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Paradoxical ventilation after chest injuries, with thoracic retraction of an isolated flail segment of chest wall during inspiration, is a complication associated with increasing ventilatory difficulty, respiratory insufficiency and hypoxia.

The scenario suggests this woman may have bled from oesophageal varices. However, even in the presence of known varices, it must not be assumed that any upper gastrointestinal haemorrhage is due to these varices. Other causes, such as peptic ulceration and metagenic mucosal rupture (Mallory-Weiss syndrome), must also be considered. In this instance the question is not so much what has caused the bleeding, but what prognostic factors are present. Management of any acute event, including a bleed, may be tempered in the presence of indicators of poor prognosis.

All the conditions listed could produce severe abdominal pain, particularly upper abdominal pain.

The scenario suggests this woman may have bled from oesophageal varices. However, even in the presence of known varices, it must not be assumed that any upper gastrointestinal haemorrhage is due to these varices. Other causes, such as peptic ulceration and metagenic mucosal rupture (Mallory-Weiss syndrome), must also be considered. In this instance the question is not so much what has caused the bleeding, but what prognostic factors are present. Management of any acute event, including a bleed, may be tempered in the presence of indicators of poor prognosis. The hypotension on admission is a reflection of the severity of the bleed and in itself is not a prognostic sign. Hypotension resistant to any therapy might certainly suggest poor prognosis, but in this case we are not told anything about the resuscitative measures. The prognostic factors considered in the assessment of a patient with portal hypertension include both physical and biochemical parameters. Encephalopathy and ascites resistant to treatment are poor signs, as are elevated bilirubin, low serum albumin and prolonged INR (international normalised ratio) (B is correct). Together, these five criteria make up the Child-Pugh classification of severity of disease in patients with portal hypertension. Other physical signs, such as number of spider naevi and liver size, may give a clue to the underlying cause of the portal hypertension but are not used as indicators of severity of disease. Likewise, the serum alanine aminotransferase (ALT) levels are less important than the albumin and INR.

The clinical picture fits best the progressive obstructive structuring of lower oesophagus by a cicatrising peptic oesophageal stricture secondary to reflux oesophagitis. Treatment of reflux oesophagitis symptoms with simple antacids/alkalis may give symptomatic relief, but these agents do not influence the natural history. The painful dysphagia of acid reflux will lessen as the stricture progresses, reflux diminishes and obstructive symptoms predominate. Each of the other conditions can be associated with progressive dysphagia, but the pattern fits a peptic oesophageal stricture best (C is correct). (缺图)

With the advent of high-resolution imaging and the increasing frequency of its use, unexpected or incidental findings are a common problem for the clinician. This case illustrates a typical scenario. The patient has symptoms that might be explained by gallstones. Has the patient experienced recurrent bouts of biliary colic? Previously, a focused examination such as an oral cholecystogram would have confined attention to the gallbladder, but with ultrasound and computed tomography (CT), not only will the targeted structure or organ be imaged, but adjacent tissues also examined. This has clear advantages in terms of definition of the chosen structure and its surrounds, but does raise problems with any unexpected and possibly irrelevant finding. Liver lesions are common and many are innocent. The CT can usually provide an exact diagnosis, but such imaging may need to be complemented by ultrasound, magnetic resonance imaging or biopsy. In this case there are two issues. First, can a diagnosis be made on the basis of the CT and, second, do the CT findings explain the patient's symptoms? Most CT examinations are performed with one or more contrast materials used to highlight particular structures (vascular, gut, urinary tract). In this case intravenous contrast has been given and image acquisition will be timed to coincide with arterial and venous flow - in addition to the observation of a contrast-free phase. The description provided is characteristic of a haemangioma (B is correct). Haemangiomas are probably the most common liver tumour and may be found in up to 20% of the general population. They may be solitary or multiple. Most are congenital, do not change size and remain asymptomatic. The lesions typically show intense enhancement during the arterial phase of CT and retain a blush of contrast during the portal venous phase. It is unlikely that this lesion was responsible for the patient's symptoms - the finding should be explained to the patient and the lesion should be left well alone. If there is any doubt to the diagnosis, a magnetic resonance imaging (MRI) scan might be performed or the CT repeated in a few months time to look for any possible changes. The other lesions provided as distractors can all surface as incidental findings on a CT. They each have their characteristic appearance. The CT appearance of metastatic liver lesions will vary according to their site of origin. They can be single or multiple. Most liver metastases are hypovascular on the non-contrast scans when compared with the surrounding parenchyma and this becomes more pronounced in the portal venous phase. In isolation, a hepatocellular carcinoma can be difficult to distinguish on CT from a metastatic deposit, but the presence of cirrhotic nodules may help in the diagnosis. Cystic lesions in the liver may be simple, multiple (polycystic disease), neoplastic or infective (hydatid, abscess). Simple cysts are extremely common and usually asymptomatic. On imaging, these cysts have a low density homogenous appearance. Polycystic disease is shown as thin-walled homogenous cysts - and the number and size of these lesions often lead to symptoms. Neoplastic cysts are rare, often multiloculated and heterogeneous. Hydatid cysts have a characteristic septate appearance and heterogeneous appearance if daughter cysts are contained within. Liver abscesses are usually symptomatic and tend to have a heterogeneous appearance. (缺图)

