初期臨床研修採用試験の出題傾向を公開 過去の研修医採用試験の一部や今年度の試験の例題を公開します。 ≪医学基本問題の例題≫ 【専門医学知識分野】 問題１．幽門に術前生検で tub2 の胃癌（T2, N0, M0）を認め、腹腔鏡補助下幽門側胃切除術 を行った。一般的に、幽門側胃切除術後の消化管再建方法は、ビルロートⅠ法、ビ ルロートⅡ法と（ 最近は（ A A ）があり、従来はビルロートⅠ法が多かったが、 ）も増加している。 問題２．通常、胸部上行大動脈は、弓部で、心臓から順に、（ B ）、左総頚動脈、 左鎖骨下動脈と、主に上半身に分布する動脈を分枝する。 ≪答え≫ A： ルーワイ法（Roux-en Y） B： 腕頭動脈 【医学常識分野】 問題１． （ A ）とは受精卵が何回かの分裂・増殖を経て成長した胚の中に存在す る未分化な細胞から樹立された幹細胞で、無限に自己増殖する能力とあらゆる組織 に分化する能力－則ち、自己複製能と多分化能を備えた細胞のことである。他方、 （ B ）とは、もともと個人の一部の組織（例えば、皮膚とか頬の粘膜 細胞等で、本人自身の遺伝子を持つ細胞）から得た細胞を人工的に処理し多能性と 多分化能を誘導された幹細胞である。 問題２．2010 年 7 月に改正臓器移植法が施行されたが、2011 年 4 月に国内で初めて （ C ）から提供された臓器にて、臓器移植手術が行われた。 ≪答え≫ A： 胚性幹細胞（ES 細胞） B： 人工多能性幹細胞（iPS 細胞） C： 15 歳未満の子供 ≪英文論述試験の例題≫ 下記の論文は New Engl J Med 2010:363:1988-1989 の perspective「Up in the Air ･ Suspending Ethical Medical Practice」から引用しています。以下は問題と模範解答です 以下の文章はある医学雑誌に載った記事です。速読した上で、以下の問に答えなさい。 Our plane was flying from the East Coast to the West carrying 167 passengers, including my wife, a hospitalist and internist, and me, a neurologist and clinical ethicist. About midflight, a woman in the row behind us reached frantically for the baggage bin over our heads. I offered to help. She was trying to get her husband’s oxygen tank. I turned and saw that he looked to be about 70 years old. His eyes were closed, and his right hand was clutching his chest as he grimaced in pain. Immediately, his grimace faded and his right arm dropped. Leaning over my seat, I caught his hand and felt for a pulse while my wife checked for the radial pulse in his left arm. There was none. Two flight attendants approached. “I am a physician,” I said. “Let’s get him down to the floor.” We lifted him into the aisle. I shined a pocket flashlight on the dimly lit scene. He had stopped breathing; his pulse was absent. We tore open his shirt to reveal a well-healed thoracotomy scar. A flight attendant brought an automated external defibrillator (AED), an Ambu bag, and other equipment. Three other passengers — an oncologist, an anesthesiologist, and a surgeon — joined us. My wife ran the code, I provided chest compressions, the anesthesiologist bagged the patient, the oncologist managed the equipment, and the surgeon attempted venous cannulation and then intracardiac injection of epinephrine. We confirmed that there was a femoral pulse only with chest compressions. We followed the protocol suggested by the AED. The device did not discharge, since its automatic rhythm-detection program had found no rhythm that might be treated with defibrillation. The monitor eventually showed a wide complex bradycardia with which we could not associate a palpable pulse. Our resuscitative efforts were taking place in full view of the passengers and the man’s wife, who stood beside us. Five previously rambunctious children were now silent. After 25 minutes of basic cardiac life support, there was still only pulseless electrical activity. The five physicians agreed that it was time to stop the code and declare the patient dead. But the flight attendant explained that if we stopped CPR, the airline’s protocol would require the cabin crew to continue it in our stead. “This is futile,” muttered the surgeon, and without discussion, he returned to his seat, leaving four of us facing a dilemma: If we turned the resuscitative efforts over to the crew, who would look after the passengers? But if we continued CPR, we would be treating a patient who had clearly been “overmastered” by his disease. The proper practice of medicine does not include treating irreversible disease when patients are overcome by illness. This principle holds true even when family members request futile interventions or when physicians are following