UA HIGH SCHOOL: HERO CLINICAL EXAM
100-Item Post-Clerkship High-Yield Comprehensive Licensure Set
Philippine Clinical Scenarios • Advanced Management Protocols
G O B E Y O N D ! P L U S U LT R A !
SECTION I: SURGERY (20 ITEMS)
ITEM 1 OF 100
A 45-year-old male medical representative comes to the emergency room due to severe, sudden-onset epigastric
pain that rapidly became generalized. On physical examination, the abdomen is board-like and rigid with diffuse
rebound tenderness. An upright chest X-ray confirms pneumoperitoneum. During emergency laparotomy, a 1-cm
perforation is noted on the anterior wall of the duodenal bulb. What is the surgical procedure of choice?
,A. Total gastrectomy with Roux-en-Y gastrojejunostomy
B. Primary closure of the perforation reinforced with a vascularized pedicle of omentum (Graham patch)
C. Highly selective vagotomy with antrectomy
D. Segmental duodenectomy with primary end-to-end anastomosis
RATIONALE: B. Primary closure of the perforation reinforced with a vascularized pedicle of omentum (Graham patch)
In the emergency management of a perforated duodenal ulcer, the standard, most effective procedure is primary suture closure
overlayed with a well-vascularized plug of omentum (Graham patch). This rapidly controls soilage and closes the hollow viscus
perforation with minimal morbidity compared to radical resections or definitive acid-reducing operations.
PLUS ULTRA PEARL
Anterior duodenal ulcers typically perforate into the peritoneal cavity causing free air; posterior duodenal ulcers erode into the
gastroduodenal artery causing massive hemorrhage.
,ITEM 2 OF 100
A 62-year-old female presents with progressive, painless jaundice, generalized pruritus, pale clay-colored stools,
and an intentional 15-lb weight loss over the past 3 months. Physical examination reveals Courvoisier's sign.
Laboratory testing demonstrates direct hyperbilirubinemia and elevated CA 19-9. Which operation is standardly
indicated if a mass is found localized to the head of the pancreas?
A. Distal pancreatectomy with splenectomy
B. Pancreaticoduodenectomy (Whipple procedure)
C. Total gastrectomy with Roux-en-Y reconstruction
D. Retroperitoneal tumor enucleation
RATIONALE: B. Pancreaticoduodenectomy (Whipple procedure)
Courvoisier's sign (painless jaundice and a palpable, non-tender gallbladder) is highly suggestive of malignant extrahepatic biliary
obstruction, most commonly adenocarcinoma of the head of the pancreas or a periampullary tumor. The standard surgical treatment for
resectable tumors localized to the head of the pancreas or periampullary region is a pancreaticoduodenectomy (Whipple procedure).
PLUS ULTRA PEARL
Courvoisier's Law states that a palpable, non-tender gallbladder in a jaundiced patient implies malignant biliary obstruction, as
gallbladder stone disease causes fibrosis that prevents distension.
, ITEM 3 OF 100
A 24-year-old male is rushed to the trauma bay of a tertiary government hospital following a high-velocity
motorcycle crash along the North Luzon Expressway (NLEX). He is tachycardic at 132 bpm and hypotensive at
82/44 mmHg. Focused Assessment with Sonography for Trauma (FAST) reveals free fluid in the splenorenal recess
and rectovesical pouch. Following a 1-liter bolus of warm balanced crystalloid solution, his blood pressure drops
further to 76/40 mmHg. What is the most appropriate next step in management?
A. Transport the patient immediately to the radiology suite for a contrast-enhanced abdominal CT scan
B. Deliver a second bolus of 2 liters of normal saline and repeat the FAST examination
C. Transfer the patient immediately to the operating room for an emergent exploratory laparotomy
D. Initiate continuous monitoring and plan for non-operative management in the ICU
RATIONALE: C. Transfer the patient immediately to the operating room for an emergent exploratory laparotomy
The patient has sustained blunt abdominal trauma, is hemodynamically unstable, and is a non-responder to initial crystalloid fluid
resuscitation with a positive FAST scan indicating hemoperitoneum. Hemodynamically unstable trauma patients with a positive FAST
must bypass CT imaging and proceed directly to emergency exploratory laparotomy for surgical control of hemorrhage.
PLUS ULTRA PEARL
Never take an unstable trauma patient to the CT scanner! A positive FAST in an unstable patient is an absolute indication for emergency
laparotomy.
