Zhejiang University Clerkship Examination

ZhejiangUniversity Clerkship Examination

Examination Pattern: closed book

Examination Date:2012-3-30 Examination Time: 10:00Am-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%.

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

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

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

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

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

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

In repair of a femoral hernia, the structure most vulnerable to major injury lies:

A. Medially

B. Laterally

C. Anteriorly

D. Posteriorly

E. Superficially

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

(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.

Which of the following portions of her history increases the risk for thyroid cancer?

(A) Age group of 20–40 years

(B) Female gender

(D) Chronicity of the nodule

(E) Past history of Hashimoto’s disease

Which of the following is the most appropriate next step in her management?

(A) Ultrasound of the neck

(B) Thyroid scintiscan

(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 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.

Which of the following is the most likely diagnosis?

(A) small-bowel obstruction

(B) Dead bowel

(D) Perforated duodenal ulcer

(E) Perforated gastric ulcer

Which of the following is the most appropriate next diagnostic test?

(A) CT scan

(B) UGI water-soluble contrast study

(D) Abdominal ultrasound

(E) None of the above

Which of the following is the most appropriate next step in management?

(A) Immediate laparotomy

(B) nonoperative management with NG decompression and antibiotics

(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.

Which of the following is the most appropriate diagnostic test in this patient?

(A) positron emission tomography (PET) scan

(B) Radionuclide liver scan

(D) CT scan

(E) MRI scan

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

(D) Radiation therapy to the liver

(E) Repeat imaging studies in 3 months to determine the growth rate of the disease

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

(D) Incarcerated indirect inguinal hernia

(E) Incarcerated femoral hernia

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

(E) Upper endoscopy and biopsy

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

(D) The complication rate is lower

(E) It includes removal of the ulcer

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)

(E) Cholangiogram

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

(D) Arthritides

(E) Iron deficiency anemia

Complication of diverticulitis includes:

(A) Carcinoma of the colon

(B) Extraintestinal manifestations such as arthritis, iritis, and skin rashes

(D) Artheriovenous fistulae of the intestine

(E) Sclerosing cholangitis

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

(D) Mesenteric vascular occlusion

(E) Sigmoid volvulus

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

(D) Ulcerative colitis

(E) Carcinoma if the right colon

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

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

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

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

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.

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

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.

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

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

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

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

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.

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

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

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

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

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

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

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

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

Which of the following would be expected to stimulate intestinal motility?

A. Fear

B. Gastrin

C. Secretin

D. Acetylcholine

E. Cholecystokinin

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

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

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

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