Download Zhejiang University Surgery Examination Paper B Student Name

Zhejiang University
Surgery Examination
Paper B
Student Name: _____________________
Student ID: ________________
Multiple choice questions
There are 100 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
1.
A 36-year-old woman complains of a 3-month history of bloody discharge from the nipple. At examination, a
small nodule is found, deep to the areola. Careful palpation of the nipple-areolar complex results in blood
arrearing at the 3 O’clock position. Mammogram findings are normal. What is the likeliest diagnosis?
A. Intraductal papilloma
B. Breast cyst
C. Intraductal carcinoma
D. Carcinoma in situ
E. Fat necrosis
2.
A 40-year-old woman presents with weight loss, palpitations, and exopthalmos. On physical examination, the
thyroid gland is diffusely enlarged. Blood tests reveal primary hyperthyroidism. Which one of the following is
not the treatment of hyperthyroidism?
A. Methimazoli
B. Lugols iodine
C. I131
D. Subtotal thyroidectomy
E. Steroids
3.
The following structures may be injured during surgery to repair an inguinal hernia:
A. The ilioinguinal, genitofemoral, iliohypogastric, and lateral femoral cutaneous nerves
B. The femoral nerve
C. The popliteal nerve
D. The nerve to the psoas major muscle
E. The pudendal nerve
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4.
A 28-year-old professional football player has sudden pain and swelling in the right groin when a attempting to
intercept a pass. He is admitted to the local emergency department. On examination, there is a tender swelling
in the right groin. The scrotum and penis show no abnormality. What is the next step in management?
A. Needle aspiration to exclude hematoma
B. Forceful manual reduction
C. Laparotomy within 20 minutes
D. Preoperative preparation and exploration of the groin with hernia repair
E. Morphine and reevaluation within 12 hours
5.
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
6.
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
7.
A 44-year-old dentist was admitted to the hospital with a 1-day history of hematemesis caused by a recurrent
duodenal ulcer. He has shown considerable improvement following operative treatment by a truncal vagotomy
and pyloroplasty, 10years prior to this incident. Which is TRUE of truncal vagotomy?
(A) It is performed exclusively via the thorax.
(B) It can be performed in the neck.
(C) If complete, it will result in increased acid secretion.
(D) It requires a gastric drainage procedure.
(E) It has been abandoned as a method to treat ulcer disease.
8.
A 63-year-old man has an upper gastrointestinal (UGI) study as part of his workup for abdominal pain. The
only abnormal finding was in the antrum, where the mucosa prolapsed into the duodenum. There were no
abnormal findings on endoscopy. What should he do?
(A) Sleep with his head elevated.
Page 2 Total page 27
(B) Be placed on an H2 antagonist.
(C) Undergo surgical resection if the antrum.
(D) Be observes and treated for pain accordingly.
(E) Have laser treatment of the antral mucosa.
9.
A 62-year-old man presents with guaiac positive stool. He is asymptomatic. Workup reveals a2-cm ulcerated
carcinoma on the antral lesser curvature. Tumor markers are negative. A CAT scan is negative for metastatic
disease and lymphadenopathy liver function tests are normal. What is the correct treatment for this patient?
(A) Chemotherapy only
(B) Radiation therapy only
(C) Combination chemotherapy and radiation therapy without resection
(D) Total gastrectomy
(E) Distal gastrectomy with en bloc removal of lymph nodes
10. A 63-year-old woman is admitted to the hospital with a UGI bleed that subsides spontaneously within a short
time after admission. A barium study shows a gastric ulceration that is described by the radiologist as having a
“doughnut sign”. What is the most likely diagnosis?
(A) Lipoma
(B) Gastric ulcer
(D) GIST
(C) Ectopic pancreas
(E) Carcinoma
11. 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
12. A 60-year-old woman complains of early satiety and undergoes an upper endoscopy. A small mass is seen in
the antrum with sparing of the mucosa. GIST is suspected. A CAT scan of the chest, abdomen, and pelvis is
performed. What does she require next?
(A) Fulguration of the tumor
(B) Distal gastrectomy
(C) Laser therapy following by radiation therapy
(D) Chemotherapy alone
(E) Total gastrectomy
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13. 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
14. Complication of diverticulitis include:
(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
15. A 60-year-old man undergoes sigmoid colectomy for cancer of the midsigmoid. Path specimen reveals the
following involvement. What is this patient’s stage?
