SECTION B

Structured Answer Essay Questions

Instructions: Please write the answer in the space provided only. Note that marks
vary for each response. Correct precise answers gain full marks. Responses that are
close may be given partial marks.

1. An 83-year old man with a history of diabetes, hypertension and chronic renal failure presents to
the surgical clinic complaining of pain and swelling to the left leg of 6 weeks duration. On
examination, a palpable pulsatile mass is felt behind the left knee extending to the lower thigh.
Left distal pulses were weak, while the ankle brachial index (ABI) for the left and right limb was
0.8 and >1, respectively.
a) List (4) four differential diagnoses for a painful swollen leg. (list the MOST likely first) (4
marks)
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b) What other areas in the body would you examine and why? (2 marks)

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c) Name (2) appropriate radiological investigations that you would request and outline your reasons
why (2 marks)
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d) Outline (3) three possible sequelae that could result from this condition (3 marks)
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e) List and explain two (2) possible options or approaches for surgical repair (4 marks)
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f) List (6) specific post-operative complications that could result from surgical intervention:

UWI ID NUMBER: ___/ _____________

(6 marks)
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UNIVERSITY OF THE WEST INDIES

UWI ID NUMBER: ___/ _____________

2. A 66-year-old man with a history of smoking and alcohol use is

referred to your service with an enlarging unilateral anterior neck
masses for the past 6 months. An excisional biopsy of one of the
masses confirms lymph node metastases with squamous cell
carcinoma from an unknown primary.
a) List six (6) possible locations of the primary tumour in the head and neck
region AND for each anatomical site state relevant symptoms in the history
that might direct your search.
(12 marks)
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b) In a systematic way outline how you would proceed in the initial
diagnostic workup of this patient
(6 marks)
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UWI ID NUMBER: ___/ _____________

c) If no obvious lesions are seen after your initial investigations, how would you then proceed?
(3 marks)
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d) If disease was confined to his neck nodes, what treatment options would be available? (3 marks)
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UWI ID NUMBER: ___/ _____________

3. A 45-year old woman is admitted for evaluation of right upper

quadrant and epigastric pain for a duration of one month. Recently
she had two attacks of chills and fever associated with jaundice,
dark urine and acholic stools. She also reported nausea and
vomiting that was not related to meals. On physical examination
she is ill looking and has scleral icterus.
a) List four (4) possible causes of obstructive jaundice?
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b) Explain the physiological basis of her symptoms (3 marks)
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c) Outline two (2) haematological/ biochemical tests and two (2)
radiological investigations that you would order to evaluate this
patient: (Briefly explain the expected results of each)
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Your investigations reveal an 18 mm dilatation in the common bile duct
along with of several stones in the distal common bile duct and left
intrahepatic duct.
d) List (2) life threatening complications that may result from stones in
the common bile duct
(2 marks)
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e) Briefly outline the steps in the pre-operative management of this
patient (6 marks)

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UWI ID NUMBER: ___/ _____________

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Explain how you would approach and remove:
f) The stone located in the distal common bile duct (3 marks)
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g) The stone located in the intrahepatic bile duct (3 marks)
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UNIVERSITY OF THE WEST INDIES

UWI ID NUMBER: ___/ _____________

4. A 61-year-old farmer is referred to your clinic with a history of

severe pain in the neck, left shoulder and arm. He also reported
associated numbness and tingling extending from his forearm to
the tips of his fourth and fifth fingers. His wife has also noticed a
change in his voice for some time now. He has a long history of
cigarette smoking and drinking rum. On examination he has a firm
mass in the right supra-clavicular fossa, ptosis of the right eye and
distension of the superficial veins of the ipsilateral neck.
a) List four (4) possible differentials that could explain his symptoms (List the
most likely diagnosis first)? (4 marks)
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b) List (6) appropriate investigations or procedures that would you request to
confirm your suspected diagnosis and evaluate the patient for resectability?
(Briefly explain the reasoning behind each investigation) (6 marks)
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c) Biopsy of the right supraclavicular nodes will likely reveal malignant cells of
which histological type (1 mark)
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d) List three (3) paraneoplastic syndromes that are associated with this this
disease (3 marks)
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Radiological Imaging of this patient shows extension of the primary
lesion through the visceral pleura to the parietal pleura and the
chest wall. There are no signs of lymph node metastases or distant
spread

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UWI ID NUMBER: ___/ _____________

e) According to the American Joint Committee on Cancer (AJCC), Lung cancer

staging classification (7th edition), what is minimum T-N-M stage
classification of this patient?
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Outline two (2) available options for treatment of this patient? (2 marks)
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List three (3) contraindications to surgical resection (3 marks)
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Briefly outline the pre-operative preparation of this patient (6 marks)
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What are the options for lung resection and what structures are typically
removed during surgery?
(6 marks)
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List six (6) possible intraoperative or postoperative complications specific to
surgical resection
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UWI ID NUMBER: ___/ _____________

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UNIVERSITY OF THE WEST INDIES

UWI ID NUMBER: ___/ _____________

5. A 65-year-old woman is admitted to the Urology department with

a complaint of dysuria, pneumaturia and faecaluria for 3 weeks.
She has a past medical history of abdominal bloating, flatulence,
occasional diarrhea and painless rectal bleeding. On physical
examination she is mildly tender in the left lower quadrant.
Urine microscopy shows ++ blood
a) List (4) differential diagnoses that could explain the symptoms related
to her presenting complaint: (4 marks)
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b) What is the MOST likely clinical diagnosis? (1 mark)
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c) List five (5) gastrointestinal complications associated with this
condition (5 marks)
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d) List (3) extra-intestinal complications associated with this disease (3
marks)
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e) How would you investigate the likely cause of this patients complaint?
(3 marks)
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UWI ID NUMBER: ___/ _____________

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f) Explain how you would surgically approach this problem and repair the
defect?
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UNIVERSITY OF THE WEST INDIES