Royal Free and University College Medical School Phase 1, Year 2: February 2007 © Copyright 2007 Royal Free and University College Medical School Modified Essay Question and OSPE Paper 2 hours are allowed for this paper. You should attempt all 12 questions, 6 MEQs and 6 OSPEs, answering each one on the page for that question. You should not spend more than about 7 – 8 minutes on any one question. You are provided with a sheet of bar-code labels. Place one label in the space marked on the page for each question. You are provided with a computer-readable card for questions 4, 5 and 6 in the OSPE. Read these questions carefully and make sure you enter your answers on the correct lines of the card. You should read through all parts of each question before you begin to answer it – the number of marks for each part question is shown. If you need more space for an answer, continue on the reverse of the page for that question only – the question paper will be split and each page will be marked by a different person. Most questions in the MEQ are linked to clinical scenarios. Information about the patient is shown at the top of each question; this may differ from one question to another, as additional information is relevant to the question being asked. This question paper must not be removed from the examination room.

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Question 1 Mr Broker fell and fractured his femur. At the time of the fracture he became extremely agitated and suffered a lot of pain. During the subsequent weeks spent in traction, the pain was carefully managed, but Mr Broker became increasingly stressed at the time he was absent from work. a) Which hormones mediate the physiological and metabolic effects of:

acute stress (1 mark)

chronic stress? (1 mark)

b) What is the common, major metabolic effect of these two hormones? (2 marks) c) How do the cellular mechanisms of action of these two hormones differ? (10 marks) d) Name 3 enzymes that are up-regulated by the chronic stress hormone to bring about its major metabolic action. (2 marks each)

2MEQ-OSPE Feb07 2

Question 2 To what extent will the Mental Capacity Act change the rules about:

a) Advance directives?

b) The position of family and friends of non-competent patients?

c) Understanding what to count as relevant to a non-competent patient’s best interests?

(20 marks)

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Question 3 Give reasons why a patient may receive some of the following drugs, indicating the receptors that these drugs may interfere with, either as a pre-medication prior to a surgical operation or in the operating theatre: a) Atropine (2 marks) b) Diazepam (3 marks) c) Pancuronium (3 marks) d) Neostigmine (3 marks) e) Thiopental (thiopentone) (3 marks) f) Nitrous oxide (3 marks) g) Fentanyl (3 marks)

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Question 4 A 37- year old man developed clumsy movements of his right arm. After 6 months they were quite difficult to cope with and when he attempted fine movements, like inserting his front door key into the lock, he noticed a tremor of his right hand, but there was no tremor at rest. He has started to reel over to the right when he walks. Passive movement of the arms and legs revealed hypotonia on the right, but not on the left side. Patellar tap causes a reflex extension at the knee but then the lower part of the limb swings back and forth. When asked to touch his nose with his right index finger, there was tremor of the right hand and the finger overshot the target. Speech was normal and there was no nystagmus. a) What brain structure is involved in this condition and why are the symptoms on the right side only. (4 marks) b) Why did the symptoms develop slowly? (2 marks) c) What specific physiological functions have been disturbed to produce the hypotonia and the pendular muscle stretch reflex? (5 marks) d) What type of tremor is seen in this patient and what causes it? (5 marks) e) What is nystagmus and why was it absent in this case? (4 marks)

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Question 5 Outline one of the causes of depression in the elderly. (20 marks)

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Question 6 The table shows the energy yield of metabolic fuels, and oxygen consumption and carbon dioxide production when they are metabolised. energy

yield O2 consumed

CO2 produced

RQ kJ /L O2

kJ /g L /g L /g carbohydrate 16 0.829 0.829 1.0 20 protein 17 0.966 0.782 0.809 20 fat 37 2.016 1.427 0.707 20

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(RQ – 0.707) percentage of energy derived from carbohydrate = (1 – 0.707)

x 100

The table below shows oxygen consumption and carbon dioxide production for a student at rest and exercising at two different rates on a treadmill. In each case the measurements were taken over a 30 minute period

A B C D E L O2

Energy expenditure kJ / 30 min

L CO2

RQ % energy from carbohydrate

% energy from fat

grams fat metabolised

at rest 10.1 7.29

speed 1 15.8 11.4

speed 2 54.5 44.7

Calculate the following and write your answers in the boxes above:

(1 mark each)

a) His energy expenditure (kJ) in each 30 minute period b) His Respiratory Quotient (RQ, the ratio of CO2 produced / oxygen consumed) in each

30 minute period c) The percentage of energy derived from carbohydrate at each level of activity,

assuming that only fat and carbohydrate are being metabolised. d) The percentage of energy derived from fat at each level of activity, assuming that only

fat and carbohydrate are being metabolised. e) The amount of fat (in grams) he will metabolise in each 30 minute period

