GSIResident’s End-of-Rotation Written Examination
September 30, 1999

(without answers)

The focus of this exam is on clinical diagnosis of GSI domains – head and neck, thyroid, breast, esophagus, soft tissue, hernia, and appendicitis.

Head and neck, thyroid, soft tissue 			- 46
Esophagus 					- 02
Appendix					- 01
Hernia						- 01
Breast						- 25
 		Total - 75						
Questions 1 – 5

Given the following clinical data, determine the most likely diagnosis based on pattern recognition and prevalence.  Choose from the list of diagnosis provided below.  Each lettered answer may be used more than once.

A.	Hemangioma
B.	Cystic hygroma or lymphangioma
C.	Branchial cleft cyst
D.	Submandibular gland cyst
E.	Mandibular bone cyst 

1. 7-year-old girl with a 5-cm cystic mass on the left submandibular area.  The mass was noted at birth which has progressively increased in size.   There was no skin discoloration. There are no other masses in the other parts of the body.

2. 5-year-old boy with a 5-cm soft mass on the right submandibular area.  The mass was noted at birth which has progressively increased in size.  There was reddish discoloration on the skin.  There are no other associated masses in the other parts of the body.

3. 12-year-old boy with a  3-cm cystic mass on the inner side of the upper right sternocleidomastoid muscle.  The mass was noted at birth which has progressively increased in size.  There was no skin discoloration.  There are no other masses in the other parts of the body.

4. 45-year-old female with a 3-cm cystic mass on the right submandibular area.  The mass was noted 7 years prior and which has progressively increased in size.  There are no skin discoloration.  There are no other associated masses in the other parts of the body.

5. 38-year-old female with a 3-cm right mandibular mass. On x-ray, there is a radiolucent mass on the mandible.

Questions 6-12

Given the following clinical data, determine the most likely diagnosis based on pattern recognition and prevalence.  Choose from the list of diagnosis provided below.  Each lettered answer may be used more than once.

A.	Parotid cyst
B.	Epidermal cyst
C.	Lymph node 
D.	Mandibular bone tumor
E.	Lipoma

6. A 40-year-old man with a 3-cm infraauricular cystic mass which was noted 2 years prior.  There were no associated symptoms.  The mass is movable, nontender, with well-defined border, with no associated skin changes.  The depth of the mass is estimated to be just beneath the epithelium of the skin.

7. A 50-year-old woman with a 2-cm infraauricular cystic mass which was noted 3 years prior.  There were no associated symptoms.  The mass is movable, nontender, with well-defined border, with no associated skin changes.  The depth of the mass is estimated to be under the subcutaneous tissue.

8. A 50-year-old woman with a 2-cm infraauricular noncystic nonosseous mass which was noted 3 years prior.  There were associated nasal stuffiness.  The mass is relatively immovable, nontender, with ill-defined border, with no associated skin changes.  The depth of the mass is estimated to be under the subcutaneous tissue.

9. A 30-year-old woman with a 4-cm infraauricular bony hard mass which was noted 3 years prior.  There were no associated symptoms.  The mass moves with opening of the mouth, nontender, with ill-defined border, with no associated skin changes.  The depth of the mass is estimated to be under the subcutaneous tissue.

10. A 50-year-old woman with a 2-cm infraauricular noncystic soft mass which was noted 3 years prior.  There were no associated symptoms.  The mass is movable, nontender, with well-defined border, with no associated skin changes.  The depth of the mass is estimated to be at the subcutaneous tissue level.

11. A 50-year-old woman with a 2-cm preauricular cystic mass which was noted 3 years prior.  There were no associated symptoms.  The mass is movable, nontender, with well-defined border, with no associated skin changes.  The depth of the mass is estimated to be under the subcutaneous tissue.

12. A 40-year-old man with a 3-cm preauricular cystic mass which was noted 2 years prior.  There were no associated symptoms.  The mass is movable, nontender, with well-defined border, with no associated skin changes.  The depth of the mass is estimated to be just beneath the epithelium of the skin.

13. A 30-year-old female with a 3-cm submucosal firm nonosseous mass at the left hard palatal area.  There were no associated symptoms.  The mass is relatively immobile, nontender, with well-defined border, with no associated mucosal changes.  There were no other masses in the other parts of the body.  What is the most likely diagnosis?

