Multiple Choice MRCOG

14 Multiple choice questions
B Accumulation of abnormal products is

The cell, chromosomes and molecular genetics 295 infiltration
Embryology 298
The fetus 302 C Increased density of the cell chromatin is
Anatomy 304 karyorrhexis
Pathology 313 D Pyknosis indicates the digestion of nuclear
Microbiology 315 material
Immunology 318
E Cloudy degeneration indicates irreversible
Biochemistry 319
cell death
Physiology 321
Drugs and drug therapy 329
5. In radiation:
A Cellular effects are potentiated by high
oxygen concentrations
THE CELL, CHROMOSOMES AND MOLECULAR B There may, after a delay, be an increased
GENETICS mitotic rate
C Multinucleated giant cells may be formed
Questions D Bones are radiosensitive

E Damage to blood vessels may cause
1. In the cell: endothelial proliferation
A Lysosomes contain proteolytic enzymes T
B Microtubules are found in the Golgi apparatus F 6. In genetics:
C Microfilaments attach to desmosomes T A The 22 pairs of autosomes are homologous
D Centrioles orientate the mitotic spindle T B Chromosomes are examined by culturing red
E Ribosomal RNA is translated into proteins T blood cells
C In a metacentric chromosome the centromere
2. The cell membrane: is near one end
A Is trilaminar T D Giemsa staining is required in order to see the
B Is made up of polypeptide chains F chromosomes
C Contains the HLA antigens T E The long arm of the chromosome is known as
D Is attached to the centrosome T p
E Synthesises and stores protein F
7. In cell division of somatic cells:
3. The intercellular matrix: A During interphase the Y body may be seen B During
the G1 stage replication takes place
A Contains interstitial extracellular fluid B Is
C Metaphase occurs after anaphase
identical for all cell types
D The G1 stage occurs after the S stage
C May be composed of mucopolysaccharides
E During anaphase the chromosomes separate
D May contain collagen of four different types
at their centromeres
E Has elastin fibres produced by the glycocalyx
8. In meiosis:
4. In cell damage: A The first division results in diploid cells
A Accumulation of normal products is called B During zygotene bivalents are formed
`degeneration' C During pachytene the bivalents contain four
295
14 BASIC SCIENCE IN OBSTETRICS AND GYNAECOLOGY
strands
E DNA polymorphisms are rarely found
D Terminalisation of the chiasmata occurs
outside of genes
during diakenesis
E Crossing over occurs during metaphase
14. The following genetic disorders are
dominant:
9. Nuclear chromatin:
A Achondroplasia
A may be seen as a triangular body, the Barr body B is
B Phenylketonuria
seen at the periphery of the cell
C Multiple polyposis of the colon D
C is seen in Turner syndrome
Tuberose sclerosis
D is seen in Klienefelter syndrome
E Congenital adrenal hyperplasia
E may be seen in the buccal smear of a normal
male 15. The following genetic disorders are
recessive:
10. Sex chromosome abnormalities: A Cystic fibrosis
A 47XXX may result from non-disjunction B Myotonia congenita
B Mosaicism may result from anaphase lag C Duchenne muscular dystrophy
C May result from a translocation D Nephrogenic diabetes insipidus
D Deletion results in the formation of E Morquio disease
isochromosomes
E 45Y results in mental retardation 16. The following are examples of X-linked
conditions:
11. In Turner syndrome: A Osteogenesis imperfecta
A Congenital lymphoedema may occur B Glucose-6-phosphate dehydrogenase
B Embryos have normal numbers of germ deficiency
cells C Christmas disease (factor IX deficiency) D
C There is commonly secondary Marfan syndrome
amenorrhoea E Amaurotic family idiocy
D Ventricular septal defects are common
E The metatarsal bones are short 17. Sexual differentiation:
A The H-Y antigen is a plasma membrane
12. In disorders of extra chromosome protein
material: B 46XX may rarely have a male phenotype
A Patau syndrome is trisomy 13 C Mullerian inhibitor appears to have a local
B Edward syndrome is trisomy 18 action on the side of the testis producing it D
C 47XXX is compatible with normal life and Androgens prevent development of the
reproduction paramesonephric duct
D 47XYY may be fertile E Wolffian tissues respond only to
E Unbalanced translocations may result in dihydrotestosterone
Down syndrome
18. Sexual differentiation:
A In the absence of ovaries or testes the
13. In the chromosome:
embryo has a female phenotype
A When genes at one locus are identical they
B Dihydrotestosterone is converted to
are called àlleles'
testosterone by 5-alpha reductase
B Genes occupy homologous loci
C In 47XXY an ovotestis develops
C Each gene consists of two purines and two
D In 5 alpha-reductase deficiency a female
pyramidines
phenotype results
D If genes at a single locus are identical the
E The karytype of true hermaphrodites is
individual is homozygous
commonly 46XX
296
MULTIPLE CHOICE QUESTIONS 14
Answers
1. AT 4. AT 7. AT 10. AT 13. AF 16. AF

