Division of Head and Neck, Breast, Soft Tissues and Esophageal Surgery
Department of Surgery
UP-PGH Medical Center
Manila

END-OF-ROTATION WRITTEN EXAMINATION FOR RESIDENTS
 (4th Quarter 1999 – October to December 1999)
December 29, 1999

Name:__________________________________________	Year level:____________________

I. CHOOSE THE BEST ANSWER:

1.	A 25 year old female presented with an anterior neck mass of 2 years. PE showed a 3 x 3 cm, non-hard, solid mass , more on the right , that moves with deglutition. No other complaints. Diagnostic procedure of choice for this patient is:
a.	FNAC of the mass
b.	Ultrasound studies
c.	Thyroid scan
d.	Serum T3 and T4 determination
e.	Open biopsy

2.	Biopsy of the mass in the previous question indicate that it is a malignant thyroid nodule. The most probable histologic type is:
a.	Papillary thyroid carcinoma
b.	Follicular thyroid carcinoma
c.	Medullary thyroid carcinoma
d.	Anaplastic thyroid carcinoma
e.	None of the above

3.	On further work up, the patient above was noted to have multiple pulmonary metastasis. What is the stage of the disease of this patient ?
a.	stage I
b.	stage II
c.	stage III
d.	stage IV

4.	The most appropriate treatment for Follicular Thyroid cancer:
a.	Total thyroidectomy
b.	Isthmectomy
c.	Subtotal thyroidectomy
d.	Lobectomy
e.	radioactive iodine

5.	In a pregnant patient with hyperthyroidism, the treatment option that would have the least effect on the thyroid gland of the fetus is:
a.	radioactive iodine
b.	anti-thyroid drugs
c.	subtotal thyroidectomy
d.	all of the above

6.	The histologic type with the worst prognosis in thyroid cancer is:
a.	Follicular Cancer
b.	Papillary cancer
c.	Medullary cancer
d.	Anaplastic cancer

7.	The single most useful test to diagnose the possible etiology of hyperthyroidism is:
a.	Free T4
b.	Free T3
c.	Serum TSH
d.	RAUI
e.	Thyroid scan

8.	The following are major blood supply of the thyroid gland, except:
a.	superior thyroid artery
b.	inferior thyroid artery
c.	thyroidea ima
d.	all of the above
e.	none of the above

9.	Indication/s to the performance of thyroidectomy is/are the following:
a.	hyperthyroidism not responsive to medical treatment
b.	thyroid cancer
c.	presence of difficulty of breathing in the presence of an enlarged thyroid gland
d.	cosmesis
e.	all of the above
f.	all except D

10.	The following are anti-thyroid drugs given to patients with hyperthyroidism, except:
a.	propylthiouracil
b.	methimazole
c.	carbimazole
d.	propanolol
e.	none of the above

11.	Among the following benign lesions in the oral cavity, the most likely to undergo spontaneous regression is:
a.	Papilloma
b.	peripheral reparative granuloma
c.	hyperkeratosis
d.	capillary hemangioma

12.	The most common type of primary malignancy encountered in the head and neck area is:
a.	adenocarcinoma
b.	basal cell carcinoma
c.	lymphoma
d.	squamous cell carcinoma

13.	The most frequent cause of primary hyperparathyroidism is
a.	Idiopathic parathyroid hyperplasia
b.	Parathyroid adenoma
c.	Familial hyperthyroidism
d.	Primary parathyroid carcinoma
e.	Ectopic production of parathormone-like substance

14.	A cystic lesion in the midline of the neck in a 6 yr old child is likely to be
a.	Sebaceous cyst
b.	Branchial cyst
c.	Thyroglossal duct cyst
d.	Cystic hygroma
e.	Lymph node

15.	The following are characteristics of Ameloblastoma, EXCEPT:
a.	It is a Non-odontogenic tumor
b.	It is an Odontogenic tumor
c.	It is a benign lesion of the jaw
d.	Usual presentation is a painless mass in the jaw
e.	All of the above

