ESA 2 Past Questions

Selected Q&A from ESA 2 Papers 1& 2; 2008

Q1Q8 A 43 year old woman reports that her previously

regular menses have become more erratic and sometimes very heavy over the past year.

a State the anatomic pre-requisites of menstruation.LO Describe the hypothalamic/pituitary mechs and

interaction with the ovaries. Describe the changes in ovary and endometrium

1. Functioning Hypothalamic- Pituitary –Ovarian axis2. Uterus with responsive/functioning endometrium3. Outflow tract for menstrual flow ( patent cervix and

vagina) [did not accept just “perforate hymen”]

(1 mark for each; max 3 marks)

b List the sequence of events in the ovarian cycle from a pre-ovulatory follicle to a corpus luteum.

LO Describe the ovarian cycle including the stages of development of follicles and the corpus luteum

• LH receptors appear on the outer granulosa cells [Marks also given for mention of FSH/LH stimulating appropriate cells]

• Oocyte restarts meiosis• Follicle size increases as antral fluid volume

increases/Graafian follicle• LH surge stimulate collagenase and follicle ruptures• Ovulation occurs• Follicle re-organises to form corpus luteum(1 mark for each; 6 marks)

c This patient’s friend has told her she probably has fibroids. What is a fibroid?

LO Identify common causes of menorrhagia

Benign, leiomyoma / smooth muscle tumour of myometrium, oestrogen dependent (1 mark for each; max 2 marks)

(2 marks)

d The patient is more concerned about possible cancer.

LO Describe presentation, pathologic features and prognosis of endometrial adenocarcinoma, describe the features of cervical cancer

List TWO types of cancer that might explain her symptoms. Use correct terms to indicate site and cell type.

Endometrial adenocarcinomaCervical squamous cell [or adeno] carcinoma

Uterine leiomyosarcoma Did NOT accept choriocarcinoma / vaginal

cancers (4 marks total)

e This patient finally has a hysterectomy. List THREE ligaments that need to be identified and ligated to enable the uterus to be removed from the abdomen.

LO Describe the anatomy of the reproductive tract.

Round LigamentUtero-ovarian LigamentCardinal ligament (Trans-cervical)

Utero-sacral ligaments (3 marks) Did NOT accept broad ligament / precise

terms only

f A year after recovering from her surgery this patient reports hot flushes despite still retaining her ovaries. Briefly explain why this has occurred.

LO Describe the changes of the menopause and their mechanisms

• Her ovarian function is waning as the number of follicles becomes depleted.

• Her oestrogen levels will fall giving rise to vaso-motor symptoms such as hot flushes.(2 marks)

Mention of menopause alone insufficient – needs explanation

Q2

• A 72 year old man is a keen golfer. He now reports severe crampy pain in his right calf when he is on the golf course. The pain subsides when he sits in his golf cart.

LO CVS: Understand peripheral vascular disease

a i) What is the likely diagnosis, given the history outlined above?

Peripheral vascular disease: Intermittent claudication (1 mark)

ii) What is the likely cause?

Atherosclerosis in the aorta or (more likely) a major artery to the lower limb

[accepted atheroma along with appropriate site] (1 mark)

LO CVS: Understand causes of pain and nature of vasodilator metabolites

bi) List TWO factors that may cause the pain felt during exercise.

Build up of the products of (anaerobic) metabolism, including: adenosine, lactate, K+,H+, insufficient oxygen supply to muscles

(1 mark for each up to a maximum of 2 marks)

ii) What effect will these factors have locally on blood vessel diameter?

They are vasodilator metabolites (1 mark)

LO Musculo skeletal: Understand basic anatomy of the lower leg

ci) Name the muscle(s) in his calf.i) Gastrocnemius (lateral and medial heads)

SoleusPopliteusFlexor digitorum longusFlexor hallucis longus

Plantaris Tibialis posterior (5 marks)

ii) How are the muscles of the calf innervated?

All are innervated by branches of the tibial nerve (1 mark)

iii) Which arteries supply the musculature of the calf ?