(A) T1 N0 M0---stage I
(B) T2 N1 M0---stage II
(C) T3 N0 M0---stage III
(D) T1 N1 M0---stage III
(E) T2 N1 M0---stage III
16. 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?
(A) Diverticulosis of the colon
(B) Peptic ulcer disease
(C) Crohn’s disease
(D) Ulcerative colitis
(E) Carcinoma if the right colon
17. A 15-year-old female presents with RUQ abdominal pain. Workup reveals a choledochal cyst. Which of the
following statements is TRUE?
(A) Choledochal cysts are more common in men
(B)Laparoscopic cholecystectomy is the recommended treatment.
(C)Patients with a choledochal cyst have an increased risk of cholangiocarinoma.
(D)All patients with a choledochal cyst have abdominal pain, a RUQ mass, and jaundice.
(E)The etiology is infectious.
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18. 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 a 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
19. A 50-year-old woman underwent wide excision of a 2.5-cm infiltrating ductal carcinoma of the breast with
axillary lymph node dissection followed by radiation and chemotherapy 2years ago. The patients now
complains of RUQ abdominal pain. A CAT scan reveals two masses in the right lobe of the liver. Select the
most likely diagnosis.
(A)Adenoma
(B)Focal nodular hyperplasia
(C)Hemangioma
(D)Hepatocellular carcinoma
(E)Metastatic carcinoma
20. A 62-year-old man is admitted with abdominal pain and weight loss of 5Ib over the past month. He has
continued to consume large amounts of rum. Examination reveals ictericsclera. The idirect bilirubin level is
5.6mg/dL with a total bilirubin of 6 mg/ dL. An ultra-sound shows a 4-cm pseudocyst. What is the most likely
cause of jaundice in a patient with alcoholic pancreatitis?
(A)Alcoholic hepatitis
(B)Carcinoma of pancreas
(C)Intrahepatic cyst
(D)Pancreatic pseudocyst
(E)Hemolytic anemia
21. A70-year-old cigarette smoker presents with a right inguinal mass that has enlarged and has caused discomfort
in recent months. He complains of recent difficulty with micturition and nocturia, The swelling, which does
not extend to the scrotum, reduces when resting. What is the likely diagnosis?
(A)Directing inguinal hernia
(B)Strangulated indirect inguinal hernia
(C)Hydrocele
(D)Aneurysm of the femornal artery
(E)Cyst of the cord
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22. In repair of a femoral hernia, the structure most vulnerable to major injury lies:
(A)Medially
(B)Laterally
(C)Anteriorly
(D) Posteriorly
(E)Superficially
23. 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
24. 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
25. 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
26. 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
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E. Multiple endocrine neoplasia, type II
27. Which of the following is not a complication of carotid artery injury is:
A. Pseudoaneurysm
B. Subcutaneous hematoma
C. Mediastinal hematoma
D. Dyspnea
E. Air embolism
(Item 28 and 29)
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%.
28. 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
29. 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 ventilator support
E. Deep breathing and coughing
30. 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
Page 7 Total page 27
31. 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
32. 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?
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
33. A 36-year-old man presents with weight loss and a large palpable tumor in the upper abdomen. Endoscopy
reveal 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. Gastointestinal stromal tumor (GIST)
C. Choledochoduodenal fistula
D. Eosinophilic gastroenteritis
E. Linitis plastica
34. Which of the following structures would be encountered during repair of an inguinal hernia in a male?
A. Spermatic cord, cremaster muscle, transversalis fascia, deep epigastric vessels, conjoined tendon
B. Round ligament
C. Obturator nerve
D. Symphysis pubis
E. Nerve to the adductor muscles of the thigh
35. In repair of a femoral hernia, the structure most vulnerable to major injury lies:
A. Medially
B. Laterally
C. Anteriorly
D. Posteriorly
Page 8 Total page 27
E. Superficially
(Item 36 and 37)
A 16-year-old girl with a history of ulcerative colitis managed with steroid therapy presents to the emergency
department with a 36-hour history of nausea,crampy abdominal pain, and severe bloody diarrhea.On examination,
the patient is febrile and pale,with a blood pressure of 90/60 mmHg and heart rate of 130 beats/min. Her abdomen is
distended and diffusely tender. Acomplete blood count (CBC) demonstrates a leukocytosis with a left shift. The
patient receives IV fluid resuscitation and nasogastric(NG) tube decompression.
