UNIVERSITY OF THE WEST INDIES

FACULTY OF MEDICAL SCIENCES

EXAMINATION OF MAY/JUNE 2016
Code and Name of Course: SU 500/MDSC 5555 STAGE II, PART IV EXAMINATION Paper: 1

Date and Time: THURSDAY, MAY 5, 2016: 9:00 a.m. -12:00 noon Duration: 3 hrs.

INSTRUCTIONS TO CANDIDATES:

This examination consists of Two Sections, A & B, and has 38 pages, including the cover page.

Section A, consist of Two Parts:

Part I contains 90 questions which require a Single Best Answer

Part II contains 25 questions of the extended matching type

DIRECTIONS:

For each of the questions, shade the appropriate box on the appropriate answer card.

Section B contains 5 questions requiring short written responses

YOUR QUESTION PAPER WILL BE COLLECTED ALONG WITH YOUR ANSWER CARD AT
THE END OF THE EXAMINATION

FAILURE TO RETURN YOUR COMPLETED PAPER WILL INVALIDATE YOUR MARKS

POINTS WILL NOT BE DEDUCTED FO INCORRECT ANSWERS GIVEN

©The University of the West Indies_______________________________________________________________________

DO NOT WRITE ON THE BACK OF THIS PAPER USE ONE SIDE ONLY
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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.

Question 1

A 52-year-old woman presented to her primary health care physician in the country with a
complaint of feeling weak and fatigued for the past (3) months. She also experienced
unintentional weight loss of 10 lbs. over the same period. Her physical examination is
essentially unremarkable. Blood investigations reveal that she has a microcytic anaemia and
she was subsequently referred to a tertiary care hospital for further management.

a) List three (3) surgically related conditions that may present with these non-specific
symptoms:

b) What other specific investigations would you order if you suspected a gastrointestinal
malignancy as the cause for her anaemia?

c) List four (4) routes of spread of colorectal cancer and give an example of each:

Diagnostic imaging tests revealed an “apple core” lesion in the ascending colon. There was no
mention of any visible metastatic deposits.
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d) The patient undergoes an exploratory laparotomy for resection of the affected segment of
colon. What specific surgical procedure should be done and list any five (5) early post-
operative complications you could expect:

Microscopic examination of the specimen by the pathologist reveals tumour invasion

through the muscularis propria into peri-colic tissues & evidence of spread to two (2)
regional lymph nodes.

e) Name three (3) pathological staging systems used for colorectal cancer AND using any (1)
system of your choice give the appropriate stage for this patient?

On routine surveillance imaging one (1) year after surgery, she is found to have a 2cm lesion
in the left lobe of the liver.

f) What are the options for management of liver metastases from colorectal carcinoma?

g) If any of her siblings or parents had a history of endometrial, ovarian or colorectal cancer,
what familial cancer syndrome would you consider? What genetic defect is responsible?
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Question 2

A 65-year-old bartender is referred to the clinic with a 6-month history of hoarseness and
unintentional 9 kg weight loss. He is known to have chronic obstructive pulmonary disease
(COPD). Neck examination demonstrates a 2 cm right-sided mass that is firm and fixed

a) List three (3) differential diagnoses that could account for his persistent hoarseness

b) What other important information would you ask about when ascertaining the medical
history?

Over the past week he has noted progressive difficulty breathing. Cranial nerve examination
is normal. There is mild biphasic stridor with deep inspiration and expiration, but the
patient has no increased work of breathing at rest, and breath sounds are clear.

c) What is the definition of stridor?