The chest X-ray shows a pocket of contrast at the root of the neck with a fluid level and contrast in the bronchi going to the lower lobe of the right lung. This patient has a pharyngeal pouch (Zenker diverticulum) and some of the contrast has spilled out of the pouch, been regurgitated and inadvertently inhaled. Whilst this inhalation may have led to chest infection, pulmonary problems are not the most common mode of presentation of a pharyngeal pouch. These patients usually have dysphagia because the primary problem is an overactive upper oesophageal sphincter which fails to relax. Even though the dysphagia is usually long standing, these patients do not usually have any appreciable change in weight. They do not necessarily have motor problems at the lower end of the oesophagus and any gastro-oesophageal reflux is coincidental. Gurgling in the neck is a well-recognised symptom of a pharyngeal pouch, but more common and usually most distressing to the patient is regurgitation of food (E is correct). (缺图)

This patient almost certainly has appendicitis. With this clinical diagnosis it would be sensible to administer antibiotics (a single dose third generation cephalosporin would be appropriate) in preparation for surgery. However, any further review is unlikely to change the management decision, which should be to make arrangements for emergency surgery - most likely appendicectomy (E is correct). The patient may have a gynaecological problem, rather than appendicitis, but in the scenario as presented the preferred management option is surgical intervention for presumed appendicitis without the delay of further tests. Imaging by ultrasound or computed tomography (CT) is being used with increased frequency in cases of acute abdominal pain, but should be reserved for cases where there is diagnostic doubt, and where delayed surgery is unlikely to affect the outcome adversely. In cases of established local peritonitis in the right lower abdomen, as in this instance, early surgery will establish the diagnosis and minimise morbidity. Usually diagnostic laparoscopy is performed, followed by appropriate surgery: appendicectomy, or dealing with focal tubal or ovarian pathology - each of which can usually be done endoscopically at the time of the laparoscopy. In most instances, a urinary beta-hCG pregnancy test would be performed while arranging transfer to surgery. If positive, it will focus the diagnosis on a complication of pregnancy but will not delay surgery.

Small bowel tumours are not common - and are certainly much less common than tumours elsewhere in the digestive tract, particularly the large bowel. Whereas the majority of colorectal tumours are malignant, most small bowel neoplasms are benign. Of the malignancies within the small bowel, perhaps 50% will be adenocarcinoma - with carcinoids, lymphomas, metastatic deposits and gastrointestinal stromal tumours accounting for the rest. In regions of the world where malignant melanoma is prevalent, metastatic deposits of this tumour may account for a large proportion of small bowel tumours. Spontaneous primary lymphoma of the small bowel is most often found in the terminal ileum, but that associated with coeliac disease tends to occur in the proximal jejunum. All the conditions listed are risk factors for some form of gastrointestinal tract malignancy. Crohn disease is associated with a 100-fold increase in risk of developing adenocarcinoma of the diseased section of bowel - usually the distal ileum. The Peutz-Jeghers syndrome is associated with development of hamartomas, which in turn may undergo malignant transformation into adenocarcinoma. As mentioned above, coeliac disease is an important risk factor to be considered in patients found to have primary jejunal lymphoma (C is correct). Patients with familial adenomatous polyposis are at increased risk of duodenal and small bowel carcinoma and, even after total proctocolectomy, need to be kept under surveillance for the development of small bowel malignancy. Patients who have undergone gastric resection more than twenty-five years earlier (usually for benign disease) are at increased risk of developing adenocarcinoma in the gastric stump.

Chest complications of pulmonary atelectasis are a cause of early postoperative fever, particularly in heavy smokers. Each of the other complications is a possible cause, but pulmonary atelectasis is the most likely (D is correct). Assessment of a patient with an episode of significant fever soon after operation mandates: • examination of the wound area for signs of haematoma or developing infection • checking vital signs of pulse and blood pressure and jugular venous pulse • careful chest examination • examination of intravenous drip sites • palpation of calves for signs of venous thrombosis • examination of site of diathermy plate for burning • checking passage of urine since surgery and presence of frequency/dysuria/retention • urinalysis with microscopy and culture when indicated • checking the drug chart (including, when relevant, previous blood transfusion) for allergic reaction to medications • further observations, checking progress and resolution.