36. Further therapeutic interventions should include which one of the following?
(A) 6-mercaptopurine
(B) azathioprine
(C) opioid antidiarrheals
(D) colonoscopic decompression
(E) high-dose IV steroids and broad-spectrum antibiotics
37. After 48 hours, there is no clinical improvement.Which of the following is the most appropriate next step in
management?
(A) colonoscopic decompression
(B) cyclosporine
(C) abdominal colectomy and ileostomy and Hartmann’s procedure
(D) proctocolectomy with ileal pouch-anal anastomosis
(E) abdominal colectomy with ileorectal Anastomosis
(Item 38 and 39)
A 40-year-old previously healthy man presents with sudden onset of severe abdominal pain that radiates from the
right loin (flank) to groin. This pain is associated with nausea, sweating, and urinary urgency.He is distressed and
restless, but an abdominal examination is normal.
38. Which of the following is the most likely diagnosis?
(A) torsion of the right testicle
(B) pyelonephritis
(C) appendicitis
(D) right ureteral calculus
(E) acute urinary retention
39. Which of the following is the most appropriate next step in management?
(A) insertion of a urethral catheter
(B) IV fluid hydration, IV analgesics, and nonenhanced computed tomography(CT) scan
(C) IV fluid hydration, IV analgesics, and arrangements for lithotripsy
Page 9 Total page 27
(D) cystoscopy and retrograde pyelogram
(E) urine culture, followed by initiation of antibiotic therapy
40. A13-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 41 and 42)
A 65-year-old woman presents to the physician’s office with a 6-month history of epigastric discomfort, poor
appetite, and 10-lb weight loss. Past history is pertinent for hypertension, diabetes, a 30 pack-year smoking history,
and occasional alcohol intake. Examination is unremarkable except for mild epigastric tenderness to deep palpation.
An abdominal ultrasound reveals cholelithiasis, and one view of a UGI x-ray series is shown in Figure-1.
41. Which of the following is the most likely diagnosis?
(A) cholecystoenteric fistula
(B) duodenal ulcer
(C) gastric ulcer
(D) gastric diverticulum
(E) duodenal diverticulum
42. Which of the following is the most appropriate next step in management?
(A) H2 blockers with re-evaluation by UGI in 6 months
(B) vagotomy and pyloroplasty
(C) total gastrectomy
(D) endoscopy
(E) CT scan
Page 10 Total page 27
Figure-1
(Item 43 and 44)
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.
43. 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
44. 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
Page 11 Total page 27
45. A 55-year-old man presents to the emergency department at 5 a.m. complaining of vomiting blood. After binge
drinking last night, the patient began to vomit repeatedly. After a number of episodes, the patient noted blood
in the vomitus, followed by a melanotic stool 5 hours later. His past history is pertinent for ethanol abuse and a
40 pack-year smoking history.Vital signs reveal a BP of 100/60 mmHg,pulse rate of 95/min, respiratory rate of
12/min, and temperature of 97°F. Examination reveals a thin man with normal chest, cardiac, and abdominal
findings. Rectal examination reveals heme-positive stool. Laboratory data show normal electrolytes and a
hematocrit of 30. A chest x-ray is unremarkable. Volume resuscitation, gastric lavage, and NG tube
decompression are initiated. Which of the following is the most appropriate diagnostic test?
(A) barium esophagogram
(B) water-soluble contrast esophagogram
(C) esophagoscopy
(D) CT scan
(E) angiogram
(Item 46-48)
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 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.
46. 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
47. 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
48. Which of the following is the most appropriate next step in management?
(A) immediate laparotomy
Page 12 Total page 27
(B) nonoperative management with NG decompression and antibiotics
(C) fluid resuscitation
(D) administration of H2 blockers
(E) placement of a central venous line
(Itam 26 and 27)
A55-year-old man presents to the physician’s office complaining of upper abdominal pain of 2 months’ duration.
The pain is described as gnawing, localized to the upper midline, and associated with nausea.The pain is
exacerbated by food, and there is an associated 20-lb weight loss over 2 months. His past history is pertinent for a
30 pack-year smoking history, occasional alcohol intake, and a prior history of a benign gastric ulcer 5 years ago.
Physical examination reveals normal vital signs, mild epigastric pain with deep palpation, and mildly hemepositive
stool. An evaluation for recurrence of a gastric ulcer is recommended.
