Phase 1 Year 2: February 2007 Copyright 2007, Royal Free and University College Medical School Multiple Choice Question (MCQ) 1 hour is allowed for this paper. There are 75 questions altogether in this paper. The questions in this paper are arranged in groups of 5; each group is headed by a theme or brief clinical scenario. There is a list of possible answers, labelled A), B), C), etc for each theme or scenario. Only one answer is correct for each numbered question. If you mark more than one answer for any single question you score zero for that question. There is no negative marking. Some answers from the list may be used more than once, some may not be used at all. You should answer each question numbered 1 75 on the line of the card that has the same number as the question, and mark only one answer from the list. You are advised to mark your answers on this question paper, which you must hand in when you leave, then transfer your answers to the computer-readable card, using a pencil. Make reasonably firm marks on the card thin hesitant marks cannot always be read by the computer scanner but do not press so hard that you indent through the card. If you make a mistake, erase your incorrect response as thoroughly as possible, and enter your revised answer clearly. Do not score through an incorrect response the computer will read this as your response.

Acetylcholine contracts the guinea-pig ileum by activating muscarinic receptors. This effect is blocked by the alkaloid atropine: the acetylcholine and atropine binding sites on the receptor overlap

A) a reduction in maximum B) an increase in maximum C) a parallel shift to the right D) potency E) efficacy F) graded G) irreversible antagonist H) partial agonist I) functional antagonist J) competitive antagonist K) the Hill equation L) the Schild equation

For each of the following statements or questions, select the one most appropriate response from the list above: 1. How do you define a drug like atropine? 2. You expect the atropine to change the dose-response curve to acetylcholine. What do you expect

to see? 3. What equation allows you to calculate the atropine dissociation constant? 4. Atropine is an antagonist because it differs from acetylcholine in what property? 5. How would you describe the effect of acetylcholine on the ileum? Theme: Neurotransmission in the central nervous system

A) Acetylcholine B) Noradrenaline C) Diazepam D) GABAA receptors E) GABAB receptors F) Glutamate G) Glycine H) NMDA receptors I) Substance P J) 5-hydroxytryptamine (5-HT; serotonin) K) Enkephalins L) Dopamine

For each of the following statements or questions select the most appropriate response from the options above: 6. Can include peptides that produce slow depolarizations 7. Benzodiazepines act to enhance the function of this receptor 8. Wind-up and long term potentiation involve this receptor 9. Mood, anxiety, temperature control and pain modulation involve this monoamine 10. The peripheral actions of this transmitter make treatment of Alzheimers difficult

2EMS Feb07 2

Theme: neurological examination

A) Tuning fork (128Hz) B) Neuropen (monofilament) C) Reflex hammer D) Cotton wool E) Neurotips (red and white headed pins) F) Tuning fork (518Hz) G) No special equipment required

For each of the following examination procedures select the most suitable instrument form the list above 11. Testing for loss of vibration sense 12. Testing for clonus 13. Testing for loss of light touch 14. Testing for loss of pain sensation over the foot 15. Testing for joint position sense Theme: Systematic reviews

A) Concealment of allocation B) Intention to treat C) Blinding D) Absolute risk reduction E) Number Needed to Treat F) Pooled estimate G) Confidence interval H) Heterogeneity I) Kappa J) Publication bias K) Grades of evidence L) None of the above.

From the above list, select the phrase which the following sentences describe:- 16. The strategy for keeping doctors ignorant of patients treatment assignments before entering them

into a clinical trial 17. The tendency for studies which do not demonstrate treatment effects to remain invisible to the

medical community 18. The tendency for studies to suggest different conclusions about the benefits of a treatment 19. The probability of observing results at least as extreme as those actually seen in the particular

study if the null hypothesis were true 20. The uncertainty associated with quantifying treatment benefit

2EMS Feb07 3

Theme: ethics and law A) YES, because members of the family are the best people to decide what is in the best interests of

the patient. B) YES, because the patient has made an uncoerced decision about what is in his/her best interests. C) YES, because evidence about what the patient would have wanted is relevant to the doctors

decision about the patients best interests. D) YES, because breaches of confidentiality may be justified when there is a danger of serious harm. E) YES, because a doctor has a duty to consult the family of a non-competent patient. F) NO, because doctors have a duty to preserve life. G) NO, because patients must first be warned about any breach of confidentiality. H) NO, because a doctor should follow the instructions of a valid advance directive. I) NO, because patients have a right to refuse treatment even if it is life saving. J) NO, because this is a breach of respect for patient autonomy and confidentiality. In the following scenarios, are the doctors conforming to current law and professional guidelines? For each choose YES or NO, with the most appropriate explanation. 21. A seriously injured woman is brought into A&E after a car accident. The medical staff know that

although they might be able to save her life, she would survive only with serious brain damage. They ask her family if they know what she would have wanted.

