UA ACADEMY: CLINICAL HERO EXAM
100-Item High-Yield Comprehensive Post-Clerkship Board Review
Philippine Medical Practice Blueprint • Trending Cases & Need-to-Knows
GO BEYOND! PLUS ULTRA!
SECTION I: SURGERY (20 ITEMS)
QUESTION 1 OF 100
A 28-year-old male presents with right lower quadrant pain, anorexia, and low-grade fever for 18 hours. On
examination, palpatory tenderness over McBurney's point is minimal, but passive extension of his right hip
with the patient in the left lateral decubitus position elicits excruciating retroperitoneal pain (Positive Psoas
Sign). Abdominal ultrasound fails to visualize the appendix. What is the anatomical location of the
appendix, and what is the next step in management?
A. Pelvic appendix; perform an urgent transrectal ultrasound
B. Retrocecal appendix; proceed with clinical diagnosis and appendectomy
C. Subcecal appendix; order a non-contrast MRI abdomen immediately
D. Pre-ileal appendix; perform diagnostic laparoscopy only if WBC > 20,000/uL
RATIONALE: B. Retrocecal appendix; proceed with clinical diagnosis and appendectomy
The retrocecal position is the most common anatomical variant of the vermiform appendix (65% of cases). In retrocecal
appendicitis, anterior abdominal wall signs (like direct tenderness or rebound) are attenuated because the appendix lies behind
the cecum. Irritation of the underlying psoas major muscle yields a positive Psoas sign. Acute appendicitis remains primarily a
clinical diagnosis; in a young male with classic symptoms and a positive retrocecal sign, clinical diagnosis is sufficient to
proceed to appendectomy.
⚡ PLUS ULTRA PEARL
Psoas sign = Retrocecal appendix. Obturator sign (internal rotation of flexed hip) = Pelvic appendix. A negative ultrasound does
NOT rule out appendicitis.
,QUESTION 2 OF 100
A 54-year-old female presents with an intensely pruritic, erythematous, scaly, crusting rash surrounding the
right nipple-areolar complex that has failed to improve with topical corticosteroids. Gentle palpation
reveals no discrete underlying mass. Nipple discharge is absent. What is the most appropriate next
diagnostic step?
A. Full-thickness skin punch biopsy of the nipple-areolar complex
B. Fine needle aspiration cytology of the subareolar tissue
C. Serum CEA and CA 15-3 level quantification
D. Topical antifungal trial for 4 weeks
RATIONALE: A. Full-thickness skin punch biopsy of the nipple-areolar complex
The presentation is classic for Paget's Disease of the Breast, an uncommon manifestation of breast cancer characterized by
malignant intraepithelial adenocarcinoma cells (Paget cells) within the epidermis of the nipple-areolar complex. Up to 90-95%
of patients with Paget's disease have an underlying ductal carcinoma (either DCIS or invasive ductal carcinoma). A full-thickness
wedge or punch skin biopsy of the nipple is required for definitive histopathologic confirmation.
⚡ PLUS ULTRA PEARL
Eczematous or non-healing nipple lesions unresponsive to topical steroids MUST undergo skin biopsy to exclude Paget's
disease of the breast.
,QUESTION 3 OF 100
A 38-year-old professional singer undergoes a total thyroidectomy for a multinodular goiter.
Postoperatively, her voice is not hoarse, and her vocal cords adduct normally on indirect laryngoscopy.
However, she complains that she can no longer hit high-pitched notes while singing and suffers from vocal
fatigue. Which nerve was inadvertently damaged during surgery?
A. Recurrent laryngeal nerve
B. External branch of the superior laryngeal nerve
C. Internal branch of the superior laryngeal nerve
D. Main trunk of the vagus nerve
RATIONALE: B. External branch of the superior laryngeal nerve
The external branch of the superior laryngeal nerve (EBSLN) travels in close proximity to the superior thyroid artery and vein
near the upper pole of the thyroid gland. It innervates the cricothyroid muscle, which tenses the vocal cords to produce high-
frequency sounds. Injury to the EBSLN preserves vocal cord motility (preventing hoarseness) but causes loss of high-pitched
voice tones and vocal fatigue.
⚡ PLUS ULTRA PEARL
Recurrent Laryngeal Nerve = Vocal cord paralysis & hoarseness (posterior cricoarytenoid). External Superior Laryngeal Nerve =
Loss of high pitch (cricothyroid muscle). Internal Superior Laryngeal Nerve = Sensory above vocal cords (loss of cough reflex).
, QUESTION 4 OF 100
A 67-year-old female presents with severe groin pain and nausea. Physical examination reveals a small,
tender, non-reducible swelling below the inguinal ligament in the right femoral triangle. Abdominal plain
film shows no evidence of mechanical bowel obstruction, and the patient continues to pass flatus and stool
normally. At surgery, a strangulated antimesenteric border of the ileum is found trapped in the femoral
ring. What type of hernia is this?
A. Littre's hernia
B. Richter's hernia
C. Amyand's hernia
D. Pantaloon hernia
RATIONALE: B. Richter's hernia
Richter's hernia occurs when only a portion of the circumferential wall (specifically the antimesenteric border) of the intestine
becomes incarcerated within a hernia defect. Because the entire bowel lumen is not occluded, patients rarely exhibit clinical or
radiological signs of mechanical intestinal obstruction. However, rapid gangrene and perforation of the incarcerated wall
segment can occur.
⚡ PLUS ULTRA PEARL
Richter hernia = Partial bowel wall (antimesenteric border) incarcerated (no obstruction signs). Littre hernia = Incarcerated
Meckel's diverticulum. Amyand hernia = Appendix inside inguinal hernia sac.