49. Which of the following tests is the most reliable method for diagnosing a gastric ulcer?
(A) UGI barium x-rays
(B) fiberoptic upper endoscopy
(C) CT scan
(D) endoscopic ultrasound
(E) MRI
50. In this patient, a benign gastric ulcer was found, and he was placed on a proton-pump inhibitor and triple
antibiotics for Helicobacter pylori. He returns to the physician’s office 3 months later with similar complaints
and, on re-evaluation, the gastric ulcer was found to persist. Which of the following is the most appropriate
next step in management?
(A) a second trial of proton-pump inhibitors with triple antibiotics and re-evaluation in 2 months
(B) a trial of H2 blockers with triple antibiotics and re-evaluation in 2 months
(C) a trial of sucralfate and re-evaluation in 2 months
(D) surgical management
(E) a trial of prostaglandins and re-evaluation in 2 months
(Item 51-53)
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 colonoscopic 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 4 weeks later was 15, and liver function tests
revealed a minimally elevated alkaline phosphatase, with normal transaminases and bilirubin.
51. Which of the following is the most appropriate diagnostic test in this patient?
(A) positron emission tomography (PET) scan
Page 13 Total page 27
(B) radionuclide liver scan
(C) ultrasound
(D) CT scan
(E) MRI scan
52. In your discussion with the patient regarding the risks and benefits of the different management options listed
above, which of the following values should you quote regarding the expected 5-year survival rate following
curative surgical resection?
(A) 5–10%
(B) 15–20%
(C) 25–35%
(D) 40–50%
(E) 60–70%
(Item 53 and 54)
A 62-year-old woman presents to the physician’s office with complaints of constipation. She has had constipation
for the last 6 months, which has worsened over the last month, associated with mild bloating. She noted that her
stool has become “pencil thin” in the last month, with occasional blood, but she continues to have bowel
movements daily. Past history is unremarkable. Examination reveals normal vital signs and heart and lung
examination. Abdominal examination reveals mild fullness, especially in the lower quadrants. Rectal examination
shows no rectal masses, but the stool is hematest positive. Abarium xray is obtained, and one view is shown in
Figure-2.
53. Which of the following is the most likely diagnosis?
(A) Crohn’s disease
(B) ischemia with stricture
(C) rectal carcinoma
(D) sigmoid volvulus
(E) diverticulitis with colovesical fistula
54. Which of the following is the most appropriate next step in management?
(A) proctoscopy and passage of a rectal tube
(B) proctoscopy and biopsy
(C) colonoscopy
(D) endoscopic dilation of the stricture
(E) NPO, IV fluids, and antibiotics
Page 14 Total page 27
Figure-2
55. 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
(B) lymph node with abscess
(C) femoral artery aneurysm
(D) incarcerated indirect inguinal hernia
(E) incarcerated femoral hernia
56. A 64-year-old woman with arthritis is a chronic NSAID user. She develops severe epigastric pain and
undergoes an upper endoscopy. She is told that she has an ulcer adjacent to the pylorus. Which of the
following is TRUE about the pylorus?
Page 15 Total page 27
(A) It cannot be palpated at laparaotomy.
(B) It is not covered completely by omentum.
(C) It is a distinct anatomic entity that can be distinguished during laparotomy.
(D) It is a true physiologic sphincter.
(E) It is a site where cancer is rarely found.
57. A 30-year-old executive learns that he has duodenal ulcer. His gastroenterologist prescribes and outlines
medical therapy.The patient worries that if medical therapy fails he may need surgery. Which of the following
is the best indication for elective surgical therapy for duodenal ulcer disease?
(A) An episode of melena
(B) Repeated episodes of pain
(C) Pyloric outlet obstruction due to scar formation from an ulcer
(D) Frequent recurrences of ulcer disease
(E) Referral of pain to the back, suggestive of pancreatic penetration
58. A 42-year-old executive has refractory chronic duodenal ulcer disease. His physican 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
59. A 63-year-old woman is admitted to the hospital with severe abdominal pain of 3-hour duration. Abdominal
examination reveals board-like-rigid-ity, guarding, and rebound tenderness. Her blood pressure is 90/50mm Hg,
pluse 110bpm (beats per minute), and respiratory rate is 30 breaths per minute. After a thorough history and
physical, and initiation of fluid resuscitation, what diagnostic study should be performed?
