Royal Free and University College Medical School

Phase 1, Year 1: resit 2003

Copyright 2003 Royal Free and University College Medical School

Modified Essay Question paper

3 hours are allowed for this paper.

You should attempt all 20 questions, answering each one on the page for that question
if you need more space, continue on the reverse of the page for that question only. Pages will
be separated and given to different people to mark.

You are provided with a sheet of bar-code labels. Place one label in the space marked
on the computer-readable card and one label on the page for each question except
questions 3 and 14 these questions are answered on the computer-readable card.

For questions 3 and 14 you must transfer your answers to the appropriate numbered
lines of the mark-sense (computer-readable) card that is provided. For this type of card
there is only one correct answer (A P) on each line, and if you enter more than one
answer on a line you will score zero for that line. Some answers may be used more than
once and some may not be used at all

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.

Most questions 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. Some questions do not refer to any
specific patient.

This question paper must not be removed from the examination room.

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Question 1
Malcolm Elks is a 50-year old man. He comes to A&E complaining of severe chest
pain. He tells the nurse that over recent months he has experienced a similar pain
when exercising. However, on this occasion the onset was not linked to exercise and
has persisted for several hours.

What is the most important mechanism controlling coronary vascular resistance: local,
nervous or hormonal?
(1 mark)

Left ventricular coronary blood flow occurs mainly in which part of the cardiac cycle, and why ?
(3 marks)

How is the regulation of coronary blood flow impaired in coronary heart disease?
(2 marks)

If the SA and AV nodes are supplied by the right coronary artery, what possible effects will a disease leading
to impaired blood flow through this artery have on the heart beat?
(2 marks)

As the left coronary artery supplies the majority of the left ventricle what effect will a disease limiting blood
flow through this vessel have on myocardial oxygen supply and what condition will develop?
(2 marks)

What is the possible outcome if the condition is not treated?

(1 mark)
Give the three important groups of drugs used to treat angina.
(1 mark each)

Give 3 main ways in which anti-anginal drugs improve myocardial blood flow and reduce myocardial oxygen
consumption?
(1 mark each)

Year 1 MEQ resit 2003

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Question 2
Malcolm Elks is 167 cm tall and weighs 87 kg.
What is his Body Mass Index: BMI = weight (kg) / height2 (m)
(1 mark)

Would you classify him as being of desirable weight, overweight or obese?

(1 mark)
Mr Elks has a total daily energy expenditure of about 12 MJ /day and a BMR of 8.4 MJ / day. What is his
physical activity level (PAL)?
(2 marks)

How much weight would you expect him to lose per week if he reduced his food intake from 12 MJ /day to 10
MJ /day ? (assume that the loss will be only adipose tissue, which is 15% water, 5% protein and 80%
triacylglycerol protein yields 17 kJ /g and triacylglycerol 37)
(4 marks)

Mr Elks GP recommends him to take more exercise and suggests that he walks moderately gently (3.5 km
/h, a PAR of 3.0) for two hours each day.
What will be his additional energy expenditure per day?
(3 marks)

Assuming that he maintains a food intake of 12 MJ /day, how much adipose tissue would he lose per week at
this level of increased activity?
(4 marks)

Year 1 MEQ resit 2003

Question 3
Answer this question on lines 1 8 of the computer-readable card. There is only one correct answer
for each line. Some answers may not be used at all and some may be used more than once.
An angiogram of Malcolm Elks heart reveals narrowing of the coronary arteries and cardiac enlargement
Diagram 1

Diagram 2

E
D

C
B

F
J

Referring to the labels in the diagrams above, answer the following questions:
(2 marks each)
1. In diagram 1, which area of the heart (A E) is normally supplied by the left coronary artery?
2. In diagram 2, which area of the heart (F K) is normally supplied by the right coronary artery?
3. Identify the left coronary artery (A K)
4. Identify the branch of the right coronary artery to the sinuatrial node (A K)
5. Identify the posterior interventricular artery (A K)
6. Identify the circumflex artery (A K)

The next two questions do not refer to the letters in the diagrams
7. In which intercostal space should you palpate the apex beat of a normal heart:
(A)
(B)
(C)
(D)

4th
5th
6th
7th

(2 marks)

8. In which intercostal space would you auscultate the aortic valve:

(A)
(B)
(C)
(D)

Year 1 MEQ resit 2003

5th left
5th right
2nd left
2nd right

(2 marks)

Question 4

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During his daily walk Mr Elks finds that he is very breathless. He mentions his to his
GP, who asks you to examine his respiratory system.
Describe how you would undertake this examination
(6 marks for communications skills, 8 marks for clinical skills)

Describe how you would measure his peak expiratory flow rate (PEFR).
(6 marks).