BF BT BF BT BT BT
CT CF CF CT CF CT
DT DF DF DT DT DF
ET EF ET EF ET EF
2. AT 5. AT 8. AF 11. AT 14. AT 17. AT

BF BT BT BT BF BT
CT CT CT CF CT CT
DT DF DT DF DT DF
EF ET EF ET EF EF
3. AT 6. AT 9. AT 12. AT 15. AT 18. AT

BF BF BF BT BF BF
CT CF CF CT CF CF
DT DF DT DT DF DT
EF EF EF ET ET ET
297
EMBRYOLOGY
5. In early development and implantation:
AThe zygote contains blastomeres
Questions B The morula is contained w ihi tn t hbl
eastocyst
1. In spermatogenesis:
CThe embryo forms from trophoblast
AFour spermatocytes are produced from one
D Th e as blt ocy st im p lants about 10 days after
spermatid
fertilisation
BThe process occurs continuously from birth
ESyncitiotrophoblast arises from the inner cell
CA spermatozoon is produced in 30 days
mass
DSpermatogonia line the basal lamina of the
epidydimis
6. In embryogenesis:
EEvery spermatogonium develops into a
AThe endocervical vesicle becomes the yolk
primary spermatocyte
sac
BThe cells adjacent to the amniotic sac form
2. In spermiogenesis:
endoderm
ANuclear material forms the acrosomal cap
CEctodermal cells are tall, columnar cells
BMitochondria form a sheath for the neck of
DThree layers of cells lie between the amniotic
the spermatozoon
and yolk sacs
CThe axial filament derives from the centriole
EMesodermal cells develop principally from
DIn the endpiece of the tail are found two
ectodermal division
central and nine peripheral filaments
ESpermatozoa may remain linked at
7. In organogenesis:
cytoplasmic bridges
AThe neural tube develops on the ventral
surface of the embryo
3. In oogenesis: BThe vitellointestinal duct may persist as
AThe early development of the primitive germ Meckel's diverticulum
cells in the ovary during intrauterine life is CParaxial mesoderm divides into
mitotic splanchnopleure and somatopleure
BPrimary oocytes are formed after 37 weeks' DLimb buds develop from splanchnopleure
gestation EThe bucopharyngeal membrane of the
CSome primary oocytes will remain in stomatodeum breaks down at the 6th week of
prophase for 12-50 years life
DDivision of the secondary oocyte occurs at the
time of ovulation 8. In the pharyngeal region:
EAt puberty there are 1-2 million oocytes AThe upper and lower jaws develop from the
present first arch
BThe styloid process develops from the
4. In fertilisation: second pouch
AThe whole spermatozoon penetrates the CThe inferior parathyroids develop from the
ovum third pouch
BThe ovum reaches the uterus within DThe superior parathyroids develop from the
24 hours third pouch
CAfter penetration cortical granules appear EThe arch of the aorta develops from the
around the perimeter of the egg fourth arch artery
DThe second meiotic division is completed just
before penetration by the spermatozoon 9. In the pharyngeal region:
EThe first division of the ovum occurs 6 hours AThe muscles of the tongue are developed
after fertilisation from first and third arches
BThe thyroid gland develops from the distal
298 end of the thyroglossal duct
CA branchial cyst arises following failure BThe lateral ventricles develop from the side
of occlusion of the second pharyngeal pouch DThe wall of the foremost part of the neural tube
primitive lungs arise from the fifth CThe neural crest cells give rise to the adrenal
pharyngeal pouch medulla
EThe fourth and sixth arches contribute to DThe commonest form of spina bifida is
the bones of the larynx cervico-thoracic
EThe notochord is ectodermal
10. In the cardiovascular system:
AThe heart develops from angiogenic cells 15. In the skeletal system:
BThe cardinal veins run into the sinus venosus AThere are three ossification centres in each
CThe vitelline veins run into the bulbus cordis vertebra
DA beating fetal heart tube can be recognised BThe nucleus pulposus is derived from a
by ultrasound techniques from the 32nd day cartilagenous ring
of intrauterine life CThe vault of the skull is preformed in cartilage DLimb
EIn the foramen ovale blood passes from left buds appear at the 7th week of
to right intrauterine life
ESynovial joints arise from endoderm
11. In the cardiovascular system:
AThe proximal bulbar septum divides the 16. In the development of muscles and skin:
aorta from the pulmonary artery AThe muscles of the head and neck develop
BDeoxygenated blood passes via the from the mesenchyme of the pharyngeal
umbilical vein to the left branch of the arches
portal vein BThe skin plate arises from proliferation of
CThe ligamentum venosum is the obliterated spindle cells of the dermomyotome
umbilical vein CThe involuntary muscles of the bladder arise
DThere is a single umbilical artery from the dorsal part of the muscle plate
EThe foramen ovale usually closes 1 month DSweat glands arise from the skin plate
after birth ESebaceous glands are ectodermal structures
12. In the alimentary system: 17. In the development of the genital organs:
AThe foregut ends at the pyloric sphincter AThe pronephros arises in intermediate
BThe spleen is a derivative of the foregut mesoderm
CThe pancreas is a derivative of the midgut BThe pronephros is found in the thoracic
DThe stomach forms a sac at the 5th week of region
intrauterine life CThe mesonephros appears in the thoracic
EThe hindgut opens into the cloaca and lumbar regions
DThe Wolffian duct connects with the tubules
13. The diaphragm: of the mesonephros
ADevelops from the septum transversum EThe genital ridge appears on the lateral
BDevelops from the pleuroperitoneal aspect of the mesonephros
membrane
CDevelops from the costal margin 18. In the development of the uterus, tubes
DDevelops from the gastrohepatic ligament and vagina:
EHas a small contribution from the AThe paramesonephric ducts reach the
mesoderm around the aorta urogenital sinus by week 7
BAt 9 weeks both mesonephric and
14. In the nervous system: paramesonephric ducts are present
AThe cerebral hemispheres originate from the CMuscular walls develop in the uterus in the
cerebral vesicles 6th month
299
DThe vaginal plate is composed of urogenital BThe vessels of the villous stems arise from
sinus epithelium and paramesonephric ducts mesenchyme within the core
EThe vagina is a solid organ until 30 weeks CVillous stems are anchored to the basal plate
DThe finding of trophoblast into the spiral
19. In the development of the external arteries is abnormal
genitalia: EThe chorion laeve develops into the
AThe genital swellings are medial to the definitive placenta
genital folds
BThe genital tubercle becomes the clitoris 23. In the development of the placenta:
CThe phallic part of the urogenital sinus AThe placental septa are simply folds of the
reaches cranially to the point where the basal plate
Mullerian ducts enter the sinus wall BThe peripheral syncytium degenerates and
DThe vestibule is derived from both the pelvic
is replaced by Rohr's layer
and phallic portions of the urogenital sinus
CThe number of lobules in a cotyledon varies
EEctopia vesicae results from deficient from 2 to 5
development of the genital folds DEach placental lobule is derived from a
single secondary stem villus
20.In the development of the testis: ETerminal villi arise from secondary stem villi
APrimitive germ cells arise from beneath the
epithelium of the amniotic sac 24.In the formation of the membranes:
BGonadal differentiation can be seen at 5 weeks AThe yolk sac is derived from trophoblast
CSex cords develop from coelomic epithelium
BThe ectoderm is a continuing source of
DThe interstitial cells of Leydig arise from
supply of amniotic cells
coelomic epithelium CThe vitelline duct is incorporated into the
EThe rete testis arises from the underlying
lower end of the body stalk
mesoderm DThe amniochorionic membrane contains a
loose reticular layer
21. In the development of the ovary:
EThe amniochorionic membrane contains a
AGranulosa cells arise from the coelomic
layer of parietal extraembryonic
epithelium
mesenchyme
BBy 20 weeks there are 700 000 germ cells
CBy 20-24 weeks follicle formation can be seen
25. The liquor amnii:
DThe mesenchyme gives rise to thecal cells
AVolume is approximately 1 1 at 36 weeks
EThe lower part of the gubernaculum
BIn early pregnancy arises by transfer of fluid
becomes the round ligament
across the fetal skin
CThe pH is usually >5.6 and <6.5
22. In the development of the placenta:
DHas bacteriostatic properties
ASyncytiotrophoblast is derived from the
EIs increased by giving the mother a
cytotrophoblast NSAID
Answers
1. AF 2. AF 3. AT 4. AF 5. AT 6. AT
BF BF BF BF BF B F
CF CF CT CT CT C T
DF DT DF DT DF D T
EF ET EF EF EF E T
300
7. AF 11. AT 15. AT 19. AF 23. AT

BT BF BF BT BF
CF CF CF CF CT
DF DF DF DT DT
EF EF EF EF EF
8. AT 12. AF 16. AT 20.AF 24. AF

BF BF BF BF BT
CT CF CF CT CT
DF DT DF DF DT
ET ET ET EF ET
9. AF 13. AT 17. AT 21. AT 25. AT

BT BT BF BF BT
CT CT CT CT CF
DF DT DT DT DT
ET ET EF ET EF
10. AT 14. AT 18. AF 22.AT

BT BF BT BT
CF CT CF CT
DT DF DT DF
EF ET EF EF
301
THE-FETUS E Chemoreceptors in the carotid body

respond in utero to alterations in pH
Questions
5. Alimentary tract:
1. Fetal growth: A Swallowing commences at 20 weeks B
A Crown-rump length is considered to be an Meconium contains vernix
accurate ultrasound measurement of fetal C Peristalsis is inhibited by hypoxia
growth up until 14 weeks D The stomach bubble on ultrasound is only
B The biparietal diameter is considered to be an visible after 20 weeks
accurate ultrasound measurement of fetal E Digestive enzymes are found by 12 weeks
growth from 10 weeks
C The head/abdominal circumference ratio 6. Respiratory system:
decreases with advancing pregnancy A Breathing movements are present from
D Fetal weight increases with increasing parity 20 weeks
E In late pregnancy occurs at the same rate as B Alveolar development is complete by 24 weeks
placental growth C Type I pneumocytes produce surfactant
D Intrathoracic pressures of up to -10 cm of
2. Fetal circulation: water may be required for the baby's first
A Circulation of blood is present by 21 days B The breath
heart originates in splanchnic E As labour approaches, fetal breathing
mesenchyme decreases
C The fetus responds to hypoxia by increasing
the circulation to adrenal glands 7. Placental transfer: 1
D In response to hypoxia, the fetus can increase A The placenta is a complete barrier to
the placental circulation by 50% substances with molecular weights greater
E In utero only 1% of the cardiac output is than 1500
directed to the lungs B 3-4 1 of fluid are exchanged between the
mother and fetus per hour
3. Renal function: C The placenta converts phospholipids to
A Renal agenesis is associated with simpler forms
oligohydramnios D The concentration of aminoacids is less in
B The kidney at term is the principal source of the fetal blood than in the maternal blood
amniotic fluid E Oxygen delivery occurs by diffusion rate
C In late pregnancy the amniotic fluid from mother to fetus
osmolarity rises
D The concentration of creatinine in amniotic 8. Oxygen and carbon dioxide transfer:
l f uid is less than in the fetal plasma A The oxygen dissociation curve for fetal
E The rate of fetal urine production can be blood is shifted to the right
measured by ultrasound B Fetal blood has a larger carrying capacity for
oxygen than maternal blood
4. Nervous system: C In low oxygen tensions fetal Hb has lesser