A.	Salivary gland tumor
B.	Maxillary tumor
C.	Palatal tumor
D.	Mucosal tumor 
E.	Torus tubarius

14. The following are reliable clinical signs for oral cavity squamous cell carcinoma EXCEPT:

A.	ulcerating mucosal lesion 
B.	submucosal mass
C.	induration suggestive of an infiltrative mass with no break in mucosa
D.	fungating mass
E.	leukoplakia

15. A long-standing 4-cm fungating mass on the scalp or face is most likely a

A.	squamous cell carcinoma
B.	basal cell carcinoma
C.	melanoma
D.	soft tissue sarcoma
E.	granuloma pyogenicum

16. A black 1-cm papular lesion on the scalp or face is most likely a

A.	squamous cell carcinoma
B.	basal cell carcinoma
C.	melanoma
D.	soft tissue sarcoma
E.	granuloma pyogenicum

17. A long-standing skin lesion with rolled elevated edges and central ulceration on the face is most likely a 

A.	squamous cell carcinoma
B.	basal cell carcinoma
C.	melanoma
D.	soft tissue sarcoma
E.	granuloma pyogenicum

18. A long-standing skin lesion on the scalp or face that easily bleeds to touch and that has a background history of an open wound in the area is most likely a 

A.	squamous cell carcinoma
B.	basal cell carcinoma
C.	melanoma
D.	soft tissue sarcoma
E.	granuloma pyogenicum

19. A 2-cm noncystic, soft, movable, nontender discrete nonosseous tumor beneath the skin and most likely at the subcutaneous tissue level is most probably a/an

A.	epidermal cyst
B.	lipoma
C.	soft tissue sarcoma
D.	fibroma
E.	sebaceous cyst

20. A discrete mass just beneath the epithelial layer of the skin without a punctum is most likely a/an

A.	epidermal cyst
B.	lipoma
C.	soft tissue sarcoma
D.	fibroma
E.	keratosis

21. A discrete mass just beneath the epithelial layer of the skin with a punctum is most likely a/an

A.	epidermal cyst
B.	lipoma
C.	soft tissue sarcoma
D.	fibroma
E.   keratosis

22. A 3-cm noncystic, firm, relatively immovable, nontender nondiscrete nonosseous tumor beneath the skin and most likely at the subcutaneous tissue level or deeper (but still outside a cavity such as peritoneal and thoracic cavity) is most probably a/an

A.	epidermal cyst
B.	lipoma
C.	soft tissue sarcoma
D.	fibroma
E.	sebaceous cyst

23. A 8-cm noncystic, firm, relatively immovable, nontender nondiscrete nonosseous tumor beneath the skin and most likely at the subcutaneous tissue level or deeper (but still outside a cavity such as peritoneal and thoracic cavity) is most probably a/an

A.	epidermal cyst
B.	lipoma
C.	soft tissue sarcoma
D.	fibroma
E.	sebaceous cyst

24. A 8-cm noncystic, firm, relatively immovable, nontender nondiscrete nonosseous tumor beneath the skin and most likely at the subcutaneous tissue level or deeper in an extremity is most probably a/an

A.	liposarcoma
B.	lipoma
C.	soft tissue sarcoma
D.	fibrosarcoma
E.	fibroma

25. A solitary paratracheal mass that moves with deglutition and that is hard in consistency, feels solid, relatively immobile, no skin changes, with ipsilateral neck nodes is most likely 

A.	colloid adenomatous nodule
B.	chronic thyroiditis
C.	papillary thyroid cancer
D.	follicular thyroid cancer
E.	anaplastic thyroid cancer

26. A solitary paratracheal mass that moves with deglutition and that is hard in consistency, feels solid, relatively immobile, no skin changes, with no neck nodes is most likely 

A.	colloid adenomatous nodule
B.	chronic thyroiditis
C.	papillary thyroid cancer
D.	follicular thyroid cancer
E.	anaplastic thyroid cancer

27. A solitary paratracheal mass that moves with deglutition and that is hard in consistency, feels solid, relatively movable, no skin changes, with no neck nodes is most likely 

A.	colloid adenomatous nodule
B.	chronic thyroiditis
C.	papillary thyroid cancer
D.	follicular thyroid cancer
E.   anaplastic thyroid cancer

