UA ACADEMY: CLINICAL PROVISIONAL
EXAM
100-Item Post-Clerkship High-Yield Comprehensive Board Review
Philippine Medical Practice Blueprint • Trending Cases & Need-to-Knows
GO BEYOND! PLUS ULTRA!
SECTION I: SURGERY (20 ITEMS)
ITEM 1 OF 100
A 45-year-old male presenting with acute, severe epigastric pain radiating to the back and a serum
lipase of 1,100 U/L is diagnosed with acute pancreatitis. Contrast CT at 72 hours reveals 40%
pancreatic necrosis. What is the evidence-based recommendation regarding antibiotic prophylaxis in
sterile pancreatic necrosis?
A. Routine administration of high-dose IV Imipenem for all cases with >30% necrosis
B. Prophylactic antibiotics are NOT recommended for sterile necrosis; give antibiotics only for documented
infection
C. Immediate initiation of oral Ciprofloxacin and Metronidazole for 14 days
D. Continuous intra-arterial antibiotic perfusion via the celiac artery
RATIONALE: B. Prophylactic antibiotics are NOT recommended for sterile necrosis; give antibiotics only for
documented infection
Guidelines from the International Association of Pancreatology and American Gastroenterological Association explicitly
state that prophylactic systemic antibiotics are NOT recommended for sterile pancreatic necrosis, regardless of the
extent of necrosis. Antibiotics should be initiated only when infection is confirmed (e.g., CT gas, fine-needle aspiration)
or strongly suspected.
💥 PLUS ULTRA PEARL
Injudicious use of prophylactic antibiotics in acute necrotizing pancreatitis increases the risk of superinfection with
resistant fungal or multi-drug resistant bacterial strains.
,ITEM 2 OF 100
A 25-year-old male presenting with a painless, hard nodule inside his right testicle undergoes scrotal
ultrasound, which confirms a 2-cm hypervascular intra-testicular mass. What is the mandatory surgical
approach for tissue diagnosis and definitive primary management?
A. Trans-scrotal needle aspiration biopsy under local anesthesia
B. Radical inguinal orchidectomy with high ligation of the spermatic cord at the internal ring
C. Open trans-scrotal incisional wedge biopsy
D. Laparoscopic trans-abdominal orchiectomy
RATIONALE: B. Radical inguinal orchidectomy with high ligation of the spermatic cord at the internal ring
Testicular masses suspected of malignancy must NEVER undergo trans-scrotal biopsy or aspiration. Violating the
scrotum alters the lymphatic drainage of the testis (normally to retroperitoneal para-aortic nodes) to the superficial
inguinal nodes, promoting local tumor seeding. The standard of care is a radical inguinal orchidectomy with high
spermatic cord ligation.
💥 PLUS ULTRA PEARL
Testicular Cancer = Inguinal incision + High Spermatic Cord Ligation. Trans-scrotal violation is strictly contraindicated!
,ITEM 3 OF 100
A 60-year-old male smoker complains of exertional left upper extremity claudication and intermittent
dizziness/vertigo that occur specifically when he vigorously exercises his left arm. Physical exam
shows a 30 mmHg blood pressure difference between the arms (right > left). What is the underlying
vascular mechanism?
A. Retrograde blood flow through the ipsilateral vertebral artery (Subclavian Steal Syndrome)
B. Axillary artery compression within the thoracic outlet
C. Carotid artery occlusion with embolization to the MCA
D. Takayasu arteritis affecting the aortic arch
RATIONALE: A. Retrograde blood flow through the ipsilateral vertebral artery (Subclavian Steal Syndrome)
Subclavian Steal Syndrome occurs when severe stenosis or occlusion of the proximal subclavian artery (before the
origin of the vertebral artery) causes blood to be 'stolen' from the contralateral vertebral artery. When the ipsilateral
arm is exercised, blood flows retrograde down the ipsilateral vertebral artery to supply the arm, causing vertebrobasilar
insufficiency.
💥 PLUS ULTRA PEARL
Arm BP discrepancy (>15-20 mmHg) + exercise-induced arm pain and vertebrobasilar neurologic symptoms =
Subclavian Steal Syndrome.
, ITEM 4 OF 100
A 35-year-old female presents with postprandial right upper quadrant pain. Ultrasound shows
cholelithiasis, a 2-mm gallbladder wall, and a dilated common bile duct (CBD) measuring 10 mm. Labs
show elevated alkaline phosphatase and direct bilirubin. What is the proper sequence of management?
A. Preoperative ERCP for ductal clearance followed by laparoscopic cholecystectomy
B. Laparoscopic cholecystectomy followed by elective outpatient MRCP
C. Open cholecystectomy with primary distal gastrectomy
D. Oral ursodeoxycholic acid for 6 months followed by re-evaluation
RATIONALE: A. Preoperative ERCP for ductal clearance followed by laparoscopic cholecystectomy
A dilated common bile duct (>6 mm) paired with cholestatic liver enzymes indicates choledocholithiasis. The
management algorithm calls for ERCP first to extract ductal calculi, followed by laparoscopic cholecystectomy during
the same hospital admission to eliminate the gallstone reservoir.
💥 PLUS ULTRA PEARL
Choledocholithiasis = Preoperative ERCP to clear the CBD, then Laparoscopic Cholecystectomy during the same stay to
prevent recurrent biliary complications.
