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UWI ID number: _____ / __________

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. You are called to see a 23-year old male who sustained a single stab
wound to the left chest in the mid-clavicular line, just below the level of
the nipple. His only complaint is shortness of breath. His vital signs are
as follows: Heart rate- 90/min, Blood Pressure- 130/70, Respiratory rate
-25 breaths per minute. On physical examination his trachea is central,
heart sounds S1 & S2 are clearly audible. However decreased breath
sounds are heard in the left lung base.
a) Name (6) possible organs or structures that could have been injured (6
marks)
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b) Outline the immediate steps in the management of this patient (6 marks)
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c) What investigations would you order (if any)AND explain why?(4 marks)
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University Of the West Indies

UWI ID number: _____ / __________


A chest tube attached to an underwater seal was inserted in the 5th left
intercostal space (directly above the rib below) and just anterior to the
mid axillary line. Approximately 500 mls of frank blood is drained and
his breathing and respiratory rate improves.
d) What is your immediate clinical diagnosis?(1 mark)
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e) Briefly explain the steps in the placement of a Chest tube and explain the
rationale behind (i) placing the tube just above the rib below and (ii)
anterior to the mid-axillary line (8 marks)
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30 minutes later you are called by the nurses who report that your
patient has started to complain of severe subscapular and bilateral
shoulder pain. A repeat blood pressure is 95/60, pulse is 110 and his
mucus membranes are pale. On repeat physical examination he is now
tender in the epigastrium
f) What could explain these clinical findings and how would you manage this
patient?(6 marks)
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University Of the West Indies

UWI ID number: _____ / __________


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University Of the West Indies

UWI ID number: _____ / __________


2. A 10-year-old girl with Sickle cell Anaemia presents to the Childrens
hospital with a history right hip and groin pain. Her mother reports
that her child was away with her grandmother on vacation for a month
and since her return home her child has been walking with a limp and
refusing to weight bear.
a) List six (6) causes of an irritable hip in the paediatric age group (6 marks)
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On physical examination she is ill- looking with a temperature of
38.5 C. Inspection reveals her right hip to being a position of flexion,
abduction and external rotation. Manipulation of the ipsilateral thigh
is painful and range of movement is decreased.
b) List four (4) relevant laboratory investigations that would aid in confirming
your suspected diagnosis. (4 marks)
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c) List four (4) diagnostic imaging tests that may also be helpful. (4 marks)
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Imaging indicates the presence of a joint effusion. Macroscopic
analysis of the synovial fluid aspirate from her right hip reveals a
thick yellow-green coloured fluid.

University Of the West Indies

UWI ID number: _____ / __________


d) On microscopic analysis of the synovial fluid How many White blood cells
(per mm3) would be considered significant to confirm your clinical
diagnosis? (2marks)
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e) Describe the appropriate microbiologic characteristics for the MOST likely
organism responsible (i.e. appearance on gram stain, shape, selective
culture media, and whether it ferments lactose or not)
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You explain to the mother that her daughter will require emergency
surgical intervention. However her mother has expressed concerns
regarding sickle cell disease and surgery.
f) List six (6) surgical and/or anaesthetic complications associated with Sickle
Cell anaemia AND briefly explain what steps are taken to prevent or
reduce the likelihood of these complications(6 marks)
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University Of the West Indies

UWI ID number: _____ / __________


g) Outline how would you continue to manage this patient pre-operatively?(4
marks)
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h) What surgical procedure is necessary?(1 mark)
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The patient is treated successfully and the immediate postoperative
period was uneventful. On review of the child in the orthopaedic clinic
her progress has been satisfactory.
i) List any three (3) sequelae of Sickle Cell Anemia that may require surgery
in the future (3 marks)
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University Of the West Indies

UWI ID number: _____ / __________


3.

A 16-year old Jamaican male presented to the clinic complaining of


headaches, unilateral hearing loss, ear ache and difficulty
swallowing for 2- months. Recently he has been experiencing right
nasal congestion which is sometimes accompanied by a blood tinged
nasal discharge. On physical examination a 3.5 cm nodule is
palpable under the upper one-third of the right sternocleidomastoid
muscle.
a) What is the MOST likely clinical diagnosis? And List two (2) other possible
differential diagnoses in this patient (3 marks)

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b) What are the different risk factors associated with the MOST likely diagnoses?
( 4 marks)
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c) What laboratory studies would you order in this case? ( 4 marks)
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d) List four (4) radiologic imaging or hearing investigations that may be useful
in this patient AND explain the rationale behind any two (2) investigations
chosen (6 marks)
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University Of the West Indies

UWI ID number: _____ / __________


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e) List two (3) operative procedures that may be considered necessary prior to
starting treatment with chemotherapy or radiotherapy in these patients (3
marks)
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f) Which histological classification system is used when categorizing this illness
AND briefly state what each category entails? (6 marks)
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g) List two (2) chemotherapeutic agents have that been shown to improve
survival in patients with this condition: ( 2marks)
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h) List any (3) complications specifically associated with Radiotherapy (3 marks)
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University Of the West Indies

UWI ID number: _____ / __________


4.

You are the doctor assigned to a busy paediatric surgery unit. You
receive a call from your paediatric medicine colleague to review a 1
month old baby with feeding intolerance, copious diarrhoea and
significant abdominal distension. On examination the neonate has
low set ears, up slanting palpebral fissures and a cardiac murmur
a) Are there any other questions you would ask about this patient?

b) Which congenital anomaly is a strong risk factor for this condition?

c) What investigations would you order initially AND what result would
you be looking for?

d) How is the definitive diagnosis made?

e) Outline your approach to the initial management of this neonate in the


acute setting;
(Assuming this patient had long segment disease and enterocolitis)

f) Microscopic examination of the resected surgical specimen will show;

University Of the West Indies

UWI ID number: _____ / __________

g) List two (2) complications that may result from surgical intervention

h) The deletion in the long arm of which chromosome is thought to be responsible for
this disease

University Of the West Indies

UWI ID number: _____ / __________

5. A 14-month-old female is referred to the ophthalmology clinic by her


family general practitioner, after she was found to have a strabismus and
a white reflex on direct ophthalmoscopy of the left eye.
a) List (4) differential diagnoses thats should be considered in a patient with
leucokoria;

b) How would you investigate this patient?

c) How would you manage this patient?

University Of the West Indies

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