16.	This type of benign salivary gland tumor is only found in the Parotid Gland.
a.	Pleomorphic adenoma
b.	Whartin’ s tumor
c.	Monomorphic adenoma
d.	Basal cell adenoma
e.	Oncocytic cell tumor

17.	A T3 malignant lesion in the oral cavity is:
a.	a tumor less than 2 cm in size
b.	a tumor 2 – 4 cm in greatest diameter
c.	a tumor more than 4 cm in greatest diameter with deep tissue invasion
d.	a tumor more than 4 cm in greatest diameter
e.	none of the above

18.	An N2 neck node by TNM classification means:
a.	No clinically evident node in the neck
b.	Single, less than 3  cm  clinically palpable ipsilateral nodes
c.	Single, 3 – 6 cm in greatest diameter
d.	Massive, matted cervical lymph nodes
e.	None of the above

19.	The following structures are included and parts of the oral cavity, EXCEPT:
a.	anterior 2/3 of the tongue
b.	buccal mucosa
c.	gingiva
d.	posterior 2/3 of the tongue
e.	floor of the mouth

20.	Components of the supraglottic larynx includes the following:
a.	true vocal cords and the anterior commisure
b.	falze vocal fords and the arytenoids
c.	cricoid cartillage
d.	laryngeal ventricles and the true vocal cords
e.	none of the above

21.	Important prognostic factors for cutaneous melanoma include/s the following EXCEPT:
a.	Tumor ulceration
b.	Level of tumor invasion
c.	Tumor thickness
d.	Degree of pigmentation
e.	None of the above

22.	In the absence of distant metastasis in malignant soft tissue tumors. The most important factor/s influencing prognosis is/are:
a.	Tumor size
b.	Recurrent tumor
c.	Histopathologic grade
d.	Tumor type
e.	Depth of invasion

23.	A 30 years-old female came for consult due to recurrent nipple discharge of several weeks in duration. The following statement/s is/are true regarding the compliant of this patient:
a.	This may be a true galactorrhea which is very common
b.	Milky discharge from multiple breast ducts is usually not a sign of disease
c.	Nipple discharge is usually a sign of underlying invasive breast cancer
d.	Discharge from multiple ducts is more worrisome than single duct dicharge

24.	In trying to establish the probability of breast cancer in a patient,  the most important and clinically useful risk factors are the following:
a.	Fibrocystic disease, age and gender
b.	Age, gender and family history in immediate relatives
c.	Cysts, family history and obesity
d.	Age, gender and family history of breast cancer in old aunts and grandmother
e.	None of the above

25.	Which of the following patients will benefit most by the use of adjuvant chemotherapy of breast cancer after surgery or radiation?
a.	Women with small cancers who have negative lymph nodes
b.	Premenopausal women with positive axillary lymph nodes
c.	Older women whose tumors contain a high content of estrogen receptors
d.	Women with large stage III or stage IV cancers

26.	Inflammatory breast cancer is best described by one of the following statements:
a.	Direct invasion of the overlying dermis by cancer
b.	Inflammation due to superinfection of the cancer by staphylococcal or streptococcal organisms
c.	Erythema of the overlying skin due to lymphatic spread of the tumor cells
d.	Inflammatory breast cancer is an early stage malignancy

27.	In a patient with operable breast cancer. Which of the following treatment options should NOT be employed?
a.	Lumpectomy or total removal of the tumor and axillary dissection
b.	Mastectomy followed by irradiation of the axillary nodes if dissection is not done
c.	Modified radical mastectomy leaving the pectoralis major muscle in place
d.	Lumpectomy followed by irradiation of the entire involved breast
e.	None of the above

28.	The following is/are true regarding adjuvant hormonal treatment in patients with breast cancer:
a.	Tamoxifen, the most commonly used drug, worked as a competitive estrogen receptor analog
b.	Usual recommended dose for tamoxifen is 20 mg given twice a day
c.	Best benefit in terms of survival and disease free interval is observed if given to premenopausal women
d.	It should not be given without an ER-assay
e.	The maximum length of treatment with tamoxifen is 3 years

