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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 14-year-old boy presents with complaints of right knee pain of
approximately 2 months' duration. He remembers falling during football
training 2 months ago, but the trauma was not severe enough to seek
medical attention. Shortly afterwards, he started having pain at night or
after football practice. The pain would initially subside with rest and overthe-counter medication. However, for the past 2 weeks the pain has
increased in intensity, causing him to limp. His mother has noticed his
right thigh is slightly larger than the left. It is also warm and tender to
touch.
a) State the MOST likely diagnosis AND list two (2) other conditions you could
consider as reasonable differential diagnoses in this patient?

b) List any three (3) risk factors associated with the condition you chose above
to be the most likely

c) What are the characteristic X-ray features that one might see if they imaged
this patients right knee?

d) What further laboratory or imaging investigations would you consider

ordering?

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e) Name any one (1) staging system criteria used to stage this disease

f) How would you proceed in the treatment of this patient if he had high grade
non-metastatic disease on presentation?

g) What is the characteristic feature of this lesion on microscopy?

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Question 2
A 25-year-old woman presents with one episode of haematochezia. She is
concerned because her mother died of colorectal cancer at 50 years of
age. She has no further information about her family history. Physical
examination is normal. She undergoes colonoscopy and is found to have
20 adenomas ranging in size from 4 to 15 mm.
a) What is the diagnosis? What gene mutation is likely to be responsible?

b) Briefly explain the adenoma-to-carcinoma sequence

c) What is Gardners Syndrome?

d) What other diagnostic test(s) would you consider ordering to obtain a

complete evaluation?

e) What are her options for operative treatment and subsequent reconstruction?

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f) If she is unwilling to undergo immediate surgical treatment and has no
contraindications to delayed surgery what is/are her option(s)

Despite undergoing a procto-colectomy the patient still develops a

malignancy.
g) In which location(s) of the gastro-intestinal tract could polyps still result in
malignant transformation?

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Question 3
A 32-year old man presents to the accident and emergency department
with vomiting and severe abdominal pain; relieved on lying forwards but
worse on lying flat. He was previously seen in the out-patient department
3 weeks ago with complaints of fatigue, muscle weakness, and
constipation. He has a past medical history of renal stones and
depression. He denies smoking or alcohol usage. Review of his blood
results show evidence of elevated serum amylase and hypercalcemia
a) What clinical findings would you look for on physical examination?

a) List (3) complications associated with this condition

b) How would you manage this patient initially in the emergency room?

c) What imaging test(s) would you consider AND what results would you expect
for each?

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d) What is your interpretation of these results?

Assuming the results of the investigations ordered show no evidence that

his symptoms were due to gall stones or alcohol.
e) What is the most likely cause of his symptoms

f) What investigations would you do to confirm your hypothesis?

g) What definitive surgical procedure(s) could be offered electively after his

symptoms subside and he settles?

h) List four (4) complications associated with this elective surgical procedure;

i) If a first degree relative of this patient was discovered to have elevated

serum calcium and a pancreatic or pituitary tumour, what familial syndrome
would you consider?

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Question 4
A 68-year-old man presents to the emergency department complaining of an
inability to urinate during the previous 12 hours. He has severe lower abdominal
pain. Prior to this, he noted a weaker force of urinary stream, difficulty in starting his
urinary stream, and frequent episodes of waking at night to pass urine. On
examination, he has lower abdominal distention, which is dull to percussion .

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Question 5
A 55-year-old woman is referred to your service for surgical management.
She has severe Crohns disease and has failed medical therapy. She now
requires bowel resection and is expected to need total parenteral nutrition
(TPN) post-operatively.
a) With regards to the assessment of her nutritional status, pre-operatively
(i)

What historical information would be important?

(ii)

What clinical features would you look for on physical examination?

(iii)

List three (3) anthropomorphic measurements that could be taken?

(iv)

List five (5) laboratory investigations that you would order;

b) What would be the daily total caloric requirement (in Kcal per kilogram) if this
patient was 60 kg?

The patient undergoes exploratory laparotomy and resection of

approximately 160 cm of inflamed small bowel. A central venous catheter
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is inserted in her right subclavian vein for total parenteral nutritional
support.
c) Outline the steps involved in central line placement and state what technique has
made it easier and safer to place these lines

d) List five (5) early AND five (5) late complications associated with total parenteral
nutrition;

e)

List three (3) reasons why a patient with Crohns disease might need total-parental
nutrition?

f) What are the effects of mal-nutrition in wound healing?

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