南京大學(xué)軍總外科學(xué)總論 外總 08級(jí)考試題目

1、感謝任建安主任，感謝張戀茹、徐驍盟、孫靜、雷藝珊、廖延年、姜婷婷、劉乃成、張吉慶等同學(xué)（排名不分先后）為大家的貢獻(xiàn)，祝大家考出好成績(jī)！一、 選擇題部分（CK，09, 10 ）1 1. CK部分Step2CK2 A healthy 35-year-old man comes to the emergency department because of a-hour history of severe abdominal pain. The pain had initially started in the periumbilical area but has now shifted to the

2、 right lower quadrant (RLQ). He also complains of nausea and two episodes of vomiting. He has no other medical problems or previous surgeries. He takes no medication. He does not use tobacco, alcohol, or illicit drugs. His temperature is 38.9C (102F), blood pressure is 125/80 mm Hg, pulse is 100/min

3、, and respiration are 20/min. Examination shows clear lung fields and normal first and second heart sounds. Abdominal examination shows tenderness in the RLQ that does not worsen with inspiration. Palpation of the left lower quadrant (LLQ) produces pain in the RLQ. Urinalysis is negative. The patien

4、ts laboratory findings reveal: WBC 16,000/ul Hematocrit 42% Platelet count 220,000/ul Leukocytes Neutrophils 86% Eosinophil 2% Lymphocytes 8% Monocytes 4% Which of the following is the most appropriate next step in management?3 Ultrasound of the abdomen4 Computed tomography (CT) scan of the abdomen5

5、 Conservative management6 Immediate surgery7 Colonoscopy 8 A 34-year-old obese man is brought to the emergency department by the paramedics after being shot while in a street fight. The patient is obtunded and had an episode of en route. He receives3 Lof normal saline. His temperature is37C(98.8F),

6、blood pressure is 85/43 mm Hg, pulse is 126/min, and respiration are 21/min. The trachea is midline, and there are breath sounds bilaterally. Examination shows a gunshot entry wound in the left sixth intercostal space anteriorly lateral to the midclavicular line and an exit wound in the left seventh

7、 intercostal space anteriorly. The patient is intubated, and mechanical ventilation is initiated. Portable chest x-ray shows hazy opacities at the let lung base. Beside ultrasound is limited due to body habitus but does not shows any definite pericardial or peritoneal fluid. Which of the following i

8、s the most appropriate next step in management?9 Chest tube placement10 CT scanning of the abdomen11 Diagnostic peritoneal lavage12 Exploratory laparotomy13 Plain radiography of the abdomen 14 An 18-year-old woman at 9 weeks gestation is brought to the emergency department because of an open fractur

9、e of the tibia and fibula. She is thermodynamically stabilized and referred to the orthopedic department. She is scheduled for internal fixation of the tibia for the following day. However, before the surgery she develops severe dyspnea and confusion. Her temperature is 37.7C (99.9F), blood pressure

10、 is 110/70 mmHg, pulse is 110/min, and respirations are 22/min. Examination shows numerous non-palpalbe petechiae in the upper part of the body. Which of the following is the most likely diagnosis?14 Air embolism14 Amniotic fluid embolism14 Thromboembolism14 Fat embolism14 Acute respiratory distress

11、 syndrome 15 A 25-year-old male is brought to the trauma center by the paramedics after being involved in a road traffic accident that occurred 90 minutes ago. He has been having some chest and epigastric burning for the past few days but says that the current pain is different. His other medical pr

12、oblems include nonischemic cardiomyopathy for which he takes furosemide, carvedilol, spironolactone, lisinopril, and potassium chloride. He also has HIV infection but has chosen not to take any medication related to this diagnosis. His temperature is 38.9C (102F), blood pressure is 110/65 mm Hg, pul

13、se is 110/min, and respirations are 22/min. examination shows that he is in obvious distress secondary to pain. His lung are clear to auscultation. The remainder of the examinations shows no abnormalities. His ECG is within normal limits. Chest X-ray shows a widened mediastinum and some mediastinal

14、air. Which of the following is the most appropriate next step in the management of this patient?15 Aspirin, clopidogrel, and repeat ECG in 30 minutes15 Contrast esophagography15 Oral omeprazole and antacids15 Transesophageal echocardiography15 Upper gastrointestinal endoscopy 16 A 25-year-old male i

