Royal Free and University College Medical School

Phase 1, Year 2: February 2004

Copyright 2004 Royal Free and University College Medical School

Modified Essay Question paper

1 hour is allowed for this paper.

You should attempt all 7 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 page for each question.

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.

You should not spend more than 7 8 minutes on any one question.

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.

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

C:\Documents and Settings\DAB\My Documents\Documents\Teaching\assessments\formative 2003-4\2MEQ Feb-04.doc

Place your bar-code

label here
Question 1
Mr RM, aged 70 years has had diabetes mellitus for 10 years and is well
controlled on diet and tablets.
Complete the following table to define the 3 major hormonal products of the islets
of Langerhans and the specific cell types in which each of these 3 hormones is
synthesised
(2 marks for each complete, correct row)
Cell type

Major hormonal product

List three factors, other than an increase in the plasma glucose concentration, that can stimulate the
synthesis and secretion of insulin in the normal, healthy pancreas
(3 marks)

Insulin has a number of metabolic effects. Tick the appropriate box if you think the process will be
increased or decreased in response to insulin in each tissue.
(1 mark for each correct tick, -1 for each incorrect answer)
Liver
increased

decreased

Adipose tissue
increased decreased

Skeletal muscle
increased decreased

Fatty acid synthesis

Glycogen synthesis
Protein synthesis
Glucose transport
Ketogenesis
Gluconeogenesis
Lipolysis

C:\Documents and Settings\DAB\My Documents\Documents\Teaching\assessments\formative 2003-4\2MEQ Feb-04.doc

Place your bar-code

label here
Question 2
Mr RM, aged 70 years has had diabetes mellitus for 10 years and is well controlled
on diet and tablets. He was working in his garden when he developed a headache
and lost the use of his right arm and leg. His wife immediately called an ambulance
and he was taken to the local hospital.
You are a medical student attached to A+E. Mr M has been taken from A+E to
have an emergency CAT scan. You are asked to speak to his wife to take a brief
history.
Describe how you would conduct this consultation, including reference to the
communication skills that are important in conducting a consultation with a
distressed relative. Do not describe the content of the medical history you would
take.
(10 marks)

Later, Mr M is stabilised and about to be discharged home. The consultant is planning to advise him to
lose weight. You are asked to gather information about his diet and eating habits.
Formulate two questions to ask Mr M for each of the following headings. For each, write down exactly
what you would say.
his weight
(2 marks)

his diet

(2 marks)

his motivation to lose weight

(2 marks)

his understanding of the connection between diet, weight and health

(2 marks)

List four communication skills that are important in promoting adherence to diet and treatment
regimens for people with diabetes.
(2 marks)

C:\Documents and Settings\DAB\My Documents\Documents\Teaching\assessments\formative 2003-4\2MEQ Feb-04.doc

Question 3

Place your bar-code

label here

Adriana G is a tense excitable woman of 35. She is 160 cm tall and weighs 50
kg. Recently she has noticed that her eyes bulge, and she has lost a great
deal of weight, although she eats more than she used to.
She was referred to the thyroid out-patient clinic at her local hospital.
Suggest six questions that the thyroidologist may ask about her well-being
relevant to her thyroid status
(6 marks)

Three hormones were measured in a blood sample to test her thyroid function. Which hormones were
measured, and how would you expect their levels to relate to the normal reference range?
(6 marks)

What is the general endocrine concept that explains the settings of these three hormones in a
hyperthyroid state?
(1 mark)

List two physical signs that would lead her thyroidologist to conclude that she has Graves disease
(1 mark each)

What pathological agent is stimulating the thyroid in a patient with Graves disease?
(1 mark)

What initial treatment will she be offered, and how does this drug act?
(2 marks)

C:\Documents and Settings\DAB\My Documents\Documents\Teaching\assessments\formative 2003-4\2MEQ Feb-04.doc

Question 4
A systematic review estimated changes in serum lipoprotein concentrations after
treatment with thyroxine in patients with mild thyroid failure. There were 247 patients in
13 studies. The mean decrease in the serum total cholesterol concentration was 0.20
mmol/L with a 95% confidence interval of 0.09 to 0.34.
J Clin Endocrinol Metab. 2000 Sep;85(9):2993-3001.

Place your bar-code

label here

State a null hypothesis for the study carried out by these reviewers, concerning effects
of thyroxine on serum total cholesterol.
(7 marks)

Are the results compatible with this null hypothesis? Explain your answer.

(6 marks)

Explain the information given by the confidence interval.

(7 marks)

C:\Documents and Settings\DAB\My Documents\Documents\Teaching\assessments\formative 2003-4\2MEQ Feb-04.doc

Place your bar-code

label here

Question 5
A 76 year old woman visited her new GP and asked for a repeat prescription for
nitrazepam. This hypnotic was started during a hospital admission ten years ago,
after a painful gall bladder operation, and she has been taking the drug ever since.
At the moment she says that she sleeps no more than five or six hours a night and
is not sure the tablets are doing much good. She wants to know why she can't
have the butobarbitone tablets which her mother found so helpful. On
examination, there are no abnormal physical signs.
Management: You decide that she doesn't really need any hypnotic and ask her
to do without. A few days later she returns to say that she is shaking, unsteady,
and that her insomnia is now worse than ever.
Give 3 causes of insomnia

(3 marks)

Do you think that hypnotics were appropriate for somebody who could not sleep because of postoperative pain? What other group of medicines would be appropriate?
(2 marks)

Do you think they are still appropriate for this patient?

(2 marks)

What other classes of hypnotic are available?

(2 marks)

How do benzodiazepines work?

(2 marks)

What is there to choose between them?

(2 marks)

How do you interpret what happened when the benzodiazepine was withdrawn?

(2 marks)

What other uses are there for benzodiazepines?

(2 marks)

C:\Documents and Settings\DAB\My Documents\Documents\Teaching\assessments\formative 2003-4\2MEQ Feb-04.doc

Place your bar-code

label here
Question 6
This question does not apply to any particular patient.
Outline the 6 conditions facilitating quick dying in the pre-modern era and slow
dying in the modern era. How might these changes have affected
communication between health care professionals and patients and their
families?
(20 marks)

C:\Documents and Settings\DAB\My Documents\Documents\Teaching\assessments\formative 2003-4\2MEQ Feb-04.doc

Question 7

Place your bar-code

label here

Label these diagrams of the trachea, thyroid and para thyroid glands:
(1 mark each label)

C:\Documents and Settings\DAB\My Documents\Documents\Teaching\assessments\formative 2003-4\2MEQ Feb-04.doc