A Nerve cell processes in the cerebrum appear affinity for oxygen than maternal HB
at 8-10 weeks D Carbon dioxide is mostly carried in the
B Nerves appear in the fetus between 4 and 5 blood as carbonic acid or bicarbonate
weeks E The Haldane effect facilitates release of
C Limb muscle fibres can contract by 8 weeks D carbon dioxide from fetal haemoglobin
Baroreceptor stimulation of the aortic
9. Oxygen:
branches of the Xth cranial nerve results in a
A The fetus at 16 weeks gestation requires 25
bradycardia
ml/min of oxygen
302
B Each gram of Hb combines with 1.34 ml of D The main factor governing the rate of
oxygen placental blood flow is the vascular
C HbF binds 2:3 DPG less effectively resistance of the spiral arteries
D AT P50, the Hb dissociation curve of the E At term the total blood flow to the placenta
fetus is less steep than that of the mother E In is about 500 ml
fetal hypoxia, both metabolic and
respiratory acidosis occur 12. The following organisms cross the
placenta:
A Variola vaccinia
10. Oxygen and carbon dioxide:
B Coxsackie virus
A The fetus requires oxygen at higher tensions
C Listeria
than that of the mother
D Neisseria meningitidis
B A fall in plasma pH decreases the affinity of
E Toxoplasma
red blood cells for oxygen
C Excess fetal lactic acid is metabolised in the
13. The average weight gain at term of-
placenta
A the uterus is 400 g
D Excess carbon dioxide dilates placental
B the breasts is 400 g
vessels
C the blood is 1200 g
E The fetus may become polycythaemic in
D the placenta is 600 g
response to low oxygen tensions
E the liquor is 800 g
11. Placental structure: 14. The placenta produces the following

A At term new placental villi continue to be substances:
formed A oestrone
B There is a positive correlation between B 5 alpha-reductase
placental weight and fetal weight C oxytocinase
C Microvilli are present on the D histaminase
vasculosyncytial membranes E progesterone
Answers
1. AF 4. AF 7. AF 10. AF 13. AF
BF BT BT BT B T
CT CT CT CT C T
DT DT DF DT D T
EF ET ET ET E T
2. AT 5. AF 8. AF 11. AT 14. AT
BT BT BT BT B T
CT CF CF CF C T
DF DF DT DF D T
EF EF ET ET E T
3. AT 6. AF 9. AF 12. AT
BT BF BT BT
CF CF CT CT
DF DF DF DF
ET ET ET ET
303
ANATOMY 5. In the anterolateral group of abdominal

muscles:
Questions A Transversus abdominis arises from the
anterior third of the iliac crest
1. In the anterior abdominal wall:
B Transversus abdominis is part of the falx
ARectus abdominis inserts into rib cartilages 7,
8 and 9 inguinalis
BPyramidalis is present in 20% of the C The conjoint tendon inserts into the crest and
population pecten pubis
CThe median umbilical ligament is the urachal D The internal oblique partially arises from the
remnant lumbar fascia
DThe ligamentum teres may be connected to E The internal oblique is attached to the
ligamentum venosum inguinal ligament in its outer two-thirds
EThe lateral umbilical ligaments are the
obliterated umbilical arteries 6. In the posterior group of abdominal
muscles:
2. The rectus sheath: A Psoas major lies behind the anterior layer of
AAnteriorly and suprapubically consists of two lumbar fascia
layers B The lateral arcuate ligament is formed by the
BBelow the umbilicus consists of three anterior middle layer of lumbar fascia
layers C Psoas major enters the abdomen behind the
CIs supplied by the dorsal rami of the lower medial arcuate ligament
sixth or seventh thoracic nerves D Psoas major leaves the abdomen medial to
DEncloses an anastomosis between the iliacus
superficial and deep epigastric vessels E Quadratus lumborum is supplied by the
EWhen present, contains pyramidalis lower six or seven thoracic nerves
3. Abdominal fascia: 7. The diaphragm:

AIn the anterior abdominal wall contains the A Right crus arises from the anterolateral part
superficial inguinal lymph nodes between its of the first two lumbar vertebral bodies
superficial and deep layers B Is traversed by the inferior vena cava at the
BHas a superficial layer attached to the linea alba CIn the level of T 12
iliac region has the lumbar plexus C Has an aortic aperture at T10
nerves behind it D Transmits the sympathetic nerves through
DIn the lumbar region has two layers the aortic aperture
EAs transversalis fascia passes into the inguinal E Transmits the superior epigastric vessels
canal between sternal and costal origins
4.In the inguinal ligament: 8. The coeliac trunk:

AIts pectineal part is called the lacunar A Gives rise directly to the right gastric artery
ligament B Gives rise directly to the left gastric artery
BThe superficial ring lies between the pubic C Gives rise to the splenic artery
symphysis and the pubic tubercle D Gives rise to the pancreatic artery
CThe deep ring lies medial to the inferior E Gives rise to the common hepatic artery
epigastric vessels
DThe round ligament passes along the inguinal 9. Branches of the superior mesenteric
canal artery include:
EThe lacunar part medially gives rise to the A The common hepatic artery
pectineal ligament B The inferior pancreatic-duodenal artery
C The superior pancreatico-duodenal artery
304
MULTIPLE CHOICE 14
QUESTIONS
DMiddle colic artery

15. Meckel's diverticulum:
ERight colic artery
AUsually arises 5-10 cm from the ileocaecal
valve
10. The oesophagus:
AIs supplied by left gastric vessels BMay contain heterotopic gastric mucosa
BIn the abdomen is covered on anterior and CMay contain heterotopic pancreatic mucosa
right aspects by peritoneum DMay secrete thyroid hormones
CIs separated from the fundus by the cardiac EMay be connected to the umbilicus by the
vitelloinestinal duct
notch
DHas vagal trunks lying on right and left
16. The large intestine:
aspects
AThe right colic flexure is higher than that on
EIs contained within the upper part of the
the left
lesser omentum
BTaenia coli arise from the circular muscle coat
CThe descending colon runs along the lateral
11. The stomach:
border of the left kidney
AIs related anteriorly to the liver
DThe right colic flexure is related to the
BAntrum is adjacent to the fundus
second part of the duodenum posteriorly EThe
CIs supplied by branches of the splenic artery
descending colon crosses the left
DLies medial to the spleen
ovarian artery
EIs related posteriorly to the left suprarenal
gland 17. The appendix:
AIn every case taenia coli lead to its base
12. The duodenum: BIs the embryological appex of the caecum
AForms the floor of the epiploic foramen CArises 2-3 cm below the ileocaecal opening
BIs joined halfway down its second part by DArtery runs in front of the terminal ileum to
pancreatic and common bile ducts reach the mesappendix
CIs related posteriorly in its second part to EHas accessory arteries in 80% of cases
the kidney
DContinues at the level of L2 as the third 18. The right kidney antero-laterally is
part related to the:
ECrosses the ureter in its fourth part ARight coronary ligament
BThe jejunum
13. The portal vein:
CThe suprarenal gland
ALies anterior to the duodenum
DThe stomach
BLies lateral to the hepatic artery
EThe pancreas
CIs related to the cystic duct posterior to the
pancreas
19. The left kidney antero-laterally is
DDrains into the hepatic vein
related to the:
EIs formed by superior mesenteric and
ALeft coronary ligament
pancreatic veins
BSpleen
CTransverse mesocolon
14. Small intestine:
DStomach
AMesentery forms the posterior wall of the
EPancreas
lesser sac
BMesentery crosses the right ovarian vessels
20. The kidney:
CIleum is more vascular than jejunum
AOn the left lies lower than on the right
DJejunum is related posteriorly to the lower
BIs related to the ilioinguinal nerve posteriorly
pole of the left kidney
CUpper pole is further from the midline than
EJejunum is thicker than ileum
the lower pole
305
DThere may be accessory arteries in up to