15、s brought to the trauma center by the paramedics after being involved in a road traffic accident that occurred 90 minutes ago. He was a front seat passenger in a 3-car accident. His initial blood pressure at the scene of the accident was 90/60 mm Hg and pulse was 126/min. The paramedics administered

16、 2 liter of normal saline in the ambulance. In the ED, his blood pressure is 110/70 mm Hg and pulse is 90/min. His abdomen is tender in the left quadrant. Ultrasound shows fluid in the spleno-renal angle. The most appropriate next step is to :16 Perform exploratory laparotomy16 Perform a CT scan16 A

17、dmit to the surgical ICU16 Admit to the ward16 Laparoscopy 17 A 55-year-old male Asian immigrant presents to the physician because of recent-onset neck swelling. He also notes having several episodes of epistaxis lately. He has not sustained any trauma to the neck or nose. His past medical history i

18、s significant for syphilis and recurrent bacterial sinusitis. He drinks 2 beers daily and has a 30-pack year smoking history. He takes daily multivitamins with antioxidants. On physical examination, you notes a mass in the posterior nasal cavity. Biopsy shows undifferentiated carcinoma. Which of the

19、 following is a risk factor for this cancer?17 Alcohol use17 Spirochete infection17 Bacterial infection17 Viral infection17 Vitamin supplements 18 A 23-year-old man is brought to the emergency department after being involved in a motor vehicle collision in which he was the restrained passenger. He h

20、as multiple organ injuries and is listed in critical condition. His physical exam shows a blood pressure of 90/60 mm Hg, pulse of 130/min, and respirations of 30/min. He appears slightly confused and does not respond appropriately to questions. His eye exam shows pupils that are reactive bilaterally

21、 with no apparent neurological deficits. He responds to pain and deep stimulation on neurological exam. Extremities are cool to the touch with decreased capillary refill and an open wound in the right lower extremity with significant blood loss. A change in which of the following is the first indica

22、tor of hypervolemia?18 Systolic blood pressure18 Pulse rate18 Respiratory rate18 Level of consciousness18 Capillary refill time 19 A 12-year-old male is brought to the emergency department after direct blunt trauma to the upper abdomen. He has epigastric pain and repeated vomiting immediately after

23、the trauma. He is afebrile and his other vital signs are stable. Barium examination shows duodenal obstruction. CT scan of the abdomen shows a duodenal hematoma and no other injuries are noted. Which of the following is the most appropriate next step in management?19 Exploratory laparotomy19 Nasogas

24、tric suction with parenteral nutrition19 Bowel rest and antibiotics19 Endoscopic removal of the hematoma19 MRI of the abdomen 20 A 45-year-old woman underwent elective surgery for an inguinal hernia. In the postoperative room, she developed nausea, vomiting, and acute abdominal pain. She has a histo

25、ry of systemic lupus erythematosus, pernicious anemia, type-1 diabetes, chronic low back pain, and uterine fibroids. Her preoperative medications include monthly vitamin B-12 injections, insulin, prednisone, hydroxychloroquine, and acetaminophen. Her blood pressure is 70/40 mm Hg and heart rate is 1

26、10/min. Initial laboratory studies show a blood glucose of 50 mg/dL. Which of the following is the most likely cause of her condition?20 Postoperative bleeding20 Diabetic ketoacidosis20 Intra-abdominal abscess20 Intestinal obstruction20 Adrenal insufficiency20 Allergic reaction20 Insulin-induced hyp

27、oglycemia20 Atelectasis20 Bleeding into uterine fibroid 21 A 34-year-old woman is brought to the emergency department after being hit by a motorcycle. She was walking across the street and hit by a speeding motorcycle, with the wheel scraping her left leg. She is able to ambulate but complains of sl

28、ight weakness in her left leg. She takes no medication and has no known drug allergies. Examination shows a 3*2-cm laceration on the left calf with surrounding erythema but no purulent drainage. The wound is dirty, and the underlying fascia can be seen. She has had four doses of tetanus-diphtheria t

29、oxoid in her life, the latest of which was 7 years ago. In addition to wound debridement and surgical management, which of the following is the most appropriate course of action to prevent the development of tetanus?21 Give no additional treatment because the patient is already vaccinated21 Administ