100-Item Post-Clerkship High-Yield Comprehensive Licensure Set
Philippine Clinical Scenarios • Advanced Management Protocols
G O B E Y O N D ! P L U S U LT R A !
SECTION I: SURGERY (20 ITEMS)
ITEM 1 OF 100
A 45-year-old male medical representative comes to the emergency room due to severe, sudden-onset epigastric
pain that rapidly became generalized. On physical examination, the abdomen is board-like and rigid with diffuse
rebound tenderness. An upright chest X-ray confirms pneumoperitoneum. During emergency laparotomy, a 1-cm
perforation is noted on the anterior wall of the duodenal bulb. What is the surgical procedure of choice?
,A. Total gastrectomy with Roux-en-Y gastrojejunostomy
B. Primary closure of the perforation reinforced with a vascularized pedicle of omentum (Graham patch)
C. Highly selective vagotomy with antrectomy
D. Segmental duodenectomy with primary end-to-end anastomosis
RATIONALE: B. Primary closure of the perforation reinforced with a vascularized pedicle of omentum (Graham patch)
In the emergency management of a perforated duodenal ulcer, the standard, most effective procedure is primary suture closure
overlayed with a well-vascularized plug of omentum (Graham patch). This rapidly controls soilage and closes the hollow viscus
perforation with minimal morbidity compared to radical resections or definitive acid-reducing operations.
PLUS ULTRA PEARL
Anterior duodenal ulcers typically perforate into the peritoneal cavity causing free air; posterior duodenal ulcers erode into the
gastroduodenal artery causing massive hemorrhage.
,ITEM 2 OF 100
A 62-year-old female presents with progressive, painless jaundice, generalized pruritus, pale clay-colored stools,
and an intentional 15-lb weight loss over the past 3 months. Physical examination reveals Courvoisier's sign.
Laboratory testing demonstrates direct hyperbilirubinemia and elevated CA 19-9. Which operation is standardly
indicated if a mass is found localized to the head of the pancreas?
A. Distal pancreatectomy with splenectomy
B. Pancreaticoduodenectomy (Whipple procedure)
C. Total gastrectomy with Roux-en-Y reconstruction
D. Retroperitoneal tumor enucleation
RATIONALE: B. Pancreaticoduodenectomy (Whipple procedure)
Courvoisier's sign (painless jaundice and a palpable, non-tender gallbladder) is highly suggestive of malignant extrahepatic biliary
obstruction, most commonly adenocarcinoma of the head of the pancreas or a periampullary tumor. The standard surgical treatment for
resectable tumors localized to the head of the pancreas or periampullary region is a pancreaticoduodenectomy (Whipple procedure).
PLUS ULTRA PEARL
Courvoisier's Law states that a palpable, non-tender gallbladder in a jaundiced patient implies malignant biliary obstruction, as
gallbladder stone disease causes fibrosis that prevents distension.
, ITEM 3 OF 100
A 24-year-old male is rushed to the trauma bay of a tertiary government hospital following a high-velocity
motorcycle crash along the North Luzon Expressway (NLEX). He is tachycardic at 132 bpm and hypotensive at
82/44 mmHg. Focused Assessment with Sonography for Trauma (FAST) reveals free fluid in the splenorenal recess
and rectovesical pouch. Following a 1-liter bolus of warm balanced crystalloid solution, his blood pressure drops
further to 76/40 mmHg. What is the most appropriate next step in management?
A. Transport the patient immediately to the radiology suite for a contrast-enhanced abdominal CT scan
B. Deliver a second bolus of 2 liters of normal saline and repeat the FAST examination
C. Transfer the patient immediately to the operating room for an emergent exploratory laparotomy
D. Initiate continuous monitoring and plan for non-operative management in the ICU
RATIONALE: C. Transfer the patient immediately to the operating room for an emergent exploratory laparotomy
The patient has sustained blunt abdominal trauma, is hemodynamically unstable, and is a non-responder to initial crystalloid fluid
resuscitation with a positive FAST scan indicating hemoperitoneum. Hemodynamically unstable trauma patients with a positive FAST
must bypass CT imaging and proceed directly to emergency exploratory laparotomy for surgical control of hemorrhage.
PLUS ULTRA PEARL
Never take an unstable trauma patient to the CT scanner! A positive FAST in an unstable patient is an absolute indication for emergency
laparotomy.