CThe coronary ligament is found on the left
30% of cases
DThe ligamentum teres runs from a notch in
EHas a posterior layer of fascia which has
the inferior border to the left end of the
attachments to the vertebral bodies
porta hepatis
EThe ligamentum venosum runs in a groove
21. On the medial aspect of the kidney:
between the left and caudate lobes
AThe artery runs anterior to the vein
BThe ureter passes anterior to the vein
26.The suprarenal gland:
CThe artery divides into anterior and
AOn the right is triangular in shape
posterior branches
BOn the right lies anterior to the vena cava
DIn the sinus there are 12 or 13 minor calyces
COn the left lies on the left crus of the
EIn the sinus each minor calyx includes up to
diaphragm
six renal papillae
DHas three sources of arterial supply
EHas a zona reticularis in the medulla
22 The ureter:
AIs partially retroperitoneal 27. In renal vessels:
BCrosses the ovarian vessels AThe inferior phrenic artery is a branch of the
CPasses behind the genitofemoral nerve renal artery
DLies medial to the tips of the transverse BThe right renal artery passes in front of the
processes vena cava
EReceives blood supply from the ovarian CThe left renal vein lies behind the aorta
vessels DThe renal arteries arise immediately below
the inferior mesenteric artery
23. The pancreas: EThe right renal artery passes behind the
AThe common bile duct crosses over the head of the pancreas
anterior surface
BThe uncinate process extends behind the 28. Peritoneal arrangements:
superior mesenteric vessels AThe right and left paracolic gutters
CThe inferior mesenteric vein lies behind the communicate with the pelvis
junction of head and neck BBoth paracolic gutters continue into
DThe portal vein lies behind the neck subdiaphragmatic spaces
EThe tail is related to the spleen CThe ligamentum teres runs in the falciform
ligament
24.The spleen: DThe greater omentum forms the anterior
AIs related posteriorly to the left suprarenal wall of the inferior part of the lesser sac
gland EThe epiploic foramen is related to the
BIs supplied by vessels running in the gastrophrenic ligament anteriorly
lienorenal ligament
29.The ovarian arteries:
CHas a notch in its anterior border
AArise just above the renal artery
DIs found between the seventh and ninth ribs
BAre crossed by the ureters
EMust increase in size by 25% before its
COn the right cross the inferior vena cava
anterior border passes beyond the left costal
DOn the left cross the left colic artery
margin
EReach the ovary through the ovarian ligament
25. The liver:
30.The following receive blood supply via
AThe caudate lobe lies to the left of the
the coeliac artery:
groove for the inferior vena cava
APancreas
BThe quadrate lobe lies to the right of the
BJejunum
fissure for ligamentum teres
CStomach
306
DFourth part of duodenum 36.The following are branches of the

E.Gallbladder posterior division of the internal iliac
artery:
31. Branches of the aorta: ASuperior gluteal
ACoeliac axis gives rise to the hepatic artery BMiddle gluteal
BMiddle mesenteric artery gives rise to the CMiddle rectal
middle colic artery DInternal pudendal
CCommon iliac artery arises at the left side of EPosterior vesical
L4
DThe inferior mesenteric gives rise to the 37. The uterine artery:
right colic artery AIs a branch of the anterior division of the
EThe superior rectal artery arises from the internal iliac artery
inferior mesenteric BRuns in front of the ureter
CGives a branch to the vagina
32. The following statements are true:
DMay anastomose with the obturator artery
AThe middle rectal artery arises from the
EDivides into arcuate arteries
inferior pudendal artery
BThe deep circumflex artery is a branch of
38. Iliac veins:
the inferior epigastric artery
ALeft external iliac vein lies lateral to the left
CJejunal straight arteries are longer and less
external iliac artery
numerous than ileal straight arteries
BThe deep circumflex iliac vein drains into
DThe right common iliac artery crosses the
the external iliac vein
obturator nerve
CThe internal iliac vein is behind and medial
EThe left common iliac artery is crossed by
to its artery
the superior rectal artery
DThe common iliac vein is formed at the level
33.The inferior mesenteric artery: of L4
AArises just below the lower border of the ERarely the left common iliac vein may
horizontal part of the duodenum receive a renal vein
BCrosses the left ureter
39.The inferior vena cava:
CGives rise to three sigmoid arteries
DEnters the pelvis as the superior rectal artery AIs related posteriorly to the right middle
ESupplies the transverse colon suprarenal artery
BIs related posteriorly to the right inferior
34.The external iliac artery is crossed by: phrenic artery
AThe corresponding vein CIs related anteriorly to the right colic vessels
BThe ovarian vessels DReceives the left suprarenal vein
CThe genital branch of the genital femoral EReceives the right gonadal vein
nerve
DThe round ligament 40.The hepatic portal system:
EThe ureter AThe hepatic portal vein forms at the level of
L1
35. The following are branches of the BThe left branch of the hepatic portal vein
anterior division of the internal iliac receives the cystic vein
artery: CThe superior mesenteric artery runs
AThe superior lateral sacral between the splenic and renal veins
BThe inferior lateral sacral DThe splenic vein receives the short gastric
CThe iliolumbar veins
DThe obturator EThe superior mesenteric vein receives the
EThe inferior rectal pancreaticoduodenal veins
307
41. Lymphatics: E Is closed by a true valve, where it enters the