28. A solitary paratracheal mass that moves with deglutition and that is not hard in consistency, feels solid, relatively movable, no skin changes, no neck nodes, with a distant mass suspected to be related to the paratracheal mass is most likely 

A.	colloid adenomatous nodule
B.    chronic thyroiditis
C.	papillary thyroid cancer
D.	follicular thyroid cancer
E.  anaplastic thyroid cancer

29. A solitary paratracheal mass that moves with deglutition and that is hard in consistency, feels solid, fixed, no skin changes, no neck nodes with the patient having significant compression symptoms of dysphagia and dyspnea, is most likely 

A.	colloid adenomatous nodule
B.	chronic thyroiditis
C.	papillary thyroid cancer
D.	follicular thyroid cancer
E.	anaplastic thyroid cancer

30. A solitary paratracheal mass that moves with deglutition and that is not hard in consistency, feels noncystic, discrete, movable, no skin changes, no neck nodes is most likely 

A.	colloid adenomatous nodule
B.	chronic thyroiditis
C.	papillary thyroid cancer
D.	follicular thyroid cancer
E.	anaplastic thyroid cancer

31. A solitary paratracheal mass that moves with deglutition and that is not hard in consistency, feels cystic, discrete, movable, no skin changes, with no neck nodes is most likely 

A.	colloid cyst
B.	colloid adenomatous nodule
C.	multiple colloid adenomatous goiter
D.	chronic thyroiditis
E.	papillary thyroid cancer

32. A solitary nodular nondiscrete paratracheal mass that moves with deglutition and that is hard in consistency, feels solid, relatively immobile, no skin changes, with no neck nodes is most likely 

A.	colloid adenomatous nodule
B.	chronic thyroiditis
C.	papillary thyroid cancer
D.	follicular thyroid cancer
E.	anaplastic thyroid cancer

33. Multiple paratracheal masses that move with deglutition and that are not hard in consistency,  relatively mobile, no skin changes, with no neck nodes.  The diagnosis  is most likely 

A.	multiple colloid adenomatous goiter
B.	multiple colloid cysts
C.	chronic thyroiditis
D.	papillary thyroid cancer
E.	follicular thyroid cancer

34. Multiple paratracheal masses that move with deglutition and that are not hard in consistency,  relatively mobile, no skin changes, with neck nodes.  The diagnosis  is most likely 

A.	multiple colloid adenomatous goiter
B.	multiple colloid cysts
C.	chronic thyroiditis
D.	papillary thyroid cancer
E.	follicular thyroid cancer

35. Multiple paratracheal masses that move with deglutition and that are not hard in consistency,  relatively mobile, no skin changes, with no neck nodes, with a skull mass most likely related to the paratracheal neck masses.  The diagnosis  is most likely 

A.	multiple colloid adenomatous goiter
B.	multiple colloid cysts
C.	chronic thyroiditis
D.	papillary thyroid cancer
E.	follicular thyroid cancer

36. Combination of the following clinical signs and symptoms are reliable cues for hyperthyroidism EXCEPT

A.	diffuse goiter
B.	nodular goiter
C.	tachycardia
D.	exophthalmos
E.	marked weight loss despite good appetite
 
37. In a patient with a solitary nodule, which of the following physical signs has the LEAST likelihood ratio or probability for thyroid cancer?

A.	distant mass suspicious for metastasis
B.	ipsilateral neck nodes
C.	vocal cord paralysis
D.	fixation
E.	hard consistency

38. In a patient with a solitary nodule, which of the following physical signs has the HIGHEST likelihood ratio or probability for nonmalignant thyroid disorder?

A.	solid nature
B.	cystic nature
C.	contralateral neck nodes
D.	soft consistency
E.	hard consistency

39. A 38-year-old female presents with a 1-cm node on the right posterior triangle which was noted 1 week prior.  The node was nontender with no skin changes. There were no associated symptoms.  There are no other masses or lesions in the other parts of the head and neck and in the entire body.  What is the most likely diagnosis?