Year 1 MEQ resit 2003

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Question 5
The table shows Respiratory Function data collected from 3 men attending an outpatient clinic at the Whittington Hospital. The normal values (1 standard deviation)
for healthy subjects matched for age and body size are also shown below each
patient.
Patient A
control
Patient B
control
Patient C
control

PEFR litres min-1

650
670 60
230
560 60
530
520 50

FEV1 litres
2.6
4.5 0.5
1.7
3.5 0.5
3.2
3.1 0.4

FVC litres
3.1
5.3 0.6
4.1
4.5 0.6
3.8
3.9 0.5

From the respiratory function data given, mark the following statements true or false:
(1 mark each)
TRUE

FALSE

Patient B is normal
Patient C is normal
Patient A has an obstructive defect
Patient B has an obstructive defect
Patient C has an obstructive defect
Patient A has a restrictive defect
Patient C has a restrictive defect
From abnormalities you have identified, mark the following statements true or false:
(1 mark each)
TRUE

FALSE

Patient A might have bronchitis

Patient A might have fibrosis of the lungs
Patient B might have fibrosis of the lungs
Patient B might have asthma
Patient C might have emphysema
Patient C might have fibrosis of the lungs
Which patient(s) would you expect to derive benefit from inhalation of a bronchodilator drug such as
salbutamol (tick one only)
(2 marks)
Patient A
Patient B
Patient C
Patients A & B
Patients A & C
Patients B & C

Year 1 MEQ resit 2003

Question 6

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Mr Elks currently smokes 20 cigarettes a day. He started smoking at the age of 11.
Rates of smoking amongst adolescents in the UK remain a public health concern.

Outline a range of factors that may influence young peoples smoking behaviour?
(5 marks)

Describe what health promotion strategies can be implemented to reduce rates of smoking amongst
adolescents
(10 marks)

What agencies outside of the NHS have an important role to play in reducing adolescent smoking
(5 marks)

Year 1 MEQ resit 2003

Question 7

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Mr Elks has been persuaded that he should give up smoking, but finds it extremely
difficult. He finds a report of the following trial of nicotine patches on the web:
A randomised double blind study was conducted in order to investigate smoking
cessation rates for people given nicotine patches versus those given placebo
patches. Five hundred smokers were recruited to the trial 260 of who were randomly
allocated to receive nicotine patches and 240 of who were allocated to receive
placebo patches. At one-year follow-up 130 people in the nicotine patches group and
60 in the placebo patches group had successfully given up smoking according to
reports from doctor-patient interviews. The data was analysed on an intention to treat
basis.
Explain what is meant by, and the importance of, the study being:
a) Double blind
(4 marks)

b) Analysed on an intention to treat basis

(4 marks)

Calculate and explain the number needed to treat (NNT)

(12 marks)

Year 1 MEQ resit 2003

Question 8

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Mr Elks plasma cholesterol was 8.5 mmol /L, compared with a desirable range of
< 5 mmol /L, and he was placed on a low-fat, cholesterol-free diet

Cholesterol is carried by plasma lipoproteins. Describe briefly the functions of the

three main types of plasma lipoprotein:

Very low density lipoprotein (VLDL)

(3 marks)

Low density lipoprotein (LDL)

(3 marks)

High density lipoprotein (HDL)

(3 marks)

After 3 months on the diet, Mr Elks plasma cholesterol was still 8.5 mmol /L. How is it possible for him to
continue to have high plasma cholesterol after adhering to a cholesterol-free diet for 3 months?
(3 marks)

Why would administering an HMG CoA reductase inhibitor lead to a fall in plasma LDL concentration?
(3 marks)

Year 1 MEQ resit 2003

Question 9

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This question does not refer specifically to any particular patient.

Outline the potential areas of conflict between doctors and pregnant women
(20 marks)

Year 1 MEQ resit 2003

Question 10

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Aminata Shah is a 45 year old stockbroker who suffers from gastric discomfort due
to dyspepsia. She takes an antacid, drug A, for this condition.
Some months later she complains of intermittent, upper abdominal pain and is
referred by her GP to the outpatients department. Endoscopy shows the presence
of a gastric ulcer.

(A) Give an example of drug A and state its mechanism of action

(4 marks)

Does drug A cause any drug interactions ?

(2 marks)

(B) What major drugs can be used for the treatment of gastric ulcers and what are their mechanisms of
action?
(10 marks)

Year 1 MEQ resit 2003

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Question 11
Aminata Shah is a 45 year old stockbroker who suffers from gastric discomfort due to
dyspepsia and is subsequently found to have a gastric ulcer.

Name the gastric cells that produce hydrochloric acid?

(1 mark)

In which anatomical part and histological layer of the stomach are they to be found?
(2 marks)

List 3 functions of gastric HCl in a healthy subject

(3 marks)

With the aid of a diagram, explain the cellular processes by which gastric HCl is produced and secreted. In
your answer describe the role of carbonic anhydrase and explain the term alkaline tide of acid secretion.
(8 marks)

Year 1 MEQ resit 2003

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Question 12
Aminata Shah is a 45 year old stockbroker who suffers from gastric discomfort due to
dyspepsia and is subsequently found to have a gastric ulcer.

Describe the role of efferent nerves in the control of gastric acid secretion.
(4 marks)

Explain why habitual aspirin ingestion may lead to peptic ulceration.