A The cysterna chyli lies in front of L1 bladder
and L2
B The cysterna chyli lies to the right of the 46. Relations of the ovary:
azygos vein A The infundibulopelvic ligament is attached
C The ovaries drain to the lateral aortic and to the upper pole of the ovary
preaortic nodes B The ovary lies in front of the ureter
D The bladder drains to the lateral and C The upper pole of the ovary lies beneath the
preaortic nodes ovary
E The urethra drains to the internal iliac nodes D The fimbria of the uterine tube is related to
its medial surface
42. Autonomic nerves: E The obturator artery and nerve pass across
A Parasympathetic stimulation increases the ovarian fossa
peristalsis
B There are four lumbar splanchnic nerves 47. In the ovary:
C The hypogastric plexus is found inferior to A The tunica albuginea lies outside the
the aortic plexus germinal epithelium
D The coeliac plexus distributes autonomic B Some primordial follicles degenerate before
nerve supply along the ovarian artery birth
E The preganglionic sympathetic efferent fibres C Oogenesis occurs until the menopause
to the cervix derive from T10 and T11 D The corona radiata surrounds the liquor
folliculi
43. In the chest: E Ovulation occurs 14 days after the start of
A The thoracic duct drains into the right the last menstrual period
subclavian vein
B The hemiazygos drains into the left 48. In the follicle:
subclavian A The theca externa cells, after ovulation,
C The azygos vein drains into the superior become the theca-lutein cells
vena cava B The corpus luteum of pregnancy functions
D The right subclavian vein runs inferior to until the 6th month of pregnancy
the clavicle C The corpus luteum of pregnancy is the
E The thoracic duct arises at the level of the corpus albicante
T12 vertebra D In the follicular phase the theca interna cells
synthesize androgens
44. The following nerves supply the vulva: E Granulosa cells secrete progesterone in the
A Genitofemoral second half of the cycle
B Iliohypogastric
C Perineal branch of S4 49. The fallopian tube:
D Pudendal A Isthmus runs a tortuous course within the
E Ilioinguinal uterine wall
B Is 2.5 mm wide in the interstitial portion
45. The ureter: C Has an inner longitudinal muscle coat
A Is uniform in size except for two slightly D Has peg cells in the epithelium
constricted portions E Has decidual changes in the epithelial
B Enters the pelvis mid-way along the external tunica propria in pregnancy
iliac artery
C Crosses the ovarian artery 50. The uterus:
D Passes about 8-15 mm from the lateral A Forward tilt at the cervical isthmus is called
fornix of the vagina anteversion
308
BBy full-term pregnancy weighs about 900 g 55. The bladder embryology and histology:
CHas an outer blend of muscle fibres which AThe urogenital sinus is formed at about the
encircle the body in spirals seventh week of intraembryonic life
DEndometrium at mid-cycle is 0.5 mm thick BCaudal portions of the mesonephric ducts
EBlood loss at mensturation is usually less are incorporated in the trigone
than 50 ml CThe lining is a mucus-secreting transitional
epithelium
51. The cervix: DIs completely surrounded by a loose layer of
AIn infancy a large area is covered with areolar tissue
columnar epithelium EHas peritoneal attachments superiorly and
BHas nabothian follicles in the original laterally
squamous epithelium
CHas an increased proportion of fibrous tissue 56.The urethra:
when compared to the body of the uterus DHas AHas an external sphincter at the urethral
a fusiform cavity meatus
EHas ciliated epithelium BIs 3-4 cm in length in the adult female
CIs lined by transitional epithelium in its
52. In the vagina: proximal half
AThe left ureter is more closely related to the DHas an inner longitudinal muscle layer
fornix than the right EIs connected by muscle fibres to the
BThe lateral walls are in contact with each urogenital diaphragm
other
57. Innervation of bladder and urethra:
CThe pouch of Douglas entends halfway
ACholinergic drugs relax the bladder
down the posterior vaginal wall
BThe pudendal nerve supplies the bladder
DThe epithelium is non-keratinised
CS3 is the main parasympathetic root for the
squamous
detrusor muscle
EMucus-secreting glands are present
DSympathetic nerve supply is via the
hypogastric nerves
53. In the vulva:
EThe voluntary urethral sphincter is suplied p
AThe vestibule lies between the fossa
by the somatic fibres of S2 , 3 and 4
navicularis and the fourchette
BThe skin in the labia minora is keratinised 58. The uterine supports:
CSkene's ducts open into the vestibule AThe pubocervical ligaments are found
DThe bulbospongiosus muscles run around lateral to the bladder
the vagina BThe round ligament terminally carries some
EBartholin's gland is 2 cm in diameter fibres from the internal oblique and
transversalis muscles
54. The rectum and anal canal: CThe uterosacral ligaments pass backwards
AThe rectum is below the peritoneal to the 3rd and 4th sacral vertebrae
reflection in its lower two-thirds DThe coccygeus muscle arises from the
BThe anal canal is about 7 cm long ischial spine
CThe junction of the columnar and squamous EMackenrodt's ligaments attach to the `white
epithelium in the middle of the anal canal is line' laterally
marked by the white lines of Houston
DThe external anal sphincter consists of three 59. The following statements are true:
parts AThe canal of Nuck is a patent processus
EThe subcutaneous portion of the external vaginalis
sphincter runs between the anococcygeal BThe endopelvic fascia is continuous with the
ligament and the perineal body fascia transversalis lining the abdomen
309
C The posterior border of the triangular

B The nerve to obturator internus passes
ligament runs across the perineum between
through the obturator fossa
the two ischial tuberosities
C Levator ani motor supply is from a muscular
D Bulbocavernosus forms part of the perineal
branch of S2
body
D The perineal branch of S4 supplies the
E The deep perineal space is related laterally
perineal skin around the anus
to the ischiopubic rami
E The nerve to obturator internus lies lateral
to the internal vessels on the outer aspect of
60. Pelvic osteology:
the ischial spine
A The plain of least dimensions is at the level
of the ischial spines
64. Sacral plexus:
B The arcuate line is part of the iliopectineal
A The pudendal nerve gives off labial branches
line
into the superficial perineal pouch
C The pubic tubercle lies at the medial end of
B The pudendal nerve supplies the clitoris
the pubic crest
C The lateral femoral cutaneous nerve gives
D The obturator crest is the everted superior
off a perineal branch
border of the inferior ramus of the pubis
D The posterior femoral cutaneous nerve
E The transversus perinei muscles are
arises from S 1, 2 and 3
attached to the inferior pubic ramus
E The nerve to coccygeus arises from S3

65. The breast:
A The pudendal canal lies above the lateral
A Oestrogen stimulates secretion of colostrum B In
insertion of the levator ani.
pregnancy may increase in weight
B The internal pudendal artery runs behind
2-3-fold
the pyriformis muscle
C Montgomery's glands are sebaceous
C The internal pudendal artery leaves the
glands
pelvis at the lower border of the greater
D The breast is an apocrine gland
sciatic foramen
E The most frequent site of an accessory
D The pudendal canal lies 2 cm above the
breast is on the chest wall
ischial tuberosity
E The pudendal canal runs through the
66. The femoral triangle:
superficial perineal pouch
A The lateral border is vastus lateralis B
Pectineus lies in the floor
C Psoas major laterally rotates the femur
A The inferior rectal artery arises in the
D The femoral vein lies medial to the artery
pudendal canal
E The femoral vein lies lateral to the nerve
B The external pudendal artery arises over the
sacroiliac joint
67. The ischio-rectal fossa:
C The superficial perineal pouch communicates
A Has a lateral wall partly formed by the
anteriorly with the pelvic cavity
falciform margin of the sacrotuberous
D The obturator internus muscle makes up
ligament
the lateral wall of the ischiorectal fossa
B Is separated from the perianal space by the
E Obturator fascia is found on the inferior
perianal fascia
aspect of a muscle
C Has fat in small loculi separated by
complete septa
63. Pelvic nerve supply:
D Extends forwards into the urogenital
A The pudendal nerve lies on the medial side
triangle
of the pudendal vessels behind the ischial
E Is separated from the lower surface of the
spine
levator and by the lunate fascia
310
Answers
1. AF 9. AF 17. AT 25. AT 33. AT 41. AT