29.	For which of the following cancers is radiation therapy is equally effective as surgery?
a.	Testicular cancer
b.	Breast cancer
c.	Laryngeal cancer
d.	Lymphoma
e.	All of the above

30.	Which one of the following diagnostic studies concerning soft tissue sarcomas is of greatest value in determining invasion into surrounding tissues?
a.	Soft tissue radiographs
b.	Angiography
c.	Magnetic resonance imaging
d.	Computed tomography
e.	Gallium scanning

31.	The following conditions leading to inadequate production of thyroid hormone and thus to the development of multinodular goiter, EXCEPT:
a.	Iodine deficiency
b.	Congenital defect in thyroid hormone biosynthesis
c.	Thyroiditis with damage to follicular cells
d.	Thyroid malignancy
e.	None of the above

32.	The etiologic factors that has been most convincingly documented as playing a role in the development of clinical thyroid cancer is:
a.	Iodine deficiency
b.	Goitrogenic drugs
c.	Thyroid hormone administration
d.	External radiation exposure
e.	None of the above

33.	The following statement/s is/are true concerning Achalasia:
a.	The etiology in most cases is a parasitic infestation by Trypanosoma cruzi
b.	Chest pain and regurgitation are the usual symptoms
c.	Distal 3rd esophageal adenocarcinoma may occur in up to 10% of patients after 15 – 25 years
d.	Characteristic manometric findings are failure of the LES to relax with swallowing and absent or weak simultaneous contractions after swallowing
e.	Both pneumatic dilatation and esophagomyotomy provide highly effective curative therapy for achalasia
f.	All of the above

34.	All of the following except one are considered as a premalignant esophageal lesion?
a.	Caustic esophageal stricture
b.	Radiation esophagitis
c.	Schatzki’s ring
d.	Plummer-Vinzon syndrome
e.	Achalasia

35.	Which of the following is most reliable in confirming the occurrence of esignificant esophageal caustic injury?
a.	Endoscopy
b.	History of the event
c.	Barium esophagogram
d.	Physical examination of the patient
e.	None of the above

36.	A 48 year old man complained of hoarseness of 8 weeks duration. Indirect laryngospcopy revealed the presence of a raised granular lesion limited to the right vocal cord, with concomittant paralysis. The left cord is normal as well as the anterior commisure. No cervical adenopathy appreciated.The next step in management should include:
a.	Antibiotic therapy
b.	Voice rest
c.	Steam inhalation
d.	Repeat laryngospcopy (direct/indirect) and biopsy of lesion
e.	None of the ablove

37.	Result of biopsy in patient in #36  revealed well-differentiated squamous cell carcinoma. Based on available data, the stage of disease is:
a.	T2N0M0
b.	T3N0M0
c.	T4N0M0
d.	T1N0M0
e.	None of the above

38.	Recommended treatment for a 62-year-old woman with a 3-cm mass in the left thyroid lobe with pathology report of follicular carcinoma.
a.	Lobectomy with radioactive iodine treatment
b.	Total thyroidectomy
c.	Biopsy and external beam radiation
d.	Enucleation
e.	None of the above

39.	A 68-year-old woman presents with bilateral parotid tumors. The most likely diagnosis is:
a.	Pleomorphic adenoma
b.	Adenoid cystic carcinoma
c.	Benign mixed tumor
d.	Warthin’s tumor
e.	None of the above

40.	Use of cervical esophagogastric anastomosis following resection for esophageal cancer is often favored over an intrathoracic anastomosis because:
a.	It has lower incidence of anastomotic leak
b.	It has lower incidence of anastomotic stricture
c.	It is associated with a lower incidence of acid reflux
d.	Anastomotic leaks are more easily managed
e.	Swallowing function and nutrition are better preserved

41.	What percentage of metastatic cervical lymph nodes arises from a primary which is infraclavicular?
a.	10%
b.	30%
c.	50%
d.	70%
e.	90%

