(A)It is mainly caused by blunt injuries
(B)It is usually an isolated single-organ injury.
(C)It often requires a total pancreatectomy.
(D)It may easily be overlooked at operation.
(E)It is proved by the elevated amylase level.
29. A 60-year-old male presents with an inguinal hernia of recent onset. Which of the following statements are
TRUE?
(A) The hernia is more likely to be direct than indirect
(B) Presents through the posterior wall of the inguinal canal, lateral to the deep inguinal ring.
(C)Is covered anteriorly by the transversal is fascia.
(D)Is more likely than a femoral hernia to strangulate.
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(E)The sac is congenital
30. A 62-year-old male presents with an irreducible swelling and severe pain in the left groin. He had a known
reducible hernia for 15years prior to this. He had a bowel movement while in the emergency room. At surgery,
a Richter’s hernia was found. Which of the following statements is TRUE?
(A)It presents lateral to the rectus sheath.
(B)It presents through the lumbar triangle.
(C)It present through the obturator
(D) It contains a Meckel’s diverticulum.
(E)It may allow normal passage of stool.
31. A 45-year-old woman undergoes cardiac catheterization through a right femoral approach.
Two months later, she complains of appearance of multiple varicosities. On examination, a bruit is heard over the
right groin. What is the most likely diagnosis?
(A)Femoral artery thrombosis
(B)Superficial venous insufficiency
(C)Arteriovenous (AV) fistula
(D)Pseudoaneurysm
(E)Deep vein insufficiency
32. A middle-aged man known to have peptic ulcer disease is admitted with upper gastrointestinal (GI)
bleeding .During his hospital stay, he develops DVT of the left lower extremity. What is the most appropriate
management?
(A)Anticoagulation
(B)Observation
(C)Thrombolytic therapy
(D)Inferior vena cava (IVC) filter
(E) Venous thrombectomy
33. A young patient sustains blunt trauma to his right knee that results in acute thrombosis of his popliteal
artery .Which tissue is most sensitive to ischemia?
(A)Muscle
(B)Nerve
(C)Skin
(D)Fat
(E)Bone
34. Evidence that a splenectomy might benefit a patient with immune (idiopathic) thrombocytopenic purpura (ITP)
includes
A. A significant enlargement of the spleen
B. A high reticulocyte count
C. Megakaryocytic elements in the bone marrow
D. An increase in the platelet count on cortisone therapy
E. Patient age of less than 5 years
35. What is the most common serious complication of an end colostomy?
A. Bleeding
B. Skin breakdown
C. Parastomal hernia
D. Colonic perforation during irrigation
E. Stomal prolapse
(Items 36–37)
A 45-year-old woman is explored for a perforated duodenal ulcer 6 h after onset of symptoms. She has a history of
chronic peptic ulcer disease treated medically with minimal symptoms.
36. The procedure of choice is
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A Simple closure with omental patch
B Truncal vagotomy and pyloroplasty
C Antrectomy and truncal vagotomy
D Highly selective vagotomy
E Hemigastrectomy
37. Six weeks after surgery, the patient returns complaining of postprandial weakness, sweating, light-headedness,
crampy abdominal pain, and diarrhea. The best management would be
A.Antispasmodic medications (e.g., Lomotil)
B.Dietary advice and counseling that symptoms will probably abate within 3 months of surgery
C.Dietary advice and counseling that symptoms will probably not abate but are not dangerous
D.Workup for neuroendocrine tumor (e.g., carcinoid)
E.Preparation for revision to Roux-en-Y gastrojejunostomy
38. A diagnosis of bleeding esophageal varices is made in this patient. Appropriate initial therapy would be
A.Intravenous vasopressin
B.Endoscopic sclerotherapy
C.Emergency portacaval shunt
D.Emergency esophageal transection
E.Esophageal balloon tamponade
39. Which of the following hernias follows the path of the spermatic cord within the cremaster muscle?
A. Femoral
B. Direct inguinal
C. Indirect inguinal
D. Spigelian
E. Interparietal
40. Which of the following colonic pathologies is thought to have no malignant potential?
A. Ulcerative colitis
B. Villous adenomas
C. Familial polyposis
D. Peutz-Jeghers syndrome
E. Crohn’s colitis
41. Laparoscopic cholecystectomy is indicated for symptomatic gallstones in which of the following conditions?
A. Cirrhosis
B. Prior upper abdominal surgery
C. Suspected carcinoma of the gallbladder
D. Morbid obesity
E. Coagulopathy
42. Operative planning and preoperative counseling for a patient with a rectal carcinoma can be best provided if
the patient is staged before surgery by
A. Rigid proctoscopy
B. Barium enema
C. MRI of the pelvis
D. CT scanning of the pelvis
E. Rectal endosonography
43. For a symptomatic partial duodenal obstruction secondary to an annular pancreas, the operative treatment of
choice is
A. A Whipple procedure
B. Gastrojejunostomy
C. Vagotomy and gastrojejunostomy
D. Partial resection of the annular pancreas
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E. Duodenojejunostomy
44. Which of the following would be expected to stimulate intestinal motility?
A. Fear
B. Gastrin
C. Secretin
D. Acetylcholine
E. Cholecystokinin
45. A 55-year-old man who is extremely obese reports weakness, sweating, tachycardia, confusion, and headache
whenever he fasts for more than a few hours. He has prompt relief of symptoms when he eats. These
symptoms are most suggestive of which of the following disorders?
A. Diabetes mellitus
B. Insulinoma
C. Zollinger-Ellison syndrome
D. Carcinoid syndrome
E. Multiple endocrine neoplasia, type II
46. Indications for operation in Crohn’s disease include which of the following?
A. Intestinal obstruction
B. Enterovesical fistula
C. Ileum–ascending colon fistula
D. Enterovaginal fistula
E. Free perforation
47. An upper GI series is performed on a 71-year-old woman who presented with several months of chest pain that
occurred when she was eating. The film lateral is obtained. Investigation reveals a microcytic anemia and
erosive gastritis on upper endoscopy. Which of the following statements about the patient’s condition is true?
A. It is congenital
B. The gastroesophageal junction is above the diaphragm
C. Ulceration, gastritis, and anemia are common
D. It usually is controlled by medical therapy
E. Surgical treatment, if indicated, should be delayed up to 3 months to
allow inflammation around the gastroesophageal junction to subside
48. Which statement concerning cholangitis is correct?
A. The most common infecting organism is Staphylococcus aureus
B. The diagnosis is suggested by the Charcot triad
C. The disease occurs primarily in young, immunocompromised patients
D. Cholecystostomy is the procedure of choice in affected patients
E. Surgery is indicated once the diagnosis of cholangitis is made
49. An 88-year-old man with a history of end-stage renal failure, severe
coronary artery disease, and brain metastases from lung cancer
presents with acute cholecystitis. His family wants “everything
done.” The best management option in this patient would be
A. Tube cholecystostomy
B. Open cholecystectomy
C. Laparoscopic cholecystectomy
D. Intravenous antibiotics followed by elective cholecystectomy
E. Lithotripsy followed by long-term bile acid therapy
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50.A 48-year-old man undergoes surgery for a chronic duodenal ulcer. The procedure is a truncal vagotomy
and which of the following?
A. Gastroenterostomy
B. Removal of the duodenum
C.Closure of the esophageal hiatus
D. Incidental appendectomy
E. No further procedure
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