22. An elderly woman is brought by ambulance to A&E with abdominal pain and vomiting. A

laparotomy reveals an inoperable cancer of the large bowel. Soon after she recovers consciousness her daughter arrives at the hospital. The consultant explains the situation to the daughter, and consults her about how much they should tell her mother about the prognosis.

23. A man who has severe Parkinsons disease makes an advance directive refusing any attempt at

resuscitation. He develops a life-threatening pneumonia and goes into respiratory failure. His family insists that he should be treated and the doctor decides to ventilate him.

24. A patient is clearly upset when a surgeon begins to describe the risks of options for treatment, and

he tells her he just wants her to do what she would choose for herself. So, having got the patients written consent, the surgeon goes ahead with the treatment she judges to be best.

25. A married man has a medical examination for life insurance, and as part of this he has an HIV

test, which comes back positive. The patient insists that the GP doesnt tell his wife. But the GP says that if the man himself will not tell his wife, he will do it.

2EMS Feb07 4

Theme: endocrine disorders

A) Acromegaly B) Achondroplasia C) Addisons disease D) Apparent mineralocorticoid excess E) Conns syndrome F) Cranial diabetes insipidus G) Cushings disease H) Glucocorticoid resistance I) Hypothyroidism J) Hyperthyroidism K) Laron dwarfism L) Nephrogenic diabetes insipidus M) Pseudohypoaldosteronism N) Pseudohypoparathyroidism

From the above list of clinical conditions, select the most likely explanation of each of the following lists of clinical findings: 26. Hypokalaemia / hypervolemic hypertension / suppressed plasma renin / low plasma aldosterone /

elevated urinary cortisol:cortisone ratio 27. Elevated plasma ACTH / elevated plasma DHEAS / elevated plasma cortisol / absence of central

adiposity / normal face and limb shape 28. Osteomalacia / myopathy / hypocalcemic tetani / elevated plasma PTH 29. Polyuria / polydipsia / elevated plasma vasopressin 30. Elevated plasma GH / elevated IGF-1 / pronounced, course facial features and hands Theme: hormones and enzymes

A) 1-hydroxylase B) 5-deiodinase C) 5-deiodinase D) 5-reductase E) 5-reductase F) 11-hydroxylase G) 17-hydroxylase H) 21-hydroxylase I) 24-hydroxylase J) 25-hydroxylase

From the above list of enzymes, select the one which: 31. Converts thyroxine into the inert molecule, reverse T3 (rT3) 32. Is defective in the majority of patients with salt-wasting congenital adrenal hyperplasia 33. Is inhibited by a high plasma calcium concentration 34. Increases the potency of testosterone by catalysing metabolism to dihydrotestosterone 35. Acts in the kidney to limit the synthesis of calcitriol from 25-hydroxy-vitamin D

2EMS Feb07 5

Theme: Muscle contraction

A) Actin B) Blood glucose C) Calcium ions D) Hydrolysis of ATP E) Muscle glycogen F) Myasthenia gravis G) Myosin H) Plasma non-esterified fatty acids (nefa) I) Release of ADP J) Thick filament K) Thin filament L) Tropomyosin

For each of the following, select the one correct answer from the list A L above: 36. The major fuel of white muscle fibres at rest 37. The power stroke of muscle contraction 38. The major protein of thick filaments 39. The region of striated muscle where myosin is the major protein 40. A rise in the RQ (ratio of CO2 produced : O2 consumed) to near 1 in the fed state indicates that

this is the major fuel for muscle Theme: vision

A) A blind region moving within the visual field B) Central (foveal) vision poor C) Deficient colour vision D) Deficient 3-D vision E) Double vision (Diplopia) F) Eyestrain from constant accommodation G) Lazy eye (unilateral poor acuity) H) Lines of particular orientation blurred I) Night vision poor J) Peripheral vision poor K) Poor acuity close-up L) Poor acuity for distant vision

Select the one sign from the list A L above that would be most characteristic of each of the following (untreated) conditions: 41. A person with normal vision wearing +2D lenses 42. An attack of migraine with visual aura. 43. Astigmatism 44. Macular degeneration 45. People with normal vision, over 50