30、er tetanus immune globulin21 Administer tetanus-diphtheria toxoid21 Administer tetanus immune globulin and tetanus-diphtheria toxoid21 Observe the patient and administer tetanus immune globulin at signs of tetanus 22 A 23-year-old woman is brought to the emergency department because of respiratory d

31、istress. Her symptoms began 1 hour ago after being stung by a bee while in the park. She has no history of asthma or heart disease. Her medications include oral contraceptives and daily multivitamins. She has no history of allergies. Her temperature is 37.1C (98.8F), blood pressure is 82/50 mm Hg, p

32、ulse is 108/min, and respirations are 26/min. Examination shows a conscious woman in respiratory distress, with audible wheezing. Her skin is warm to touch. Which of the following is the most appropriate next step in management?22 Continuous albuterol nebulizer22 Intramuscular epinephrine22 Intraven

33、ous dopamine infusion22 Intravenous corticosteroids22 Subcutaneous epinephrine 23 A 29-year-old woman is brought to the emergency department after burning her right upper extremity in a cooking accident. Examination shows a circumferential burn of the right extremity. She is given fluids, an analges

34、ia and a wound dressing. On day three she develops severe deep tissue pain in the right limb with edema of the hand. Examination shows a circumferential eschar over the right arm. Her right radial and ulnar pulse are faint compared to the left and she has paresthesias in her right hand. Which of the

35、 following is the most appropriate next step in management?23 Increase the dose of her analgesics and discharge her23 Do an angiography to assess arterial blood flow23 Do an escarotomy23 Look for missed fracture of the right upper limb23 Elevation of the limb 24 A 34-year-old unrestrained male drive

36、r is brought to the ER after a motor vehicle accident. His cervical spine is immobilized. He is stuporous. At the scene of the accident, his blood pressure is 70/30 mm Hg and heart rate is 130/min. Lungs are clear to auscultation. Abdominal wall ecchymosis is present. Abdomen is mildly distended. Bo

37、wel sounds are decreased. Neck veins are collapsed. After two liters of intravenous fluids, his blood pressure is 80/40 mm Hg. A focused assessment with sonography foe trauma shows blood in the peritoneal cavity but no obvious sold organ injury. Which of the following is the most appropriate next st

38、ep in management?24 Laparoscopy24 Laparotomy24 X-ray films of the abdomen and pelvis24 CT scan of the abdomen24 Diagnostic peritoneal lavage24 Observation and resuscitation 25 A newborn infants is found to have a scrotal mass. The mass is cystic and transilluminated with light. He is born without an

39、y other complications. The vital signs are within normal limits. Other physical examination is unremarkable. Which of the following is the most appropriate next step in management?25 Aspiration of fluid25 Surgical intervention25 Ultrasound examination25 Reassurance and observation25 Check 24-hour ur

40、inary protein excretion 26 A 23-year-old man is brought to the emergency department in an obtunded state following a gun shot wound to the right upper quadrant of the abdomen. His systolic blood pressure is 60 mm Hg and unable to obtain diastolic blood pressure. His pulse is 136/min. Chest auscultat

41、ion shows clear heart and breath sounds. The abdomen appears distended, and there is an obvious gun shot wound on the right upper quadrant. The bowel sounds are decreased. Which of the following is the most appropriate next step in management?26 Angiography26 Diagnostic peritonea lavage26 Focused ul

42、trasonography26 Laparoscopy26 Laparotomy26 X-ray chest26 CT scan of the abdomen 27 A 60-year-old man undergoes a laparotomy for intestinal obstruction secondary to postoperative adhesions. Her other medical problems include type 2 diabetes meliitus, hypothyroidism, and hypertension. He underwent a c

43、holecystectomy 2 year ago. His medications include long-acting insulin, hydrochlorothiazide, levothyroxine, enalapril, and pravastatin. On postoperative days 3, he complains of pain around the wound. His temperature is 38.3C(101F), blood pressure is 121/76 mmHg, pulse is 100/min, and respirations ar

44、e 16/min. Fingerstick glucose level is 312 mg/L. Examination of the wound shows abundant cloudy-gray discharge and dusky friable subcutaneous tissue. Sensation is decreased at the edges of the wound. Which of the following is the best management for this patient?27 Intravenous antistaphylococcal ant