Flexible fibre-optic laryngoscopy demonstrates a necrotic, ulcerating mass involving the

right true and false vocal cords, and extension onto the epiglottis and aryepiglottic folds. The
right true vocal cord is immobile. The glottic airway is partially obstructed.

d) What further investigations would you request (give reasons for your choice)?

e) List two(2) surgical procedures that are sometimes performed in these patients prior to
definitive treatment
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f) What is the definitive surgical procedure used in the treatment of laryngeal cancer and List
any four (4) complications associated with this procedure

g) What other modalities are available in the treatment of suspected carcinomas of the larynx:

Six months after surgery the patient returns to the clinic with a painless 5 x 5cm firm fixed
mass close to the site of the original neck incision. Repeat radiological imaging is done and
review of the images determines that he is not a candidate for surgical neck dissection due
to encasement of a particular structure.

h) What structure is likely to be encased?

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Question 3

A 65-year-old woman with a known history of hypertension, presented to the accident and
emergency department with severe sternal chest pain radiating to the back and a cold
pulseless left leg. She describes the pain as “tearing” in nature and has no preceding history
of trauma. Her blood pressure on arrival was 195/90mmHg in the right arm and 160/70 in
the left arm.

a) What important clinical diagnoses should be considered in this patient:

b) Name four (4) clinical manifestations associated with further extension or extravasation of
blood into the layers of the affected organ or surrounding structures

c) What urgent investigations should be requested to aid in the management of this patient?

d) Name two (2) classification systems used to describe this condition

e) What is the definitive treatment of this condition, and what techniques/ approaches are
available to definitively treat this condition if diagnosed early?

f) List the monitors would you would want to place for the surgical treatment of this condition
and give (1) reason why you would want each monitor you have listed
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g) List four (4) outcomes or complications associated with surgical repair of this condition

h) Name any three (3) diseases that may be associated with this condition
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Question 4

A 25-year-old man is brought to the casualty department, with severe burns and a grossly
deformed, bleeding left leg after a motorcycle collision. He had become trapped under the
motorcycle, which caught on fire. On physical examination he is awake and alert but in
excruciating pain. In addition he has partial and full thickness burns to the chest, right upper
limb and lower limb. An open 5 cm wound is seen anteriorly in the mid-tibia. Dorsalis pedis
and posterior tibial pulses are palpable bilaterally.

a) List four (4) features on clinical examination that would indicate the need for immediate
endotracheal intubation of this patient

b) Outline the steps you would take in the initial resuscitation and management of this patients
injuries in the emergency room

c) Name five (5) common complications that are associated with burns
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Plain radiographs of the left leg reveal an angulated and displaced tibial shaft fracture. The
patient is taken to the operating theater for further debridement, and fixation of the fracture

d) List three (3) benefits of early fixation in this patient?

Five (2) hours after the procedure, he becomes increasingly confused and develops a
◦
temperature of 38.5 C. His oxygen saturation falls from 97% to 85%.

e) What complication has developed AND how would you manage it?

The patient is admitted to the burn unit for further intensive care and wound management.

f) What topical antibacterial agents are commonly used for the treatment of burns?
Name one disadvantage of each

His wounds heal satisfactorily and she is discharged after 3 months in hospital. 6 months
later he returns to the orthopedic clinic with a complaint of persistent pain, swelling and a
discharging sinus from the left leg. X-rays reveal non-union of the tibial shaft.

g) How would you manage this unfortunate complication?

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Question 5

A 66-year-old man who recently attended a prostate screening symposium is referred to the urology
clinic after he was found to have a prostate-specific antigen (PSA) level of 8 ng/mL. His physical exam
was normal and the digital rectal examination revealed a slightly enlarged but benign-feeling
prostate. His past medical history was unremarkable.

a) What are the criteria necessary to initiate a screening programme for a particular disease?

b) List four (4) conditions that may cause to an elevated PSA:

c) What general historical information would you ask this patient?

d) If you were concerned about advanced prostate malignancy what symptoms might you expect
the patient to have?
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e) Name two (3) radiologic imaging tests that could be helpful in this patient

f) Briefly outline the steps involved in performing a prostate biopsy

Prostatic biopsy revealed a Gleason score 7 (4 + 3) adenocarcinoma in 6 of 12 specimens.

g) Would you offer a surgical procedure to this patient and if so what procedure?

h) If the patient declined to have surgery done what treatment options are available?