A.	tuberculous lymphadenopathy
B.	nonspecific lymphadenopathy
C.	metastatic lymphadenopathy
D.	lymphoma

40. A 40-year-old male presents with a 3-cm left infraauricular lymph node.  The lymph node was relatively immobile with no skin changes.  There was history of nasal stuffiness and bleeding.  There are no other masses in other parts of the body.  The most likely diagnosis is

A.	tuberculous lymphadenopathy
B.	nonspecific lymphadenopathy
C.	metastatic lymphadenopathy
D.	lymphoma

41. A 40-year-old male presents with bilateral 3-cm infraauricular lymph nodes.  The lymph nodes were relatively immobile with no skin changes.  There were no associated symptoms.  There are no other masses in other parts of the body. The most likely diagnosis is

A.	tuberculous lymphadenopathy
B.	nonspecific lymphadenopathy
C.	metastatic lymphadenopathy
D.	lymphoma

42. A 50-year-old male presents with multiple lymph nodes on both sides of the neck, more on the posterior triangles.  There were no associated symptoms.  There are no other massess in the other parts of the body.
The most likely diagnosis is

A.	tuberculous lymphadenopathy
B.	nonspecific lymphadenopathy
C.	metastatic lymphadenopathy
D.	lymphoma

43.	An 18-year-old female presents with 3 2 to 3 cm lymph nodes on the posterior aspect of the left sternocleidomastoid muscle.  There were no associated symptoms.  There are no other masses in the other parts of the body.  The most likely diagnosis is

A.	tuberculous lymphadenopathy
B.	nonspecific lymphadenopathy
C.	metastatic lymphadenopathy
D.	lymphoma

44.	A 46-year-old female presents with a solitary 4-cm lymph node on the lower third of the left sternocleidomastoid muscle.  There were no associated symptoms.  There is a 1-cm mass on the left paratracheal area which moves with deglutition.  This  paratracheal mass is not hard, movable and nontender.  The most likely diagnosis for the lymph node is:

A.	tuberculous lymphadenopathy
B.	nonspecific lymphadenopathy
C.	metastatic lymphadenopathy
D.	lymphoma

45.	A 30-year-old female presents with a solitary 2-cm lymph node in the right submandibular triangle.  
In the oral cavity, there is an ulcerating mass on the floor of the mouth.  The most likely diagnosis for the lymph node is

A.    tuberculous lymphadenopathy
B.	nonspecific lymphadenopathy
C.	metastatic lymphadenopathy
D.	lymphoma

46.	A 15-year-old presents with a tender 2-cm right subdigastric lymph node.  There was note of dental caries.  The most likely diagnosis for the lymph node is

A.	tuberculous lymphadenopathy
B.	nonspecific lymphadenopathy
C.	inflammatory lymphadenopathy
D.	metastatic lymphadenopathy
E.	lymphoma

47. The most reliable clinical sign that an esophageal disorder is present consist of 

A.    pain on swallowing
B.	difficulty in swallowing
C.	vomiting of digested foods 
D.	persistent vomiting of undigested foods 
E.	vomiting of bile

48. There are NO pathognomonic signs and symptoms for

A.	esophageal cancer
B.	achalasia
C.	esophageal stricture secondary to corrosive substance ingestion
D.	esophageal stricture secondary to reflux esophagitis
E.	esophageal obstruction secondary to foreign body ingestion

49. The most reliable cue for the diagnosis of an inguinal hernia is a/an

A.	inguinal mass
B.	recurrent, reducible inguinal mass
C.	palpation of huge external ring of the inguinal canal
D.	thrust felt by the examining finger when patient is asked to cough
E.    inguinal bulge on coughing by the patient

50. The most reliable clinical cue for acute appendicitis consists of:

A.	right lower quadrant direct tenderness
B.	right lower quadrant rebound tenderness
C.	psoas sign
D.	Rovsing’s sign
E.	persistent, progressive, direct tenderness with at  least guarding at the right lower quadrant with no reliable cues for another diagnosis

Questions 51-75

Given a set of clinical data of a patient with a breast problem, give the primary clinical diagnosis by selecting from the list provided.  The item in the list of clinical diagnosis may be used more than once.