The essence of this question is the importance of knowing that a young person with chronic active hepatitis secondary to Hepatitis B is at significant risk of developing hepatocellular carcinoma and needs to be monitored accordingly (D is correct). The association between the hepatitis B carrier state and hepatocellular carcinoma has been demonstrated in several large population-based studies and in other reports. In one report, for example, 22,707 male government employees in Taiwan, 15 percent of whom were HBV carriers [hepatitis B surface antigen (HBsAg) positive], were followed between 1975 and 1978. The relative risk of HCC in these carriers was 223 times that of non-carriers. Jaundice is a fairly late manifestation of chronic active hepatitis. Steroid treatment has not been shown to influence the natural history of chronic active hepatitis.

The clinical picture fits a postoperative superficial wound infection with abscess formation, which requires effective drainage as the first step in treatment by making an incision over the swelling using local anaesthesia.【试题选项缺失，请补充】

The most important diagnostic procedure in this patient is to establish the site of his gastrointestinal haemorrhage, and this is best achieved by upper gastrointestinal endoscopy (B is correct). In the majority of instances, in patients with cirrhosis and portal hypertension, bleeding will be from oesophageal varices. If active bleeding is continuing, insertion of a Sengstaken-Blakemore tube after diagnostic endoscopy can gain temporary control of bleeding while resuscitation and further investigations are proceeding. But some cirrhotic patients will be bleeding from an associated peptic ulcer, which can only be diagnosed by endoscopy. Abdominal computed tomography (CT) will help define liver and splenic enlargement and morphology, and the presence of ascites, but would not be otherwise diagnostic. Assessment of the portal circulation by noninvasive triple phase CT, coeliac axis angiography, and transjugular intrahepatic portal venography are each potentially helpful investigations to assess the degree and severity of portal hypertension, but would not be the preferred initial investigations. These further investigations may follow initial endoscopic injection sclerotherapy in treatment of bleeding oesophageal varices. Such investigations may help determine indications for further treatment by transjugular intrahepatic or open portal-systemic shunting procedures for recurrent or persisting bleeding. (缺图)

Her condition of familial adenomatous polyposis (FAP) is inherited as an autosomal dominant mutation with high penetrance, as illustrated. Half of her offspring of either sex are likely to be affected - a probability of 0.5 (C is correct). In FAP there is an inherited propensity to develop multiple adenomas through the colon and rectum, some of which inevitably become malignant in time. Treatment of affected patients can be by total proctocolectomy and ileostomy, or total colectomy with ileorectal anastomosis and continuing endoscopic review of the rectal segment. Half the children of affected parents are likely to inherit the parent's condition. The polyps appear at around puberty. Most affected patients have developed polyps by age 20 years. If untreated, malignant change develops earlier than the normal age range, often in the 30s to 40s. Prophylactic colonoscopic screening of all children of affected parents and total proctocolectomy or colectomy with ileorectal anastomosis and subsequent rectal surveillance are recommended early after diagnosis. Ophthalmoscopic screening for associated retinal pigmentation is also helpful. The genetic mutation is a deletion of genetic material, causing a derangement of cell formation common to many tissues, so that extracolonic manifestations can occur; and patients require additional ongoing upper gastrointestinal endoscopy for the presence of duodenal malignancies. Gardner syndrome of FAP is the most severe form of the syndrome - with associated osteomas, desmoid tumours of the abdominal wall, and sebaceous cysts. (缺图)

该患者既往因乳腺癌行改良根治性乳房切除术（Patey乳房切除术），现需终身定期临床和乳腺影像学检查。以下关于该患者后续诊疗的描述，正确的是？

关于乳腺溢液，以下描述正确的是？

该乳腺钼靶检查显示慢性广泛线性及球形钙化，5年未变化，提示钙化分散于 inspissated 导管分泌物中，典型表现为浆细胞性乳腺炎（乳腺导管扩张症，'spilt milk mastitis'）。该条件完全良性，常与乳头溢液伴发，溢液为牙膏样厚绿色或黄色物质，以下描述正确的是？ (缺图)

该患者临床表现为库欣综合征相关症状，血浆生化异常，胸部X线示肺门肿块，最可能的诊断为？

该38岁女性，8年前行甲状腺次全切除术治疗Graves病，现复发甲状腺毒症，最合适的管理方案是？

该患者为长期2型糖尿病患者，现出现血糖控制恶化，以下描述正确的是？