2MEQ-OSPE Feb07 7

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OSPE 1 Study this diagram of a hypothetical (theoretical) endocrine axis.

a) What action is hormone Z likely to exert on the synthesis and secretion of hormone X and/or Y? Explain your answer. (3 marks) b) Based on your knowledge of defined endocrine axes, what is the most likely site of synthesis for:

hormone X? (1 mark)

hormone Y? (2 marks)

c) Explain why your understanding of the somatotrophic / growth hormone axis might cause you to suspect the existence of an additional hormone that can antagonise the effect of hormone X on hormone Y. (4 marks)

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OSPE 2 The graph below shows a “Forest plot”, displaying results of a meta-analysis for the effects of corticosteroids in preventing death in people with acute traumatic brain injury. The lines represent estimates of Relative Risk (RR) with their 95% confidence intervals.

RR.1 1 2 5

Combined

Zagara

Stubbs

Saul

Ransohoff

Pitts

Hemesniemi

Grumme

Giannotta

Gaab

Faupel

Dearden

Cooper

Chacon

Braakman

Alexander

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a) Explain why meta-analysis is carried out when several studies have been conducted on given research topic (6 marks)

b) Explain what the diamond labelled “Combined” is telling us. (8 marks)

c) What is meant by “heterogeneity” in a systematic review? Does the Forest plot suggest any evidence of this? (6 marks)

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OSPE 3 The traces below showing the effects of isoprenaline (analogue of adrenaline), CaCl2 and the cardiac glycoside ouabain on the heart rate and force of ventricular contraction in an isolated perfused rat heart. Drugs are delivered via the coronary artery.

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a) What effect is isoprenaline having? Name the receptor/s that mediates these effects. What type of drug, giving a named example, could be used to block this affect? (3 marks) b) Give 3 major clinical uses of the drug type used to block the receptors isoprenaline acts on? (3 marks)

c) What are CaCl2 and the cardiac glycoside ouabain doing to the force of contraction? Give an outline of the mechanism by which this occurs for ouabain? (4 marks)

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OSPE 4 Answer this question on lines 1 – 10 of the computer marked card The picture shows a brain scan.

1) On line 1 of the card, select the letter that matches the type of brain imaging used in this scan: A) CT scan B) MRI -T1 weighted C) MRI, T2 weighted D) Angiogram 2) On line 2 of the card, select the letter that matches the plane of section of this brain image: A) Coronal B) Transverse C) Horizontal D) Saggital

On lines 3-10 of the card, identify the structures lying exactly under the point of each arrow - numbered 3-10. Each answer may be used once, more than once, or not all.

A) Third ventricle B) Septum pellucidum C) Lateral ventricle D) External capsule E) Caudate nucleus F) Fourth Ventricle G) Internal capsule H) Thalamus I) Left Temporal lobe J) Right occipital lobe K) Arachnoid L) Left occiptal lobe M) Cerebellum N) Dura O) Sub-arachnoid space P) Skull

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OSPE 5 Answer this question on lines 11 - 19 of the computer marked card The drawing represents a pair of pre- and post-ganglionic autonomic neurones. Select the one most appropriate letter for each label 11 - 19 on the diagram. It may be appropriate to use a letter more than once, while some letters will never be used. However, each individual question must be answered with a single letter only. If you indicate more than one letter per numbered line you will score zero for that part of the question.

A) Myelinated nerve fibre B) Gap junction C) Varicosities containing transmitter D) Presynaptic terminal containing transmitter E) Node of Ranvier F) Nerve cell body G) Macrophage H) Unmyelinated axon I) Synaptic cleft J) Synapse K) Purkinje cell

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OSPE 6 Answer this question on lines 20 -33 of the computer marked card

For each structure labelled 20 – 33, select the one correct label from the list below. Note that there are two separate lists of possible labels for structures 20 – 26 and 27 - 33

Use this list for lines 20 - 26 Use this list for lines 27 - 33 A Trochlear nerve A Trochlear nerve B Mammillary body B Vestibulocochlear nerve C Optic chiasma C Optic tract D Olfactory tract D Abduscens nerve E Pituitary stalk E Medial lemniscu F Optic tract F Oculomotor nerve G Medial lemniscus G Glossopharyngeal, vagal and cranial accessory

nerve roots H Oculomotor nerve H Dorsal column I Trigeminal nerve I Trigeminal nerve J Abduscence nerve J Fimbria K Facial nerve K Olive L Olfactory bulb L Facial nerve M Optic nerve M Olfactory bulb N Corpus callosum N Optic nerve O Anterior perforated substance O Decussation of the pyramidal tract P Fimbria P Corpus callosum

END OF PAPER

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