BF BT BT BT BF BF
CT CF CT CF CT CT
DT DT DF DT DT DF
ET ET ET ET EF ET
2. AT 10. AT 18. AT 26. AT 34. AF 42. AT

BF BF BT BT BT BT
CF CT CT CT CT CT
DF DF DF DT DT DT
ET ET EF EF ET EF
3. AT 11. AT 19. AF 27. AF 35. AF 43. AF

BF BF BF BF BF BF
CT CT CT CF CF CT
DF DT DT DF DT DT
ET ET ET ET EF ET
4. AT 12. AT 20. AF 28. AT 36. AT 44. AF

BT BT BT BF BF BF
CF CT CF CT CF CF
DT DF DT DT DF DT
EF EF ET EF EF ET
5. AF 13. AF 21. AF 29. AF 37. AT 45. AF

BT BF BF BF BT BF
CT CF CT CT CT CF
DT DF DT DF DF DT
ET EF EF EF ET EF
6. AF 14. AF 22. AF 30. AT 38. AF 46. AT

BF BT BF BF BT BT
CT CF CF CT CT CT
DT DT DF DF DF DT
EF ET ET ET ET ET
7. AF 15. AF 23. AF 31. AT 39. AT 47. AF

BF BT BT BF BT BT
CF CT CT CT CT CF
DF DF DF DF DF DF
ET ET ET ET ET EF
8. AF 16. AF 24. AT 32. AT 40. AF 48. AF

BT BF BT BF BF BF
CT CT CT CT CT CF
DF DT DF DT DT DT
ET ET EF EF ET ET
311
49. AF 53. AF 57. AF 61. AF 65. AF

BF BF BF BF BT
CF CT CT CT CT
DT DT DT DF DT
ET EF ET EF EF
50. AF 54. AF 58. AT 62. AT 66. AF

BT BF BT BF BT
CF CF CF CT CF
DF DT DT DT DT
EF ET EF EF EF
51. AT 55. AT 59. AT 63. AT 67. AT

BF BT BT BF BT
CT CF CT CF CF
DT DF DF DT DT
EF EF ET ET ET
52. AT 56. AF 60. AT 64. AT

BF BT BT BT
CF CT CF CF
DT DT DF DT
EF ET ET EF
31
2
CMild arteritis is common

PATHOLOGY
DInfectivity is low
E Thdi e sease pro ceeds to tertiar y shilis in yp
Questions over 50% of cases
1. In acute inflammation:
7. In tertiary syphilis:
AThere is increased capillary permeability
AWeakening of the aorta commences with
BThere is `margination' of white blood cells
inflammation of the intima
CThere is rouleaux formation near the centre
B `Windowing' is due to focal destruction of
of the capillaries
the aorta lamina media
DThe exudate may include globulins
CEnlargement of the cerebral ventricles may
EBradykinin is released
occur
DTabes dorsalis results in motor loss
2 In chronic inflammation:
ELesions contain many spirochaetes
AThe cells are mostly polymorphonuclear
BThere is associated proliferation of new
8. Congenital syphilis:
capillaries
AIs more severe if contracted in the first
CMacrophages may form multinuclear giant
trimester
cells
BIs due to ascending vaginal infection
DDoes not occur as a result of fungal infection
C May cause nasal ` snuffles '
EThere may be a preceding episode of acute
DCharacteristically causes chorioretinitis
inflammation
EIs more likely if the mother has tertiary syphilis
3. Granulomata may be found in:
AHypersensitivity reactions 9. Wound healing by regeneration
BParasitic infestations invariably occurs:
CSarcoidosis AIn the liver
DPrimary biliary cirrhosis BIn the small intestine
ECrohn's disease CIn the renal tubular epithelium
DIn the neuronal system
4. In tuberculosis: EIn the thyroid
AThe primary site may be the small intestine
BThe Ghon focus consists of a small aggregate 10. Wound healing by organisation occurs in:
of tubercles with caseation AThe epidermis
CThe Kveim test is usually positive BInfarcts
DAbdominal ascites rarely causes adhesions CThrombi
EInfection of the fallopian tube is usually DFibrinous inflammatory exudate
secondary to tuberculous peritonitis EChronic inflammation
5. In primary syphilis: 11. Wound healing is delayed by

AThe chancre appears about 3 days after deficiency:
infection AOf vitamin D
BThe chance is usually painful BOf zinc
CThere are many polymorphs in the ulcer base COf calcium
DHard, painless lymph nodes appear DOf sulphur-containing amino acids
EGiant cells are found in the ulcer base EOf glucocorticosteroid hormones
6. In secondary syphilis: 12. Surface epithelium give rise to:

AThere may be anaemia APapillomas
BThere may be generalised lymphadenopathy BCystadenomas
313
C Choriocarcinoma
Answers
D Mimasi enngo
E Nephroblastoma
1. AT 7. AF 13. A T
13 Red blood cells: BT BT B T
ABurr cells may be found in uraemia CT CT CT
BPoikilocytes have irregular shapes DT DF D F
CThe diameter of a red blood cell is about 7.5 ET EF E F
µm
DPappenheimer bodies occur in macrocytic 2. AF 8. AF 14. A T
anaemia BT BF B T
EHave a lifespan of 50 days CT CT CF
DF DF D F
14. In iron deficiency anaemia: ET EF E T
A There may be anisocytosis
B There may be poikilocytosis 3. AT 9. AF 15. A T
CThe bone marrow is hypocellular BT BT B F
DIntestinal apoferritin is high CT CF CT
EHaemosiderin reserves are mobilised DT DF D T
ET EF E F
15. Vitamin B 12:
AIs found in eggs 4. AT 10. AF 16. A T
BIs absorbed from the jejunum BF BT B F
CDeficiency may be associated with vaginal CF CT C F
atrophy D F D T D F
D Deficiency may be associated with E F E T E T
anisocytosis
E Deficiency may be associated with 5. AF 11. AF
degeneration of the anterior columns of the B F B T
spinal cord C F C F
D T D T
16. Folic acid:
E F E F
A Is found in liver
B Is found in milk
6. AT 12. AT
CIs absorbed in the ileum
BT BF
DDeficiency is diagnosed by the Schilling test
CT CF
EDeficiency may result from anticonvulsant
DF DF
treatment
EF EF
314
7 Cl ostridium tetani.
MICROBIOLOGY
AProduces an exotoxin: tetanospasmin
BMay be found in the gut
Questions
CMainfect the ft y eus v i a t h e vag i na
1. Bacteria: D Neurotoxin interferes with the action of the
AAre eukaryotic lower motor neurone
BEach have a cytoplasmic membrane EIs an obligate anaerobe
CAll have cell walls
DAll have pili (fimbriae) 8. Neiserria spp.:
EAll have mitochondria AInclude a number of normal commensals
BN. gonorrhoeae are free-living bean-shaped
2. Staphylococcus: diplococci
AAureus forms long chains CN. gonorrhoeae may be isolatable from
BAureus produces coagulase asymptomatic carriers
CEpidermidis is coagulase negative DN. gonorrhoeae infection is diagnosed by a
DPhage Group II produces enterotoxins high vaginal swab
EPhage Group III produces impetigo and EStain pink on Gram's stain
pemphigus neonatorum
9. Gram-negative bacteria:
3. Streptococcus sp.:
APseudomonas is a facultative anaerobe
AMay be classified on cell wall C-carbohydrate BKlebsiella is an obligate aerobe
antigens
CBacteroides is an obligate anaerobe
BMay produce endotoxins
DProduce lipopolysaccharide endotoxins
CMay produce haemolysins
EDrug resistance is due to penicillinase
DThe majority of dangerous strains are
production.
Group-B, Beta-haemolytic
ES. pneumoniae may cause peritonitis 10. The normal vaginal flora may include:
AChlamydia trachomatis
4. Corynebacterium spp.:
BClostridium perfringens (welchii)
AShow Chinese lettering on staining
CBacteroides
BContain many commensal bacteria
DFusobacterium spp.
CInfection with C. diphtheriae can be shown by
EHuman papilloma virus
the Schick test
DAre gram positive
11 Actinomyces s pp. :
EAre sporing
AAre gram-negative
5. Clostridium spp.: BHave acid fast filaments
AProduce endotoxins CA. israelii is a normal commensal
BAre gram-positive DAre sensitive to penicillin
CAre anaerobes EMay colonise an intrauterine contraceptive
DBear spores device
EAre obligate intracellular bacteria
12. The spirochaetes:
6. Clostridium perfringens: ATr. pallidum can be visualised by Giemsa
AType A may cause gas gangrene staining
BIs a normal commensal in the large bowel of BTr. pallidum may be identified by tissue
man culture
CIs sensitive to metronidazole CBorrelia cause undulant fever
DMay cause food poisoning DLeptospira cause chancroid
EIs identified by the Nagler reaction EAre motile by axial filament
315
13. Syphilis serology:

