UWI ID NUMBER: ___/ _____________SECTION BStructured Answer Essay QuestionsInstructions: 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)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________b) What other areas in the body would you examine and why? (2 marks)

______________________________________________________________________________c) Name (2) appropriate radiological investigations that you would request and outline your reasons why (2 marks)

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________d) Outline (3) three possible sequelae that could result from this condition (3 marks)__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________e) List and explain two (2) possible options or approaches for surgical repair (4 marks)_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________f) List (6) specific post-operative complications that could result from surgical intervention: (6 marks)_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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)___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________b) In a systematic way outline how you would proceed in the initial diagnostic workup of this patient (6 marks)___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

c) If no obvious lesions are seen after your initial investigations, how would you then proceed? (3 marks)_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________d) If disease was confined to his neck nodes, what treatment options would be available? (3 marks)_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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?

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

b) Explain the physiological basis of her symptoms (3 marks)

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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)

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________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)

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________e) Briefly outline the steps in the pre-operative management of this patient (6 marks)

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Explain how you would approach and remove:

f) The stone located in the distal common bile duct (3 marks)

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________g) The stone located in the intrahepatic bile duct (3 marks)

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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)

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________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)

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________c) Biopsy of the right supraclavicular nodes will likely reveal malignant cells of which histological type (1 mark)

__________________________________________________________________________________________________________________________________________________________d) List three (3) paraneoplastic syndromes that are associated with this this disease (3 marks)

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________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

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?

__________________________________________________________________________________________________________________________________________________________Outline two (2) available options for treatment of this patient? (2 marks)

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________

List three (3) contraindications to surgical resection (3 marks)

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Briefly outline the pre-operative preparation of this patient (6 marks)

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________What are the options for lung resection and what structures are typically removed during surgery?(6 marks)

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________List six (6) possible intraoperative or postoperative complications specific to surgical resection

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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)

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________b) What is the MOST likely clinical diagnosis? (1 mark)

____________________________________________________________________________________________________________________________________________________c) List five (5) gastrointestinal complications associated with this condition (5 marks)

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________d) List (3) extra-intestinal complications associated with this disease (3 marks)

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________e) How would you investigate the likely cause of this patients complaint? (3 marks)

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________f) Explain how you would surgically approach this problem and repair the defect?

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

UNIVERSITY OF THE WEST INDIES