45、ibiotics27 Negative pressure wound therapy27 Topical antimicrobial agents27 Urgent surgical exploration27 Wound culture and tight glucose control 28 09部分2009 Examination單選題擇（每題一分）29 One of the goal of the Early goal-directed resuscitation is to maintain the mean arterial pressure (MAP) 29 55mm Hg29

46、65mm Hg29 75mm Hg29 85mm Hg29 45mm Hg 30 According to the International guidelines for management of severe sepsis and septic shock, intravenous antibiotic therapy should be started as early as possible and within the ( )hour of recognition of septic shock (1B) and severe sepsis without septic shock

47、 (1D).30 first hour30 second hour30 third hour30 forth hour30 fifth hour 31 The TAC was used in the early stage of ( )31 Control body temperature31 Severe sepsis31 Cold injury31 Open abdomen31 reduce feeling of pain 32 Acute compartment syndrome should be considered, if the bladder pressure is above

48、 ( )mm Hg32 1232 2432 4832 5032 10 33 ( ) is widely recognized and respected throughout the scientific, academic and clinical world for his innovative and pioneering research in the development of the specialized central venous feeding technique known as intravenous hyperalimentation (IVH) or total

49、parenteral nutrition (TPN)33 Van den Berghe33 John Hunter33 Janet Cushing33 Joseph Murray33 Stanley J. Dudrick 33 According to the International guidelines for management of severe sepsis and septic shock, the aim is to keep blood glucose < ( mmol/L) using a validated protocol for insulin dose ad

50、justment.33 6.333 7.333 8.333 9.333 10.3 34 The first stage of wound repair is ( ) stage. It occurs immediately after tissue damage, and components of the coagulation cascade, inflammatory pathways and immune system are needed to prevent ongoing blood and fluid losses, to remove dead and devitalized

51、 (dying) tissues and to prevent infection.34 Bleeding34 Sepsis34 Inflammation34 new tissue formation34 remodeling 35 The SAFE study compared 4% ( ) with 0.9% sodium chloride in 6997 ICU patients and showed that ( ) administration was not associated with worse outcomes; however, there was a trend tow

52、ard higher mortality in the trauma subgroup that received ( ).35 glucose35 albumin35 5%GNS35 antibiotics35 10% sodium chloride 36 Critical care textbooks had long recommended tidal volumes of 10 to 15 ml/kg actual body weight. But now, several randomized trials suggest that tidal volumes of ( ) in c

53、onjunction with other strategies could prevent ALJ.36 5ml/kg actual body weight)36 6 ml/kg actual body weight)36 7 ml/kg actual body weight)36 8 ml/kg actual body weight)36 9 ml/kg actual body weight) 37 Cushing ulcer usually occurs after severe37 Burns37 Brain trauma37 Abdominal operation37 Cold in

54、jury37 Sepsis. 38 Transfusion-related acute lung injury (TRALI) is among the most common causes of fatal transfusion reactions. In typical cases, TRALI is characterized by acute respiratory distress and non-cardiogenic lung oedema developing during, or within ( ? ) h of, transfusion.38 during, or wi

55、thin 3 h of, transfusion38 during, or within 6 h of, transfusion38 during, or within 9 h of, transfusion38 during, or within 12h of, transfusion38 during, or within 24 h of, transfusion 39 Van den Berghe et al. demonstrated that intensive insulin therapy that maintained the blood glucose level at (

56、) resulted in lower morbidity and mortality among critically ill patients than did conventional therapy that maintained the blood glucose level at180 to 200 mg per deciliter.39 2.2 to 4.5 mmol per liter39 4.4 to 6.1 mmol per liter39 6.1 t0 8.8 mmol per liter39 8.8 to 10.1 mmol per liter39 10.0 to 11

57、.1 mmol per liter 13. Protective ventilation in treating ARDS involved a tidal volume at or below 6 ml per kilogram, a high PEEP, and permissive ( ).A. HypertensionB. HyperglycemiaC. HypercapniaD. HypopertensionE.Hypoglycemia 14.Which one is not sign of systemic inflammatory response syndrome (SIRS) 40 Body temperature >38·5°C or <35·0°C41 Heart rate >90 per minute42 Respiratory rate >20 breaths per