Phase 1 Year 2: February 2008 Copyright 2008, Royal Free and University College Medical School Multiple Choice Question (MCQ) paper One hour is allowed for this paper. There are 80 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 80 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, 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.

Y2 EMQ Feb 08 2

Theme: Innervation of the face Possible answers are:

A) mandibular division of the trigeminal nerve B) facial nerve C) trigeminal nerve D) vagus nerve E) ophthalmic division of the trigeminal nerve F) buccal nerves G) greater auricular nerve H) long ciliary nerves I) maxillary division of the trigeminal nerve J) mental nerve K) supraorbital nerve L) mandibular division of the trigeminal nerve

Select the most suitable term to place in each of the spaces where a word is replaced by a number. Each answer can be used once, more than once or not at all. Most of the skin of the face is supplied with somatosensory fibres by the [ 1 ]. An exception to this rule is provided by the skin covering the angle of the mandible which is supplied by the [ 2 ]. Somatosensation from the cornea and the anterior surface of the nose is carried by the [ 3 ], whereas skin covering the sides of the nose and the upper lip is supplied by the [ 4 ]. Somatosensation from the external ear is carried by several nerves including the greater auricular nerve, the mandibular division of the trigeminal, the facial nerve and the [ 5 ]. Theme: the embryonic tongue Possible answers are:

A) copula B) median tongue bud C) lateral tongue bud D) hypobranchial eminence E) terminal sulcus F) chorda tympani nerve G) hypoglossal nerve H) glossopharyngeal nerve I) vagus nerve J) accessory nerve K) trigeminal nerve L) long ciliary nerves M) facial nerve

Choose the one item from the list above that best matches each of the following descriptions: 6. It lies in the midline of the pharyngeal floor and in first arch territory 7. It innervates tongue muscle fibres anterior to the terminal sulcus 8. Its fibres mediate temperature sensation in the tongue 9. Its fibres innervate taste-buds in the posterior part of the tongue 10. Its fibres pass anterior and dorsal to the first pharyngeal pouch

Y2 EMQ Feb 08 3

Theme: brain regions Possible answers are:

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 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 brain region from the list above that best fits each definition below: 11. The route through which pontine mossy fibres enter the cerebellum 12. The major target of efferent fibres from the dentate nucleus of the cerebellum 13. The route through which climbing fibres enter the cerebellum 14. A brain region where damage causes ataxia of gait 15. A cerebellar region important for the control of balance Theme: States of consciousness Possible answers are:

A) coma B) stupor C) confusion D) cerebral death E) rapid eye movement (rem) sleep F) alert, eyes open G) awake, eyes closed H) stage 3 & 4 sleep I) contusion J) concussion K) stage 2 sleep L) absence seizure

Choose the state of consciousness from the list above that best fits each definition below: 16. A sleep state during which the EEG is desynchronized and movements of the limbs are

paralyzed 17. A state during which the EEG shows a 3 Hz spike-wave complex 18. A state during which the EEG shows predominant alpha (8-13 Hz) waves 19. A state during which strong sensory stimulation cannot rouse the subject and brain

metabolic activity is reduced 20. A state that may follow a concussion in which the patient is aware but has difficulty in

carrying out simple commands and thinking processes are slowed

Y2 EMQ Feb 08 4

Theme: Evaluation of Evidence The diagram shows a Forest plot for three randomised trials which compared the risk of hypoglycaemia for Type II diabetes patients treated with metformin versus those treated with placebo. (data taken from Cochrane library)

Risk ratio.01 .1 1 10

Study % Weight Risk ratio (95% CI)

1.02 (0.15,7.15) A 66.2

2.90 (0.12,70.69) B 17.0

17.00 (1.00,289.83) C 16.7

4.01 (1.14,14.17) Overall (95% CI)

Heterogeneity test: p=0.23 Possible answers are:

A) 14.17 B) 17.0 C) 0.12 D) 1 E) 0 F) 2.90 G) 4.01 H) >0.05 I) 1 L) None of the above

Select the value for each of the following from the list above: 21. The expected value of the risk ratio if hypoglycaemic episodes were equally likely to occur

for patients treated with metformin versus those treated with placebo. 22. The upper confidence limit when information from all studies were combined. 23. The best estimate of the risk ratio from study B. 24. The p-value when comparing incidence of hypoglycaemic episodes between metformin

and placebo patients in study. 25. The p-value for assessing whether studies A, B, C showed different risk ratios from each

other.