(A) Supine abdominal x-rays
(B) Upright chest x-ray
(C) Gastrograffin swallow
(D) Computerized axial tomography (CAT) scan of the abdomen
(E) Abdominal sonogram
60. A-68-year-old man has been diagnosed with a benign ulcer on the greater curvature of her stomach, 5 cm
proximal to the antrum. After 3 months of standard medical therapy, she continues to have guaiac positive
stool, anemia, and abdominal pain with failure of the ulcer to heal. Biopsies of the gastric ulcer have not
identified a malignancy. The next step in management is which of the following?
(A) Treatment of the anemia and repeat all studies in 6 weeks
Page 16 Total page 27
(B) Endoscopy and bipolar electrocautery or laser photocoagulation of the gastric ulcer
(C) Admission of the patient for total parenteral nutrition (TPN), treatment of anemia, and endoscopic therapy
(D) Surgical intervention, including partial gastric resection
(E) Surgical intervention, including total gastrectomy
61. A 55-year-old school bus driver was diagnosed 3 months ago with an antral ulcer. He was treated for H. pylori
and continues to take a PPI. Repeat endoscopy demonstrates that the ulcer has mot healed. What is the next
treatment option?
(A) Treatment with H2 blockers
(B) Vagotomy alone without additional surgery
(C) Endoscopy and laser treatment of the ulcer
(D) Distal gastrectomy with gastroduodenal anastomosis (Billroth I)
(E) Elevating the head of the bed when asleep
62. A 55-year-old man complains of anorexia, weight loss, and fatique. A UGI study demonstrates an ulcerated
lesion at the incisura. Where is the incisura?
(A) Cardia
(B) Fundus
(D) Lesser curvature
(C) Greater curvature
(E) Gastrocolic ligament
63. A 74-year-old man presents with anorexia and self-limited hematemesis. During endoscopy a mass is
discovered and a biopsy is done. A hematopathologis diagnoses non-Hodgkin’s lymphoma. What is the
recommended therapy?
(A) Chemotherapy alone
(B) Immunotherapy
(C) Radiation and chemotherapy
(D) Surgery, radiation, and chemotherapy
(E) Surgery alone
64. A 50-year-old woman is diagnosed with multiple hyperplastic polyps in the stomach during endoscopy and
biopsy. How are these best treated?
(A) Total gastrectomy
(B) Partial gastrectomy
(C) Staged endoscopic removal after brushing for cytologic examination
(D) Ablation laser
(E) No treatment other than repeated endoscopy and multiple brush biopsies
65. A 78-year-old woman undergoes an uncomplicated minor surgical procedure under local anesthesia. At the
completion of the operation, she suddenly develops pallor, sweating, bradycardia, hypotension, abdominal pain,
and gastic distension. What is the next stem in management?
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(A) Rapid infusion of 3 L of Ringer’s lactate
(B) Digoxin
(C) Insertion of a nasogastric tube
(D) Morphine
(E) Neostigmine
66. 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
67. A recent immigrant to the United States has had persistent epigastric discomfort. He delays seeking treatment
because he could not afford to pay a doctor. He finally went to the emergency department and was referred to
an endo-scopist. A submucosal mass was seen and it was thought to be a GIST. The most common site of a
GIST is which of the following?
(A) Esophagus
(B) Stomach
(C) Jejunum
(D)Ileum
(E) Colon
68. A 67-year-old woman complains of paresthesias in the limbs. Examination shows loss of vibratory sense,
positional sense, and sense of light touch in the lower limbs. She is found to have pernicious anemia.
Endoscopy reveals an ulcer in the body of the stomach. What does she most likely have?
(A) Excess of vitamin B12
(B) Deficiency of vitamin K
(C) Cancer of the stomach
(D) Gastric sarcoma
(E) Esophageal varices
69. Ten years after diagnosis of total proctocolitis this patient undergoes colonoscopy and biopsy reveals
high-grade dysplasis in 2-10 specimens. What should the physician recommend?
(A) Pepeat colonoscopy in 1 year
(B) Increase steroid dosage
(C) Early repeat colonoscopy and biopsy area again
(D) Total proctocolectomy
(E) Resection of the involved segment
70. A patients CT scan reveals diverticulitis confine to the sigmoid colon. There is no associated peri-colic abscess.
What is best course of treatment?
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(A) Bowel rest, nasogastric suction, IV fluids, and broad spectrum antibiotics
(B) Urgent surgical resection
(C) Urgent surgical resection
(D) Diverting colostomy
(E) Ileostomy
71. 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
72. A 33-year-old woman is noted to have a Meckel’s diverticulum when she undergoes an emergency
appendectomy. The diverticulum is approximately 60 cm from the ileocecal valve and measures 2-3 cm in
length. What is the most common complication of Meckel’s diverticulum among adults?