a well-meaning protocol. To prolong CPR under the circumstances in which we found ourselves would be to subvert medicine’s goal from the good of the patient to the benefit of the community. Given this understanding, we could not consider our actions to be within the scope of the practice of medicine; rather, as we continued administering CPR, we were acting less as physicians than as skilled passengers assisting a flight crew. The pilot announced that he was diverting the plane to a small airport. The crew calmed the passengers, addressed their other needs, and attended to landing preparations. As we descended steeply, the pilot ordered everyone to be seated. The anesthesiologist and oncologist complied. We were down to two physicians administering CPR. A flight attendant took over the use of the Ambu bag and required coaching on technique. I was instructed to hold onto my wife as she continued chest compressions, both of us half-strapped into stretched safety belts to allow us to continue CPR during the landing. We landed with a light bump, then braked and taxied along the 6500-ft runway to a stop. The resuscitative efforts had continued for some 35 to 40 minutes. Firefighters and paramedics arrived and carried the patient to the door and down a fire-truck ladder. He died that day, according to news reports we later found online. As it turned out, he had also been a physician. We had knowingly delivered medically ineffective CPR. But we did so because of practical concerns arising from the demands of the airline’s protocol. CPR was going to go forward whatever we decided, and we chose to continue it ourselves so that the four flight attendants could attend to their duties during an emergency landing. On solid ground, I believe that medical policy and protocols should preclude such dilemmas. The responsibility for deciding to stop CPR should rest with a physician who is focused solely on the good of the patient. CPR should be deemed ineffective when it cannot be expected to meaningfully alter the natural course of the disease; it should be deemed futile when it no longer serves the patient. We should ensure that our medical policies and protocols exclude considerations such as mitigation of liability or the exclusive interests of third parties from playing a role in resuscitative decisions. Such policies will help support the efforts of physicians to act always for the good of the patient and within the bounds enunciated in the Hippocratic Corpus. 参考：ethicist：道徳家、frantically：大わらわで、clutch：つかむ、 grimace ：しかめっ面･顔をゆがめること、flashlight：懐中電灯 Ambu bag：救命用の人工呼吸用バッグ、rambunctious：騒々しい、futile：むだな subvert：くつがえす、overmaster：支配下に置く･圧倒する、comply：従う、応ずる mitigation：軽減･緩和、liability：責務 質問１．以下の質問に答えなさい ① 筆者の職業は何か？ ≪答え≫ 医師（神経内科学、倫理学）※医師だけでは半分 ② 最も早く CPR を止めた人は誰か？ ≪答え≫ 外科医 ③ 70 歳位の心肺停止になった患者さんの職業は何か？ ≪答え≫ 医師 ④ 飛行中に乗客が心肺停止になった場合、乗務員は航空会社のガイドラインに従いどうしなければなら ないか？ ≪答え≫ 着陸後、救急隊にわたすまで救命処置を続けなければならない（if we stopped CPR, the airline’s protocol would require the cabin crew to continue it in our stead.） 質問２．筆者の言いたいことを簡単に１～２文程度でまとめなさい。 ≪答え≫ The proper practice of medicine does not include treating irreversible disease when patients are overcome by illness. First I will define what I conceive medicine to be. In general terms, it is to do away with the sufferings of the sick, to lessen the violence of their diseases, and to refuse to treat those who are overmastered by their disease, realizing that in such cases medicine is powerless. — The Hippocratic Corpus The responsibility for deciding to stop CPR should rest with a physician who is focused solely on the good of the patient.
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