Y2 EMQ Feb 08 5

Theme: Children, Parents and the law Possible answers are:

A) not give valid consent to medical treatment B) treat the child without the parents consent C) be presumed non-competent unless proven otherwise D) apply to the courts for an emergency protection order E) explain why they do not want their parents involved in their care F) apply to the courts for a specific issue order G) give valid consent to medical treatment H) not treat the child without the parents consent I) understand what the benefits and risks of the treatment are and why it is proposed J) be presumed competent unless proven otherwise

Select the one best answer for each of the following from the list above: 26. Any competent person, of any age can 27. If a non-competent child needs non-urgent treatment for which the parents refuse

consent, doctors should 28. In order to be assessed as Gillick competent a child must 29. Minors over the age of 16 should 30. If a non-competent child needs immediate life-saving treatment for which the parents have

refused consent, doctors should

Theme: the upper limb Select the most suitable term to place in each of the spaces where a word or phrase is replaced by a number. Each answer can be used once, more than once or not at all. Possible answers are:

A) all the interossei and medial two lumbricals B) the radial nerve C) the upper trunk of the brachial plexus D) the extensor digitorum E) the ulnar nerve F) the middle trunk of the brachial plexus G) the muscles of the hypothenar eminence H) the lower trunk of the brachial plexus I) the median nerve J) the lateral two lumbricals and interossei K) the musculocutaneous nerve L) the lateral cord

Injury to [ 31 ] at the elbow results in a claw hand. This is because of paralysis of [ 32 ]. Distal to the carpal tunnel, [ 33 ] gives a motor branch to abductor pollicis brevis. This muscle will be paralysed by lesions of [ 34 ] in the posterior triangle of the neck. [ 35 ] is the principal extensor nerve in the upper limb, but supplies no muscles in the hand.

Y2 EMQ Feb 08 6

Theme: the shoulder

For each of the following statements select the one correct label from the diagram above: 36. Cutting this nerve results in anaesthesia of the upper lateral arm 37. Cutting this nerve results in wrist drop 38. This muscle is supplied by the spinal accessory nerve 39. This muscle inserts into the lesser tubercle of the humerus 40. This is the thoracodorsal nerve to latissimus dorsi

A

B

C

D

E

F

G

H

Y2 EMQ Feb 08 7

Theme: bone disease Possible answers are:

A) 1,25-hydroxyvitamin D (calcitriol) B) alkaline phosphatase C) calcium D) hydroxyapatite E) osteoblasts F) osteocalcin G) osteoclasts H) osteocytes I) osteomalacia J) osteoporosis K) rickets L) vitamin D

For each of the following, select the one correct answer from the list A L above: 41. Cells with a ruffled border for a large surface to interact with bone 42. Increased likelihood of vertebral crush fractures in elderly women 43. Osteoblasts have receptors for this hormone 44. Mineral that forms tiny crystals that infiltrate the organic matrix of bone 45. Cells with receptors for oestrogens, parathyroid hormone and 1,25-dihydroxyvitamin D Scenario: A 30 year old woman develops a deep vein thrombosis. She presents to the A/E department.

A) heparin B) international normalized ratio (INR) C) paracetamol D) warfarin E) vitamin k F) dipyridamole G) simvastatin H) codeine I) protamine J) imipramine K) activated partial thromboplastin time (APTT) L) aspirin

46. What is the most appropriate drug to give her immediately? 47. What drug would then be given for long term therapy (3-6 months)? 48. What over the counter drug on this list could cause a dangerous interaction with the drug

used in question 2? 49. Some weeks later the patient is dangerously over anticoagulated an requires an antidote.

Which drug would you use? 50. What is the most appropriate means of measuring her anticoagulation?

Y2 EMQ Feb 08 8

Scenario: A student aged 18 suffers from hay-fever (seasonal allergic rhinitis) and is skin-test positive for several grass and tree pollens. The student will shortly be sitting examinations.

A) ranitidine B) diphenhydramine C) oral D) inhalation E) beclometasone F) cetirizine G) hydrocortisone H) intranasal I) sodium cromoglicate J) theophylline K) ipratropium L) montelukast

51. Select an appropriate histamine antagonist with which to start treatment. 52. What is the route of administration. 53. The student finds that the histamine antagonist does not control the symptoms well.

Select an anti-inflammatory drug for further treatment. 54. What is the route of administration. 55. Select a drug that could be used prophylactically to prevent rhinitis.

Theme: Neuromuscular transmission A patient is given a skeletal muscle "relaxant" drug to aid tracheal intubation in preparation for surgery and then given another skeletal muscle "relaxant" drug to aid surgery.