100-Item High-Yield Comprehensive Post-Clerkship Board Review
Philippine Medical Practice Blueprint • Trending Cases & Need-to-Knows
GO BEYOND! PLUS ULTRA!
SECTION I: SURGERY (20 ITEMS)
QUESTION 1 OF 100
A 28-year-old male presents with right lower quadrant pain, anorexia, and low-grade fever for 18 hours. On
examination, palpatory tenderness over McBurney's point is minimal, but passive extension of his right hip
with the patient in the left lateral decubitus position elicits excruciating retroperitoneal pain (Positive Psoas
Sign). Abdominal ultrasound fails to visualize the appendix. What is the anatomical location of the
appendix, and what is the next step in management?
A. Pelvic appendix; perform an urgent transrectal ultrasound
B. Retrocecal appendix; proceed with clinical diagnosis and appendectomy
C. Subcecal appendix; order a non-contrast MRI abdomen immediately
D. Pre-ileal appendix; perform diagnostic laparoscopy only if WBC > 20,000/uL
RATIONALE: B. Retrocecal appendix; proceed with clinical diagnosis and appendectomy
The retrocecal position is the most common anatomical variant of the vermiform appendix (65% of cases). In retrocecal
appendicitis, anterior abdominal wall signs (like direct tenderness or rebound) are attenuated because the appendix lies behind
the cecum. Irritation of the underlying psoas major muscle yields a positive Psoas sign. Acute appendicitis remains primarily a
clinical diagnosis; in a young male with classic symptoms and a positive retrocecal sign, clinical diagnosis is sufficient to
proceed to appendectomy.
⚡ PLUS ULTRA PEARL
Psoas sign = Retrocecal appendix. Obturator sign (internal rotation of flexed hip) = Pelvic appendix. A negative ultrasound does
NOT rule out appendicitis.
,QUESTION 2 OF 100
A 54-year-old female presents with an intensely pruritic, erythematous, scaly, crusting rash surrounding the
right nipple-areolar complex that has failed to improve with topical corticosteroids. Gentle palpation
reveals no discrete underlying mass. Nipple discharge is absent. What is the most appropriate next
diagnostic step?
A. Full-thickness skin punch biopsy of the nipple-areolar complex
B. Fine needle aspiration cytology of the subareolar tissue
C. Serum CEA and CA 15-3 level quantification
D. Topical antifungal trial for 4 weeks
RATIONALE: A. Full-thickness skin punch biopsy of the nipple-areolar complex
The presentation is classic for Paget's Disease of the Breast, an uncommon manifestation of breast cancer characterized by
malignant intraepithelial adenocarcinoma cells (Paget cells) within the epidermis of the nipple-areolar complex. Up to 90-95%
of patients with Paget's disease have an underlying ductal carcinoma (either DCIS or invasive ductal carcinoma). A full-thickness
wedge or punch skin biopsy of the nipple is required for definitive histopathologic confirmation.
⚡ PLUS ULTRA PEARL
Eczematous or non-healing nipple lesions unresponsive to topical steroids MUST undergo skin biopsy to exclude Paget's
disease of the breast.
,QUESTION 3 OF 100
A 38-year-old professional singer undergoes a total thyroidectomy for a multinodular goiter.
Postoperatively, her voice is not hoarse, and her vocal cords adduct normally on indirect laryngoscopy.
However, she complains that she can no longer hit high-pitched notes while singing and suffers from vocal
fatigue. Which nerve was inadvertently damaged during surgery?
A. Recurrent laryngeal nerve
B. External branch of the superior laryngeal nerve
C. Internal branch of the superior laryngeal nerve
D. Main trunk of the vagus nerve
RATIONALE: B. External branch of the superior laryngeal nerve
The external branch of the superior laryngeal nerve (EBSLN) travels in close proximity to the superior thyroid artery and vein
near the upper pole of the thyroid gland. It innervates the cricothyroid muscle, which tenses the vocal cords to produce high-
frequency sounds. Injury to the EBSLN preserves vocal cord motility (preventing hoarseness) but causes loss of high-pitched
voice tones and vocal fatigue.
⚡ PLUS ULTRA PEARL
Recurrent Laryngeal Nerve = Vocal cord paralysis & hoarseness (posterior cricoarytenoid). External Superior Laryngeal Nerve =
Loss of high pitch (cricothyroid muscle). Internal Superior Laryngeal Nerve = Sensory above vocal cords (loss of cough reflex).
, QUESTION 4 OF 100
A 67-year-old female presents with severe groin pain and nausea. Physical examination reveals a small,
tender, non-reducible swelling below the inguinal ligament in the right femoral triangle. Abdominal plain
film shows no evidence of mechanical bowel obstruction, and the patient continues to pass flatus and stool
normally. At surgery, a strangulated antimesenteric border of the ileum is found trapped in the femoral
ring. What type of hernia is this?
A. Littre's hernia
B. Richter's hernia
C. Amyand's hernia
D. Pantaloon hernia
RATIONALE: B. Richter's hernia
Richter's hernia occurs when only a portion of the circumferential wall (specifically the antimesenteric border) of the intestine
becomes incarcerated within a hernia defect. Because the entire bowel lumen is not occluded, patients rarely exhibit clinical or
radiological signs of mechanical intestinal obstruction. However, rapid gangrene and perforation of the incarcerated wall
segment can occur.
⚡ PLUS ULTRA PEARL
Richter hernia = Partial bowel wall (antimesenteric border) incarcerated (no obstruction signs). Littre hernia = Incarcerated
Meckel's diverticulum. Amyand hernia = Appendix inside inguinal hernia sac.