42.	A modified radical mastectomy on the right breast was done on a 45-year-old female diagnosed with Stage III-B breast cancer. Because of presence of matted Rotter’s node, the pectoralis minor muscle has to be removed en-bloc with the whole specimen. The pectoralis major muscle was left behind. This technique of MRM is also known as:
a.	Auchincloss technique 
b.	Patey’s technique
c.	Halsted mastectomy
d.	Urban mastectomy
e.	None of the above

43.	This type of functional neck dissection entails removal and dissection of all lymph bearing tissues in levels I – III cervical lymph nodes, usually employed as an elective procedure in cancers of the oral cavity.
a.	Type III modified radical neck dissection
b.	Anterolateral neck dissection
c.	Supraomohyoid neck dissection
d.	Type I modified radical neck dissection
e.	Radical Neck dissection

44.	This type of neck dissection entails removal of all lymph nodes and lymph bearing tissues in levels I – V cervical lymph nodes with preservation of the internal jugular vein, the spinal accessory nerve and sternocleidomastoid muscle.
a.	Type I modified radical neck dissection
b.	Type II modified radical neck dissection
c.	Type III modified radical neck dissection
d.	Posterolateral neck dissection
e.	Radical neck dissection

45.	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

46.	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

47.	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

48.	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

49.	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

50.	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

51.	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

52.	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

53.	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

54.	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

55.	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

II, Matching Type : Questions 56-80

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	

56.	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.

57.	15 y.o. male with enlargement of one breast, slightly tender, no erythema, no warmth, no axillary nodes.

58.	45 y.o. male with enlargement of one breast, slightly tender, no erythema, no warmth, no axillary  nodes.

59.	35 y.o. female with sanguinous nipple discharge on one breast.  No palpable breast mass.  No axillary nodes.

60.	45 y.o. female with nodular breast tissues, no definite breast mass, slightly tender, no erythema, no warmth, no axillary nodes.

61.	45 y.o. female with nipple-areolar erosions on one breast.  No palpable breast mass. No axillary nodes.

62.	30 y.o. female with firm, solid, nontender, very movable well-defined breast mass on one side.  No axillary nodes.

63.	30 y.o. female, lactating, with slightly tender breast mass noted recently, no erythema, no warmth, no axillary node.

64.	40 y.o. female, nonlactating, with multiple slightly tender breast masses on both breasts, no erythema, no warmth, no axillary nodes.

65.	40 y.o. female with hard mass with ill-defined border, not fixed to underlying nor overlying structures.  No axillary nodes.

66.	40 y.o. female with erythema over  one breast, tender, warm, with no definite mass.

67.	20 y.o. female with well-defined movable masses, no axillary nodes.

68.	55 y.o. female with bilateral breast masses, not fixed, slightly tender, no erythema, no warmth, no axillary nodes.

69.	30 y.o. female with a breast mass on one side with an ipsilateral axillary lymph node.

70.	35 y.o. female with a breast mass, tender, with erythema, and warmth.

71.	40 y.o. female with 10cm multinodular breast mass on one side, movable but fixed to overlying skin, no axillary nodes.

72.	40 y.o. female with one breast 3x the size of the other breast.  No definite breast mass. No axillary nodes.

73.	45 y.o. male with hard mass, not fixed, no axillary nodes.

74.	30 y.o. female with fungating mass on one breast, no axillary nodes.

75.	50 y.o. female with no definite breast mass, but with erythema, no tenderness, no warmth, no axillary nodes.

76.	80 y.o. female with breast mass on one side with ill-defined border, no axillary nodes.

77.	60 y.o. female with a breast mass on one side, depressible, no axillary nodes.

78.	35 y.o. female with well-defined movable mass, nontender, solid, no axillary nodes.

79.	30 y.o. female with an area of prominence, slightly tender, no erythema, no warmth, no axillary nodes.

80.	65 y.o. male with fixed mass, no axillary nodes.

END OF EXAMINATION