19. The following viruses contain DNA:
A The Reagin tests depend upon antibody
A Rubella
reaction with cardiolipin
B Measles
B Cardiolipin is also used in VDRL and WR
C Mumps
tests
D Papilloma
C The TPHA test makes use of immune
E Parvovirus B 19
l f uorescence
D Reagin tests remain positive many years 20. Cytomegalovirus:
after effective therapy A May cause pneumonitis
E FTA-ABS becomes positive earlier in the B Is associated with òwl's eye' inclusion bodies C May
disease than TPHA be transmitted to the fetus
transplacentally
14. False-positive Reagin tests may arise in: D May be transmitted to the fetus in the birth
A Malaria canal
B Infectious hepatitis E May be transmitted in breast milk
C Pregnancy
D Tuberculosis 21. Candida albicans:
E Rheumatoid arthritis A Is dimorphic
B May cause paronychia
15. Chlamydia: C May be found as a normal commensal in the
A Have cell walls vagina
B Multiply by binary fission D May cause septicaemia
C Cause granuloma inguinale E Has gram-negative pseudohyphae
D Infection results in the formation of cold
agglutinins 22. Trichomonas vaginalis:
E Have ribosomes A Has eight flagella
B Has two nuclei
16. Mycoplasma: C Forms cysts
A May cause pelvic inflammatory disease D Has a sexual cycle completed in the cat E Has a
B Are sensitive to penicillin sucking disc
C Have cell walls
D Are obligate intracellular parasites
Answers
E Cause spotted fever
1. A F 4. AT 7. AT
17. Viruses: B T B T B T
A The capsid is a lipoprotein envelope C F C F C F
B Herpes virus is associated with an D F D T D F
intranuclear inclusion body E F E F E T
C Contain a number of capsomeres in the capsid
D Can be cultivated in appropriate cell 2. AF 5. AF 8. AT
cultures B T B T B F
E Can be identified by polymerase chain CT CF CT
reaction D F D T D F
E F E F E T
18. The herpes virus group includes:
A Papilloma virus
3. AT 6. AT 9. AF
B Rubella virus
B F B T B F
C Varicella-zoster virus
C T C T C T
D Cytomegalovirus
D F DT D T
E Epstein-Barr virus
E T E T E T
316
10. AF 13. AT 16.AT 19.AF 22.A F

BT BT BF BF B F
CT CF CF CF C F
DT DF DF DT D F
EF ET EF ET E F
11.AF 14.AT 17.AF 20.AT

BF BT BT BT
CT CT CT CT
DT DT DT DT
ET ET ET ET
12.AT 15.AT 18.AF 21.AT

BF BT BF BT
CT CF CT CT
DF DF DT DT
ET ET ET EF
317
C IgE can `fix' complement

IMMUNOLOGY
D IgD contains Kappa and Lambda chains
Questions E IgA crosses the placenta
1. HLA-system: 4. Hypersensitivity reactions:

A Within the HLA system there are six A Lupus erythematosus arises due to a Type I
transplantation antigens reaction
B HLA-C antigens are not present on normal B Autoimmune haemolytic anaemias result
trophoblastic tissue from Type III reactions
C Blocking antibodies cause the rejection of the C Type IV reactions are independent of
implanted blastocyst immunoglobulins
D Is represented on chromosone 8 D May be cell activated
E HLA DR antigens are called class I antigens E Acute anaphylactic reactions occur due to
IgE release
2. Cells of the immune system:
A B cells are made in the Buras-of-Fabricus in
the fetus Answers
B Kupffer cells are modified macrophages
C B cells have immunoglobulin on their plasma 1. AF 3. AF
membranes B T B F
D T are able to kill `self' cells CF CF
E T cells recognise antigens only after they have D F D F
been processed by the Active Protein C E F E F
System (APCS)
2. AF 4. AF
3. Immunoglobulins: B T B F
A Tetanus neonatorum is prevented by CT CT
maternal IgM DT D T
B Maternal IgG in the baby is catalysed after E T E T
6 months
318
CGalactose is a pentose monosaccharide

BIOCHEMISTRY
DDisaccharidases are found in the intestinal
lumen
Question ESaliva assists absorption of complete
carbohydrates
1. Proteins:
AThe amino acids are always of the
6. In fat metabolism:
D-configuration
AThe action of lipase results in the hydrolsis y
BMost proteins contain between 10 000 and
of fats
100 000 amino acid residues
BChylomicrons contain protein
CProteins are usually 60% nitrogen
CFatty acids are converted to esters of
DIn gel filtration large molecules emerge first
coenzyme-A
EThe way in which protein chains link together
DAnimals can convert fatty acids to glucose
is called the Quaternary structure
EFatty acids are synthesised and degraded by
different pathways
2. Proteins:
AHaemoglobin changes shape markedly as it
7. In glycolysis:
functions physiologically
AIn anaerobic glycolysisthree molecules of ,
BThere are over 30 different amino acids
lactate are produced
found in proteins
BIn aerobic glycolysis the end product is
CDisulphide bridges occur between glutamine
acetaldehyde
residues
CAcetaldehyde undergoes decarboxylation to
DThe most common type of bond in proteins is
acetyl-CoA
the salt bond between acidic and basic amino
DIn glycolysis there is a net gain of two ATP
acids
molecules
ELipoproteins are not produced by man
EGlycogen is the primary source of substrate
3. Nutrition: 8. The following hormones lower the

ADuring pregnancy an extra 6 g of protein is blood sugar:
required daily AAdrenalin
BDuring lactation an extra 30 g of protein is BInsulin
required daily CGlucagon
CProtein may be found in potatoes DThyroxine
DPhenylalanine is an essential amino acid EGrowth hormone
EVegetable protein contains all the essential
amino acids. 9. Ketone bodies:
AKetone bodies arise from acetyl-CoA
4. Nutrition: BBeta-hydroxybutyric acid is a ketone body
APeptidase acts in the stomach CThe liver is the major site of manufacture of
BAmino acids are absorbed by passive transport acetoacetate
CNitrogenous compounds may be excreted in DHeart muscle metabolises acetoacetone in
sweat preference to glucose
DVitamin K is found in egg yolk EThe brain cannot utilise acetoacetone to any
EMilk increases absorption of iron major degree for its metabolic needs
5. In carbohydrate metabolism: 10. In the tricarboxylic acid (TCA) cycle:

AInsulin is a glycoprotein AAcetyl-CoA condenses with succinate
BHuman placental lactogen is a steroid BSix pairs of hydrogen atoms are made
hormone available
319
CEach pair of hydrogen atoms yields three

molecules of ATP Answers
DA six-carbon glucose molecule yields 48 1 AF 6. AT 11. AT
ATPs in total BF BT BF
EOxidative phsophorylation results in carbon CF CT CT
dioxide and water DT DT DT
ET ET ET
11 Enzymes:
AIncrease reaction velocity 2. AT 7. AF 12. AT
BIn a high salt concentration the solubility of BF BF BT
enzymes is high CF CF CF
CIn chromatography, acidic enzymes are DF DT DT
retained by a positively ionised field EF EF EF
D Co-enzymes are non-proteins
EAdenosine triphosphate (ATP) is a 3 AT 8. AF 13. AF
co-enzyme BT BT BF
CT CF CT
12 Active transport: DT DF DF
A Takes place in the kidney EF EF ET
B Takes place in the placenta
CTakes place in the liver 4. AF 9. AT
D Takes place in the red blood cell BF BT
E Of glucose requires Na+ to move across the CT CT
cell membrane in the opposite direction DT DT
EF ET
13. In competitive inhibition of enzyme
action: 5. AF 10. AF
AThe Vmax is increased BF BF
BThe Km is decreased CF CT
CThere is direct competition between the DT DF
substrate and inhibitor EF ET
D Km is a measure of how tightly a substance
binds to enzyme
E Competitive inhibitors typically bear a
structural similarity to substrate
320
C Th e p at w c Hhih 50% of a buffer is