	A. Breast cancer			H.  Paget’s disease of the nipple
	B. Fibroadenoma			I.   Virginal hypertrophy or macromastia
	C. Macrocyst			J.   Gynecomastia
	D. Galactocoele			K.  Fibrocystic changes
	E. Phyllodes tumor		L.  Intraductal papilloma
	F.  Mastitis			M. Tuberculosis of the breast
	G. Breast abscess			N.  Inflammatory breast cancer
			 
___ 51. 30 y.o. female with draining sinuses on one breast of one year duration.  No definite breast mass,
	just indurations.  Positive ipsilateral axillary lymph nodes.
 
___ 52. 15 y.o. male with enlargement of one breast, slightly tender, no erythema, no warmth, no axillary
 	nodes.

___ 53. 45 y.o. male with enlargement of one breast, slightly tender, no erythema, no warmth, no axillary 
	nodes.

___ 54. 35 y.o. female with sanguinous nipple discharge on one breast.  No palpable breast mass.  No
	axillary nodes.

___ 55. 45 y.o. female with nodular breast tissues, no definite breast mass, slightly tender, no erythema, no 
	warmth, no axillary nodes.

___ 56. 45 y.o. female with nipple-areolar erosions on one breast.  No palpable breast mass. No axillary 
	nodes.

___ 57. 30 y.o. female with firm, solid, nontender, very movable well-defined breast mass on one side.  No
	axillary nodes.

___ 58. 30 y.o. female, lactating, with slightly tender breast mass noted recently, no erythema, no warmth,
 	no axillary node.

___ 59. 40 y.o. female, nonlactating, with multiple slightly tender breast masses on both breasts, no 
	erythema, no warmth, no axillary nodes.

___ 60. 40 y.o. female with hard mass with ill-defined border, not fixed to underlying nor overlying
 	structures.  No axillary nodes.

___ 61. 40 y.o. female with erythema over  one breast, tender, warm, with no definite mass.

___ 62. 20 y.o. female with well-defined movable masses, no axillary nodes.

___ 63. 55 y.o. female with bilateral breast masses, not fixed, slightly tender, no erythema, no warmth, no
	axillary 	nodes.

Given a set of clinical data of a patient with a breast problem, give the primary clinical diagnosis by selecting from the list provided.  The item in the list of clinical diagnosis may be used more than once.

	A. Breast cancer			H.  Paget’s disease of the nipple
	B. Fibroadenoma			I.   Virginal hypertrophy or macromastia
	C. Macrocyst			J.   Gynecomastia
	D. Galactocoele			K.  Fibrocystic changes
	E. Phyllodes tumor		L.  Intraductal papilloma
	F.  Mastitis			M. Tuberculosis of the breast
	G. Breast abscess			N.  Inflammatory breast cancer
			 
___ 64.  30 y.o. female with a breast mass on one side with an ipsilateral axillary lymph node.

___ 65.  35 y.o. female with a breast mass, tender, with erythema, and warmth.

___ 66. 40 y.o. female with 10cm multinodular breast mass on one side, movable but fixed to overlying
 	skin, no axillary nodes.

___ 67. 40 y.o. female with one breast 3x the size of the other breast.  No definite breast mass. No axillary
 	nodes.

___ 68. 45 y.o. male with hard mass, not fixed, no axillary nodes.

___ 69. 30 y.o. female with fungating mass on one breast, no axillary nodes.

___ 70. 50 y.o. female with no definite breast mass, but with erythema, no tenderness, no warmth, no
	axillary nodes.

___ 71. 80 y.o. female with breast mass on one side with ill-defined border, no axillary nodes.

___ 72. 60 y.o. female with a breast mass on one side, depressible, no axillary nodes.

___ 73. 35 y.o. female with well-defined movable mass, nontender, solid, no axillary nodes.

___ 74. 30 y.o. female with an area of prominence, slightly tender, no erythema, no warmth, no axillary
	nodes.

___ 75. 65 y.o. male with fixed mass, no axillary nodes.

Student ID: ________________________________            Score: __________________
Subject: GSI Residents’ End-of-Rotation Exam 

	A 	B	C	D	E		A	B	C 	D  	E
1. 	O	O	O	O	O	26.	O	O	O	O	O
2.	O	O	O	O	O	27.	O	O	O	O	O
3.	O	O	O	O	O	28.	O	O	O	O	O
4. 	O	O	O	O	O	29.	O	O	O	O	O
5.	O	O	O	O	O	30. 	O	O	O	O	O