A) -adrenoceptor B) atropine C) dopamine receptor D) dyflos E) edrophonium F) hemicholinium G) hexamethonium H) muscarinic receptor I) neostigmine J) nicotinic receptor K) pancuronium L) suxamethonium

For each of the following statements or questions, select the one most appropriate response for the list above: 56. The first muscle "relaxant" drug used caused an initial muscle twitch (fasciculation).

Which drug was it? 57. Which drug would be used to reverse the effects of the second skeletal muscle "relaxant"

drug that was used? 58. Both muscle relaxant drugs act on the same receptor type, and interference with this

receptor can also cause a fall in blood pressure. Which receptor type is involved? 59. Patients with myasthenia gravis are normally sensitive to one of the drugs listed above.

Which drug is it? 60. Which of the drugs listed above is used to diagnose myasthenia gravis?

Y2 EMQ Feb 08 9

Theme: Adrenoceptors Adrenoceptors mediate the effects of noradrenaline on target organs innervated by the autonomic nervous system

A) two B) five C) three D) milliseconds E) seconds F) ligand-gated ion channels G) G-protein coupled receptors H) protein synthesis I) GTP hydrolysis J) GDP : GTP exchange K) reverse uptake L) calcium influx

For each of the following statements or questions, select the one most appropriate response from the list above: 61. To which class of receptors do adrenoceptors belong? 62. How many subunits make up the G-protein? 63. What is the effect of activated receptor on G proteins? 64. What is the timescale of responses mediated by G-proteins? 65. What process is required for the repriming of G-proteins after activation? Scenario: A middle-aged man has a hernia repair. In the immediate post-operative period he is given two drugs that relieve his pain. He recovers well and returns to work but several months later has numbness, burning pain and touch-evoked pain. He is given a different drug.

A) 5-hydroxytryptamine (5-HT, serotonin) B) calcium channels C) diazepam D) GABA E) gabapentin F) glutamate G) ibuprofen H) morphine I) neuropathic pain J) prostaglandins K) selective serotonin reuptake inhibitors (SSRIS) L) substance P

For each of the following statements or questions, select the one most appropriate response from the list above. 66. What transmitter is likely to be involved in spinal transmission of both pain states? 67. Name one drug that would be used first line for the post-operative pain. 68. Name another drug that also would be used for post-operative pain. 69. What drug was he given for the delayed chronic pain? 70. What is the pharmacological site of action of this drug?

Y2 EMQ Feb 08 10

Scenario: A young man was prescribed a drug to control his schizophrenia, however he then suffered from involuntary muscle movements, tremor and rigidity. The drug was then changed to another in order to reduce his movement disorders.

A) amantadine B) bromocriptine C) chlorpromazine D) clozapine E) dopamine D1 receptors F) dopamine D2 receptors G) dopamine D3 receptors H) muscarinic receptors I) oestrogen J) progesterone K) prolactin L) selegiline

For each of the following statements or questions select the most appropriate response from the options above: 71. The blockade of these receptors is thought to be responsible for the involuntary muscle

movements, tremor and rigidity. 72. The first drug that was prescribed causes a high degree of sedation as it also blocks

histamine receptors. Which drug is it? 73. Both drugs lead to a high circulating concentration of a hormone, reducing fertility in

women. which hormone is elevated? 74. The second drug that was prescribed causes agranulocytosis. which drug is it? 75. The movement disorders caused by the first drug can be prevented by prescribing an

additional drug that blockades a different receptor system. however, this causes a dry mouth. Which receptor system is blockaded by this additional drug?

Y2 EMQ Feb 08 11

Scenario: The transmitter acetylcholine activates the neuromuscular junction nicotinic receptor and makes its intrinsic ion channel open. The result is depolarisation of the endplate and ultimately muscle contraction. A patient undergoing surgery is given a skeletal muscle "relaxant" drug: this drug blocks the effect of the neurotransmitter acetylcholine on the receptor. Possible answers are:

A) mediated by cAMP B) fast C) slow D) mediated by G-proteins E) enzyme F) ligand-gated ion channel G) voltage-gated ion channel H) choline transporter I) sodium pump J) cations K) anions L) chloride M) choline N) agonist O) partial agonist P) antagonist

For each of the following statements or questions, select the one most appropriate response for the list above: 76. How do you define a drug that has the same mechanism of action of this muscle

"relaxant" drug? 77. How do you define a drug that imitates the effects of acetylcholine? 78. Which type of receptor is the nicotinic muscle receptor? 79. What is the channel in nicotinic muscle receptors permeable to? 80. Responses to acetylcholine at the muscle receptor are?

END OF PAPER