EXAM
100-Item Post-Clerkship High-Yield Comprehensive Board Review
Philippine Medical Practice Blueprint • Trending Cases & Need-to-Knows
GO BEYOND! PLUS ULTRA!
SECTION I: SURGERY (20 ITEMS)
ITEM 1 OF 100
A 45-year-old male presenting with acute, severe epigastric pain radiating to the back and a serum
lipase of 1,100 U/L is diagnosed with acute pancreatitis. Contrast CT at 72 hours reveals 40%
pancreatic necrosis. What is the evidence-based recommendation regarding antibiotic prophylaxis in
sterile pancreatic necrosis?
A. Routine administration of high-dose IV Imipenem for all cases with >30% necrosis
B. Prophylactic antibiotics are NOT recommended for sterile necrosis; give antibiotics only for documented
infection
C. Immediate initiation of oral Ciprofloxacin and Metronidazole for 14 days
D. Continuous intra-arterial antibiotic perfusion via the celiac artery
RATIONALE: B. Prophylactic antibiotics are NOT recommended for sterile necrosis; give antibiotics only for
documented infection
Guidelines from the International Association of Pancreatology and American Gastroenterological Association explicitly
state that prophylactic systemic antibiotics are NOT recommended for sterile pancreatic necrosis, regardless of the
extent of necrosis. Antibiotics should be initiated only when infection is confirmed (e.g., CT gas, fine-needle aspiration)
or strongly suspected.
💥 PLUS ULTRA PEARL
Injudicious use of prophylactic antibiotics in acute necrotizing pancreatitis increases the risk of superinfection with
resistant fungal or multi-drug resistant bacterial strains.
,ITEM 2 OF 100
A 25-year-old male presenting with a painless, hard nodule inside his right testicle undergoes scrotal
ultrasound, which confirms a 2-cm hypervascular intra-testicular mass. What is the mandatory surgical
approach for tissue diagnosis and definitive primary management?
A. Trans-scrotal needle aspiration biopsy under local anesthesia
B. Radical inguinal orchidectomy with high ligation of the spermatic cord at the internal ring
C. Open trans-scrotal incisional wedge biopsy
D. Laparoscopic trans-abdominal orchiectomy
RATIONALE: B. Radical inguinal orchidectomy with high ligation of the spermatic cord at the internal ring
Testicular masses suspected of malignancy must NEVER undergo trans-scrotal biopsy or aspiration. Violating the
scrotum alters the lymphatic drainage of the testis (normally to retroperitoneal para-aortic nodes) to the superficial
inguinal nodes, promoting local tumor seeding. The standard of care is a radical inguinal orchidectomy with high
spermatic cord ligation.
💥 PLUS ULTRA PEARL
Testicular Cancer = Inguinal incision + High Spermatic Cord Ligation. Trans-scrotal violation is strictly contraindicated!
,ITEM 3 OF 100
A 60-year-old male smoker complains of exertional left upper extremity claudication and intermittent
dizziness/vertigo that occur specifically when he vigorously exercises his left arm. Physical exam
shows a 30 mmHg blood pressure difference between the arms (right > left). What is the underlying
vascular mechanism?
A. Retrograde blood flow through the ipsilateral vertebral artery (Subclavian Steal Syndrome)
B. Axillary artery compression within the thoracic outlet
C. Carotid artery occlusion with embolization to the MCA
D. Takayasu arteritis affecting the aortic arch
RATIONALE: A. Retrograde blood flow through the ipsilateral vertebral artery (Subclavian Steal Syndrome)
Subclavian Steal Syndrome occurs when severe stenosis or occlusion of the proximal subclavian artery (before the
origin of the vertebral artery) causes blood to be 'stolen' from the contralateral vertebral artery. When the ipsilateral
arm is exercised, blood flows retrograde down the ipsilateral vertebral artery to supply the arm, causing vertebrobasilar
insufficiency.
💥 PLUS ULTRA PEARL
Arm BP discrepancy (>15-20 mmHg) + exercise-induced arm pain and vertebrobasilar neurologic symptoms =
Subclavian Steal Syndrome.
, ITEM 4 OF 100
A 35-year-old female presents with postprandial right upper quadrant pain. Ultrasound shows
cholelithiasis, a 2-mm gallbladder wall, and a dilated common bile duct (CBD) measuring 10 mm. Labs
show elevated alkaline phosphatase and direct bilirubin. What is the proper sequence of management?
A. Preoperative ERCP for ductal clearance followed by laparoscopic cholecystectomy
B. Laparoscopic cholecystectomy followed by elective outpatient MRCP
C. Open cholecystectomy with primary distal gastrectomy
D. Oral ursodeoxycholic acid for 6 months followed by re-evaluation
RATIONALE: A. Preoperative ERCP for ductal clearance followed by laparoscopic cholecystectomy
A dilated common bile duct (>6 mm) paired with cholestatic liver enzymes indicates choledocholithiasis. The
management algorithm calls for ERCP first to extract ductal calculi, followed by laparoscopic cholecystectomy during
the same hospital admission to eliminate the gallstone reservoir.
💥 PLUS ULTRA PEARL
Choledocholithiasis = Preoperative ERCP to clear the CBD, then Laparoscopic Cholecystectomy during the same stay to
prevent recurrent biliary complications.