Muscles are supplied by the posterior tibial and peroneal (fibular) artery. (1 mark) 

LO CVS: Understand the relationship between resistance and radius in blood vessels.

di) Explain how the resistance of blood vessels changes with a change in vessel radius in laminar flow?

Resistance increases as the radius of the vessel falls. In laminar flow:

0.5 mark for ‘inversely proportional’ 1 mark for full equation

(1 mark)ii) Whose law summarises the relationship between radius

and resistance?

Poiseuille’s Law (1 mark)

4

1

rR

LO CVS/Clinical skills: Understand characteristics of the pulse and how it is altered in a simple disease state.

e i) What are the FOUR characteristics of the pulse?

Rate [frequency accepted]RhythmCharacter Volume [Force / strength also accepted] (0.5 marks for each)

ii) How would the pulse change in the area affected in this patient?

Pulse diminished (or absent) to the affected area (1 mark) NOT accepted ‘thready’

iii) Where would you elicit it?

Popliteal or tibialis posterior or femoral (1 mark) (anatomical location accepted)

Dorsalis pedis NOT accepted: from anterior tibial artery

LO CVS/Mechanisms of disease: Understand factors that increase the risk of vascular disease.

f Give TWO modifiable or treatable factors that

increase the risk of peripheral vascular disease.

SmokingDiabetesHypertensionDiet – high fat/cholesterol

Obesity/ overweightHypercholesterolaemiaLack of exercise(1 mark for each; max 2)

Q3

A 82 year old woman with Type 2 diabetes mellitus falls and sustains a fracture of the neck of the left femur at the hip joint.

a Describe the TWO major types of fracture of the neck of the femur and the TWO types of fracture in each group.

1. Intracapsular (1)–

Subcapital and Trans-cervical(1)

2. Extracapsular-(1)

Basal and Intertrochanteric(1)

(1 mark for each correct part)

Subtrochanteric accepted

b Describe the clinical appearance of the leg in this situation.

• Shortening of the leg.• External Rotation of the leg at the hip.

Both required for 1 mark

C The adductor muscles of the thigh are in spasm as she is lying.

(i) Describe the nerve supply of the adductor magnus muscle

Adductor part – Obturator nerve (1)Hamstring part – Sciatic Nerve (1)

(ii) Which muscle of the medial compartment of the thigh has an attachment distal to the femur?

Gracilis(1)

(iii) Name TWO muscles which ABDUCT the femur when the hip is EXTENDED.

Gluteus Medius (1) Gluteus Minimus (1)

LO: describe the basis of insulin secretion and insulin action

d) Name TWO hormones associated with the stress response that counter regulate the action of insulin.

Adrenaline and cortisol(2 marks)(Do not accept Glucagon and Growth hormone- not necessarily associated with the stress response)

LO: Describe the common long term side effects of diabetes

e) Give FOUR long term complications of poorly controlled Type 2 diabetes.

Neuropathy (1 mark)

Nephropathy (1 mark)

Peripheral Vascular Disease (including ‘diabetic foot’ – 1 mark)

Retinopathy (1 mark)

Macrovascular complications (including answers such as atherosclerosis and increased risk of MI - 1 mark)

Increased risk of GU infection (1 mark)

Max. 4 marks

LO: Describe drug therapies and lifestyle regimes used to treat NIDDM

F Give TWO lifestyle changes and TWO different pharmacological strategies that can be used as treatment of Type 2 diabetes.

Life style: Reduce weight, reduce cholesterol/fat, stop smoking, reduce alcohol and increase exercise (1 mark each; max 2)

Pharmacological strategies (2 marks)Insulin

Reduce glucose output from the liver (eg. biguanides)Increase insulin sensitivity (eg. biguanides / thiazolidinediones)Decrease carbohydrate absorption (eg. alpha glucosidase inhibitor) Increase insulin output (eg. sulphonylureas)Reduce cholesterol/fat absorption (eg statins, fibrates etc)

An example of specific drug from the different classes above = 1 mark