(A) Bleeding
(B) Perforation
(D) Ulceration
(E) Carcinoma
(C) Intestinal
73. A-30-year-old male is diagnosed with Peutz-Jeghers syndrome. What findings is consistent with the diagnosis?
(A) Adenomas
(B) Hamartomas
(C) Adenomatous polyps
(D) Villoglandular polyps
(E) Villotubular polyps
74. A 65-year-old woman with a history of chronic constipation is transferred from a nursing home because of
abdominal pain and marked abdominal distention. On examination, her abdomen is found to be distended and
tender in the LLQ. What is the most likely diagnosis?
(A) Appendicitis
(B) Carcinoma of the colon
(C) Volvulus of the sigmoid colon
(D) Volvulus of the cecum
(E) Small-bowel obstruction
75. A 13- year- old female presenting with PUQ abdominal pain is suspected of having a choledochal cyst. Which
of the following studies would be least helpful in confirming the diagnosis in this case?
(A)Computed tomography (CT)scan
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(B)percutaneous transhepatic cholagiography
(C)Endoscopic retrograde cholangiopancreatography
(D)Magnetic resonance cholangiopancreatography (MRCP)
(E)Upper GI series
76. A 40-year-old patient with a history of trauma to the RUQ presents with RUQ pain, clinical jaundice, and
guaiac positive stools. Which one of the following studies would be most useful to confirm the patient’s
diagnosis?
(A)Abdominal ultrasound
(B)CT of the abdomen
(C)Angiography
(D)HIDA scan
(E)Diagnostic laparoscopy
77. 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
78. 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
79. 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
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(E)Splenic vein thrombosis
80. 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.
81. 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.
(E)The sac is congenital
82. 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.
83. Which of the following structures would be encountered during repair of an inguinal hernia in a male?
(A)Spermatic cord,, cremaster muscle, transversalis, fascia, deep epigastric vessels ,conjoined tendon
(B)Round ligament
(C)Obturator nerve
(D)Symphysis pubis
(E)Nerve to the adductor muscles of the thigh.
84. A middle-aged man is found to have a small pulsating mass at the level of the umbilicus during a routine
abdominal examination. What is the best initial test to establish the diagnosis?
(A)Aortography
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(B)Ultrasound
(C)Computed tomography(CT)
(D)Magnetic resonance imaging(MRI)
(E)Plain films of the abdomen
85. 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
86. A young basketball player develops an acute onset of subclavian vein thrombsis (effort thrombosis) after heavy
exercise. What is the next step in management?
(A)Active exercise of the limb
(B)Anti-inflammatory drugs
(C)Thrombolytic therapy
(D)Antibiotics
(E)First-rib resection
87. 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 88 and 89)
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.
88. The procedure of choice is
A Simple closure with omental patch
B Truncal vagotomy and pyloroplasty
C Antrectomy and truncal vagotomy
D Highly selective vagotomy
E Hemigastrectomy
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89. 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 mo 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 Rouxen-Y gastrojejunostomy
90. 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
91. 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
92. 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
93. 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
E. Duodenojejunostomy
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94. Which of the following would be expected to stimulate intestinal motility?
A. Fear
B. Gastrin
C. Secretin
D. Acetylcholine
E. Cholecystokinin
95. 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
96. 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 below is obtained (Figure-3). 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
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E. Surgical treatment, if indicated, should be delayed up to 3 mo to allow inflammation around the gastroesophageal
junction to subside
Figure-3
97. Which of the following statements regarding direct inguinal hernias is true?
A. They are the most common inguinal hernias in women
B. They protrude medially to the inferior epigastric vessels
C. They should be opened and ligated at the internal ring
D. They commonly protrude into the scrotal sac in men
E. They incarcerate more commonly than indirect hernias
98. 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
99. 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
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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
100. Correct statements regarding carcinoembryonic antigen (CEA) and colorectal tumors include which of the
following?
A. Elevated CEA is indicative of a tumor of gastrointestinal origin
B. A low CEA level after resection of a colon tumor is a poor marker of disease control
C. Ninety percent of colorectal tumors produce CEA
D. There is a high likelihood of liver involvement if the CEA level is high (greater than 100 ng/mL)
E. CEA levels are unusually low in cigarette smokers
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