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. 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)
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________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)
__________________________________________________________________________________
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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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)
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________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)
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________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.
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)
__________________________________________________________________________________________________________________________________________________________________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)
__________________________________________________________________________________________________________________________________________________________________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)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
g) Outline how would you continue to manage this patient
pre-operatively?(4 marks)
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________h)
What surgical procedure is necessary?(1 mark)
_________________________________________________________________________________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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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)
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________b)
What are the different risk factors associated with the MOST likely
diagnoses? ( 4 marks)
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________c)
What laboratory studies would you order in this case? ( 4
marks)
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________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)
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________e)
List two (3) operative procedures that may be considered necessary
prior to starting treatment with chemotherapy or radiotherapy in
these patients (3 marks)
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________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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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;
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
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