	A 	B	C	D	E		A	B	C 	D	E
6.	O	O	O	O	O	31.	O	O	O	O	O
7.	O	O	O	O	O	32. 	O	O	O	O	O
8.	O	O	O	O	O	33.	O	O	O	O	O
9.	O	O	O	O	O	34.	O	O	O	O	O
10. 	O	O	O	O	O	35.	O	O	O	O	O

	A 	B	C	D	E		A	B	C 	D	E
11.	O	O	O	O	O	36.	O	O	O	O	O
12.	O	O	O	O	O	37. 	O	O	O	O	O
13.	O	O	O	O	O	38.	O	O	O	O	O
14.	O	O	O	O	O	39.	O	O	O	O	O
15. 	O	O	O	O	O	40.	O	O	O	O	O
	
	A 	B	C	D	E		A	B	C 	D	E
16.	O	O	O	O	O	41.	O	O	O	O	O
17.	O	O	O	O	O	42. 	O	O	O	O	O
18.	O	O	O	O	O	43.	O	O	O	O	O
19.	O	O	O	O	O	44.	O	O	O	O	O
20. 	O	O	O	O	O	45.	O	O	O	O	O

	A 	B	C	D	E		A	B	C 	D	E
21.	O	O	O	O	O	46.	O	O	O	O	O
22.	O	O	O	O	O	47. 	O	O	O	O	O
23.	O	O	O	O	O	48.	O	O	O	O	O
24.	O	O	O	O	O	49.	O	O	O	O	O
25. 	O	O	O	O	O	50.	O	O	O	O	O

Student ID: ________________________________            Score: __________________

		 Subject: GSI Residents’ End-of-Rotation Exam

A    B    C	D    E	    F    	G     H     I	   J	K    L     M     N	 
51. 	O    O	   O	O    O    O	O     O     O	   O    O    O     O      O  
52.	O    O	   O	O    O    O	O     O     O	   O    O    O     O      O  
53.	O    O	   O	O    O    O	O     O     O	   O    O    O     O      O  
54. 	O    O	   O	O    O    O	O     O     O	   O    O    O     O      O  
55.     O    O	   O	O    O    O	O     O     O	   O    O    O     O      O  
 
A    B    C	D    E	    F    	G     H     I	   J	K    L     M     N	 
56. 	O    O	   O	O    O    O	O     O     O	   O    O    O     O      O  
57.	O    O	   O	O    O    O	O     O     O	   O    O    O     O      O  
58.	O    O	   O	O    O    O	O     O     O	   O    O    O     O      O  
59. 	O    O	   O	O    O    O	O     O     O	   O    O    O     O      O  
60.     O    O	   O	O    O    O	O     O     O	   O    O    O     O      O  

A    B    C	D    E	    F    	G     H     I	   J	K    L     M     N	 
61. 	O    O	   O	O    O    O	O     O     O	   O    O    O     O      O  
62.	O    O	   O	O    O    O	O     O     O	   O    O    O     O      O  
63.	O    O	   O	O    O    O	O     O     O	   O    O    O     O      O  
64. 	O    O	   O	O    O    O	O     O     O	   O    O    O     O      O  
65.     O    O	   O	O    O    O	O     O     O	   O    O    O     O      O  

A    B    C	D    E	    F    	G     H     I	   J	K    L     M     N	 
66. 	O    O	   O	O    O    O	O     O     O	   O    O    O     O      O  
67.	O    O	   O	O    O    O	O     O     O	   O    O    O     O      O  
68.	O    O	   O	O    O    O	O     O     O	   O    O    O     O      O  
69. 	O    O	   O	O    O    O	O     O     O	   O    O    O     O      O  
70.     O    O	   O	O    O    O	O     O     O	   O    O    O     O      O  

 A    B    C	D    E	    F    	G     H     I	   J	K    L     M     N	 
71. 	O    O	   O	O    O    O	O     O     O	   O    O    O     O      O  
72.	O    O	   O	O    O    O	O     O     O	   O    O    O     O      O  
73.	O    O	   O	O    O    O	O     O     O	   O    O    O     O      O  
74. 	O    O	   O	O    O    O	O     O     O	   O    O    O     O      O  
75.     O    O	   O	O    O    O	O     O     O	   O    O    O     O      O