(2 marks)

What processes normally serve to reduce gastric HCl secretion in order to prevent gastric pH from reaching
dangerously low levels?
(3 marks)

How are the gastric and duodenal mucosal lining normally protected from damage by secreted HCl?
(3 marks)

Give two reasons why patients with peptic or duodenal ulceration are often anaemic.
(2 marks)

Year 1 MEQ resit 2003

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Question 13
Aminata Shah is a 45 year old stockbroker who suffers from gastric discomfort due to
dyspepsia and is subsequently found to have a gastric ulcer. One of the drugs she was
prescribed acts as an irreversible enzyme inhibitor.

Explain what is meant by the term irreversible enzyme inhibitor?

(4 marks)

Describe an experiment to determine whether a given compound is a reversible or irreversible inhibitor you
can assume that there is a simple way of measuring the product of the enzyme reaction you are studying.
(6 marks)

What is the advantage to the patient of taking a compound that acts as an irreversible inhibitor of a target
enzyme, rather than a reversible inhibitor?
(3 marks)

What is a possible disadvantage of using an irreversible inhibitor as a drug?

(3 marks)

If a drug is an irreversible inhibitor of an enzyme, why does the patient have to continue to take it?
(4 marks)

Year 1 MEQ resit 2003

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Year 1 MEQ resit 2003

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Question 15
Peter Choo is a medical student who acquired an intestinal infection while on
elective. He became dehydrated as a result of severe vomiting and diarrhoea. His
rate of urine production decreased and urine became excessively hypertonic with a
darker colour than normal.

Explain what is meant by the term hypertonicity.

(2 marks)

State the normal range of values for plasma and urine osmolality.
(2 marks)

What regions of the nephron are involved in the production of hypertonic urine?
(2 marks)
Briefly describe the tubular processes in the nephron involved in the production of hypertonic urine.
(5 marks)

What is the approximate normal body water content of a healthy 70 kg male.

(2 marks)

Approximately what percentage of total body water is:

(1 mark each)
Plasma
Intracellular fluid
Extracellular fluid
Describe briefly how you would determine Peter Choos plasma volume
(4 marks)

Year 1 MEQ resit 2003

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Question 16

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Peter Choo is a medical student who acquired an intestinal infection while on elective.
He became dehydrated as a result of severe vomiting and diarrhoea. His rate of urine
production decreased and urine became excessively hypertonic with a darker colour
than normal.

Which hormone is particularly important in minimising Peters excretion of water? State

where it is released, what physiological stimuli cause it to be released, and what major
renal actions it has.
(6 marks)

Describe in outline the mechanism of action (at the molecular level) of fast acting (peptide) hormones
(10 marks)

Year 1 MEQ resit 2003

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Question 17
Martina Swift was told by her optician at a routine eye test that she should see her
doctor as she had raised intra-ocular pressure. Her GP prescribed the -adrenoceptor
antagonist timolol as eye drops. Two days later she returned to the surgery complaining
of great shortness of breath.

Explain how timolol caused this problem?

(8 marks)

The GP subsequently prescribed pilocarpine eye drops. Describe what effects this would have in the eye
and indicate the mechanisms involved.
(6 marks)

Tropicamide, a muscarinic receptor antagonist, is used to aid examination of the eye. State briefly why it is
useful and why it may be dangerous.
(6 marks)

Year 1 MEQ resit 2003

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Question 18
This question does not concern a particular patient
Draw the oxygen dissociation curves for haemoglobin and myoglobin in the box
below. You must label the axes
(6 marks)

myoglobin

haemoglobin

Explain briefly how the structures of haemoglobin and myoglobin account for the difference in the curves you
have drawn.
(6 marks)

After even moderate exercise (eg climbing a flight of stairs), there is a considerable increase in the plasma
concentration of lactate, resulting in lowering of plasma pH. What is the effect of this fall in plasma pH on
oxygen binding to haemoglobin?
(4 marks)

Year 1 MEQ resit 2003

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Question 19
This question does not concern a particular patient
Explain briefly what is meant by each of the following terms:
(2 marks each)

mRNA

tRNA

DNA replication

Transcription

Translation

Ribosome

Polysome

A number of antibiotics act to inhibit bacterial protein synthesis but have little or no effect on human protein
synthesis. What differences between bacterial and human protein synthesis explain this?
(6 marks)

Year 1 MEQ resit 2003

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Question 20
A newborn girl developed a severe pneumococcal infection (Streptococcus
pneumoniae) at 8 weeks of age. She was investigated and found to have low levels of
IgG, increased neutrophils and reduced levels of lymphocytes in her blood. On further
examination it was found that no cells with surface antibodies were present in her
blood stream.
Describe what kind of immunodeficiency is consistent with the clinical and laboratory
findings
(2 marks)

Where are the lymphocytes which are deficient in this patient made in a healthy baby?
(2 marks)

Why did the baby have IgG but not IgM in her blood stream?
(2 marks)

Describe the basic structure of an antibody molecule

(5 marks)

What forces contribute to the interaction between specific antibody and its antigen
(5 marks)

Year 1 MEQ resit 2003

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