2EMS Feb07 6

Theme: blood vessels of the neck

A) Common carotid artery B) External carotid artery C) Facial artery D) Inferior thyroid artery E) Internal carotid artery F) Internal thoracic artery G) Lingual artery H) Maxillary artery I) Subclavian artery J) Superficial temporal artery K) Superior thyroid artery L) Vertebral artery

From the list above select the one correct name for each of the blood vessels labelled 46 50 in the diagram below:

46

47

48

49

50

2EMS Feb07 7

Theme: vitamin D

A) 1-Hydroxylase B) 24-Hydroxylase C) 25-Hydroxylase D) Calbindin E) Calcidiol F) Calcitriol G) Calcitroic acid H) Cholecalciferol (calciol) I) Ergocalciferol (ercalciol) J) Osteoblasts K) Osteoclasts L) Osteomalacia M) Osteoporosis N) RAR O) Rickets P) RXR

For each of the following statements select the one correct answer from the list above: 51. Required to form a dimer with the occupied vitamin D receptor. 52. The final active form of vitamin D. 53. Undermineralisation of bones in children. 54. Formed in the skin by uv irradiation. 55. Induced in various tissues by calcitriol. Theme: Measures of disease

A) Age-specific death rate B) Case fatality C) Crude death rate D) Cumulative incidence E) Death rate F) Period prevalence G) Person-time incidence H) Point prevalence I) Risk ratio J) Standardised mortality ratio K) None of the above

From the above list, select the measure that is defined by each of the following: 56. The number of new cases of disease in a defined population over a defined period, divided by the

number of subjects in the population at the start of the period. 57. The number of existing cases of disease in a defined population during a defined period divided by

the number of people in the population at the mid-point of the period. 58. The number of deaths occurring in a defined population in one year. 59. The proportion of all cases of a specific disease in a defined population that are fatal within a

specified period. 60. The number of deaths in a defined population over a defined period divided by the person-time at

risk of death over that period.

2EMS Feb07 8

Theme: Short Stature A) Basic fibroblast growth factor receptor B) Cranial irradiation C) Excess GH production from a pituitary tumour D) Growth Hormone E) Hypothalamic GHRH F) Insulin-like growth factor I G) Laron dwarfism H) Panhypopituitarism I) Sindh Dwarfism J) Somatostatin K) The growth hormone receptor

For each of the following questions, select the one correct answer from the list A-K above: 61. A genetic condition which results from a mutation of the GH receptor. 62. Lack of function of the GHRH receptor lead to this condition. 63. High circulating GH can be observed in this clinical condition of short stature 64. Achondroplasia is caused by a mutation in. 65. This hormone would be raised in most cases of GH deficient short stature. Theme - cerebellar control of movement

A) The dentate nucleus of the cerebellum B) The globose/emboliform nuclei of the cerebellum C) The flocculo-nodular lobe of the cerebellum D) The anterior lobe vermis of the cerebellum E) The inferior olive F) The ventral posterior nucleus of the thalamus G) The ventral lateral nucleus of the thalamus H) The superior olive I) The cerebellar hemispheres J) The middle cerebellar peduncle K) The superior cerebellar peduncle L) The inferior cerebellar peduncle

Choose the option from the list A L above that best fits each definition: 66. The route through which pontine mossy fibres enter the cerebellum. 67. The major target of efferent fibres from the dentate nucleus of the cerebellum. 68. The source of climbing fibre input to the cerebellar cortex. 69. A brain region where damage causes ataxia of gait. 70. A cerebellar region important for the control of eye movements.

2EMS Feb07 9

Theme: Diagnostic use of the pupillary reflex

A) Raised intracranial pressure or midbrain lesion B) Left oculomotor nerve lesion C) Right oculomotor nerve lesion D) Normal behaviour E) Left optic nerve lesion F) Right optic nerve lesion

From the above list, select the appropriate diagnosis indicated by the following signs: 71. Light in right eye elicits contraction of both pupils, light in left eye elicits contraction of both pupils 72. Light in right eye elicits contraction of both pupils, light in left eye does not elicit contraction of

either pupil 73. Light in right eye does not elicit contraction of either pupil, light in left eye elicits contraction of both

pupils 74. Light in right eye elicits contraction of right eye pupil only, light in left eye elicits contraction of right

eye pupil only 75. Light in right eye elicits contraction of left eye pupil only, light in left eye elicits contraction of left

eye pupil only

END OF PAPER

2EMS Feb07 10

Theme: Neurotransmission in the central nervous systemTheme: Measures of diseaseA genetic condition which results from a mutation of the GH receptor.