PHYSIOLOGY
changed
from acidic to base form is the pK
Questions
DBicarbonate is the most important buffer in
1. Given the atomic weights Na+ 23, Cl- bodily fluids
35.5 and Ca++ 40, the following EPlasma protein has at least 6x the buffering
statements are true: capacity of haemoglobin
A 1 mole of Na+ is 46 g
B 1 mole of NaCl is 58.5 g 6. With a pH of 7.4 (and the logarithmto of 4
CA normal (molar) solution of NaCl contains to be 0.6):
117 g of NaCl AThe hydrogen concentration is 0.00004
DThe concentration of NaCl in a mmol/l
physiologically `normal' solution is 6% BThe H+ concentration is 0.00004 mmol/l
E 1 equivalent of Ca++ is 20 g CBodily fluids would be slightly acidic
DDissociation of 02 from haemoglobin is
2. In a normal man weighing 70 kg: increased compared to a pH of 7
A40% of the weight is composed of water EThe pH of urine would be very low
B 30% of the weight is composed of protein
CTwo-thirds of the body water is intracellular 7. Acid-base:
DThe total blood volume is about 8 1 ABase excess is negative in metabolic acidosis
Eminerals make up 0.7% of the body weight BExcessive sedation may give rise to a
respiratory alkalosis
3. The distribution of electrolytes:
CIn pregnancy there is a respiratory alkalosis
ANa+ and Mg++ are the major intracellular DProlonged vomiting may cause a metabolic
cations acidosis
BPhosphate is the major intracellular anion EMetabolic alkalosis frequently accompanies
CDuring pregnancy the plasma osmolarity rises hypokalaemia
DIn acidosis there is a decrease in the anion gap
EThe concentration of sodium is more in the 8. Cardiac physiology:
interstitial fluid than in the plasma AThe dominant tone of control at the sinoatrial
node is parasympathetic
4. Movement of solute and solvent:
BBlood in the left side of the heart is 99%
AOsmosis describes the movement of solute
satuarated with oxygen
across a semi-permeable membrane
CThe à'-wave in the JVP trace is due to atrial
BThe pressure that stops osmosis is the
systole
osmotic pressure
DA third heart sound may occur at the time of
COsmosis describes the process wherein bulk
rapid atrial filling
movement of solvent drags some molecules of
EThe end-diastolic volume is the àfter-load'
solute with it
DIn non-ionised diffusion there is preferential
9. In pregnancy:
transport of molecules of high molecular
weight AThe blood volume increases by 1200-1400
ml
EPhagocytosis involves the use of carrier-
BThe cardiac output continues to increase
mediated transport
until the end of the third trimester
5. Acid-base: CThe heart rate is increased by 40%
AAn acid is a proton acceptor DThe arteriovenous oxygen gradient
BThe pH is the -logarithm10 of the Hydrogen decreases
ion concentration EThe diastolic blood pressure tends to rise
slowly throughout
321
10. Local control of blood flow:

A Hypoxia causes vasodilatation 15. In the neonate:
B Carbon dioxide causes vasoconstriction A Respiratory distress syndrome (RDS) is due
to the absence of type 2 pneumocytes B The
C Adenosine is a vasodilator
D Hydrogen ions cause vasoconstriction tidal volume is 10 ml/kg
E Prostaglandin E is a vasoconstrictor C RDS may be prevented by administering
dexamethasome to a mother in premature
labour before 30 weeks gestation
11. Respiratory physiology:
D Intraventricular haemorrhage is most
A The proportion of oxygen in inspired air is
common after 4 days of age
28%
E Congenital heart disease is the commonest
B The proportion of carbon dioxide in
fetal abnormality
inspired air is 3%
C The partial pressure of oxygen in alveolar air
16. The haemoglobin dissociation curve:
is 158 mmHg
A The presence of carboxyhaemoglobin shifts
D The physiological dead space is increased in
the curve to the right
pulmonary oedema.
B Acidosis shifts the curve to the left
E In normal individuals the anatomic dead
C Increased temperature shifts the curve to
space nearly equals the physiological dead
the right
space
D The Bohr effect helps haemoglobin to
unload oxygen
12. Respiratory physiology:
E 2:3 DPG is produced during glycolysis
A The normal tidal volume is 350 ml/breath
B Under normal circumstances 45% of
17. The levels of 2:3 DPG are:
oxygen delivered to the peripheral tissues is
A Increased by androgens
extracted
B Decreased by thyroxine
C In normal individuals the FEV1/FVC ratio
C Increased by anaemia
is at least 75%
D Decreased in banked blood
D deoxygenated haemoglobin is a better buffer
E Decreased by living at altitude
than oxygenated haemoglobin
E the Bezold Jarisch reflex results in an 18. Carriage of oxygen and carbon dioxide:
increased respiratory rate A The presence of haemoglobin increases the
oxygen carrying capacity of blood 70-fold B
13. In pregnancy: Cyanosis is only seen when the
A The total lung volume increases concentration of deoxygenated haemoglobin
B The residual volume decreases is more than 5 g/dl
C Ventilation increases by 40% C Some carbon dioxide is carried by plasma
D The total lung capacity decreases proteins
E Oxygen consumption increases by 50 D 2/3 of carbon dioxide is carried by
ml/min by term haemoglobin
E In the chloride shift, chloride ions diffuse
14. In pregnancy: out of the red blood cell
A The Pco2 falls
B There is a decrease in the sensitivity of the 19. In the kidney:
respiratory centre to CO2 A The capillaries of the glomerulus are a
C Respiratory rate increases due to the effect portal system
of progesterone B The vasa recta supply the loop of Henle
D Total increase in respiration is 60% C 85% of the tubules are juxtamedullary
E Residual volume increases by 200 ml. D Juxtamedullary tubules have thickened
ascending and descending loops of Henle
322
E The loop of Henle is concerned with the 25. In pregnancy:

reabsorption of chloride ions A The kidneys increased by 2-3 cm in length
B The renal blood flow remains constant
20. In the kidney: C The renal blood flow is decreased in the
A The normal creatinine clearance is about erect position
1.2 1/min D The serum creatinine remains at
B There is an increase in renal blood flow pre-pregnancy levels
during pregnancy E The creatinine clearance rate falls
C the filtration fraction is the glomerular
filtration rate/renal blood flow 26. The bladder and micturition:
D glucose is absorbed in the distal tubule A The normal residual volume of the bladder
E amino acids are absorbed in the proximal is 0-100 ml
tubule B The bladder capacity is 350 ml
C The maximum urethral pressure in the
21. Sodium is reabsorbed in the following absence of micturition is 50-100 cm of water
places: D The maximum urine flow rate is 5 ml/sec
A Proximal tubule E Detrusor sensation is relayed through the
B Loop of Henle sympathetic nervous system
C Distal tubule
D Collecting duct 27. The gastrointestinal tract:
E Ureter A During pregnancy the rate of gastric
emptying is increased
22. In the kidney: B Cholecystokinin is produced by the
A Carbonic anhydrase is found in the brush gallbladder
border for the cells of the loop of Henle C Gastrin acts on the parietal cells of the
B Potassium is reabsorbed actively in the stomach
proximal tubule D Pepsin is produced by the oxyntic cells of
C In the distal tubule the pH is less than 4 the stomach
D Hydrogen ions are actively excreted in the E the pH of the stomach is approximately 3
proximal tubule and distal tubule
E Concentration of urine occurs due to the 28. In the intestine:
high osmotic pressure of the medulla A Amylase converts glycogen to glucose
B Cholecystokinin secretion causes the release
23. Antidiuretic hormone: of pancreatic enzymes
A increases chloride absorption in the loop of C Brunner's glands secrete mucus
Henle D Goblet cells are present in the large bowel E
B secretion is stimulated by morphine Meissner's plexus is submucous
C secretion is stimulated by alcohol
D is a glycoprotein 29. Nutrition:
E is secreted from the anterior pituitary gland A The calorific value of protein and
carbohydrate is approximately the same
24. In the kidney: B The increase in dietary requirement of
A Urea is actively secreted in the distal tubule pregnancy is 20 kcal/day
B At low urine flow, 50-70% of filtered urea is C The average dietary intake of carbohydrate
excreted is 400 g/day
C erythropoietin is a glycoprotein D The pregnancy requirements of protein are
D natriuretic peptide is synthesised in the 1.5-2 g/kg/day
juxtaglomerular apparatus E Fat is important for the absorption of
E natriuretic peptide causes sodium retention vitamin C
323
30. The following are essential amino acids: 36. In urine the following can be found:
A Arginine A Unconjugated bilirubin
B Proline B Conjugated bilirubin
C Glycine C Urobilinogen
D Valine D Stercobilin
E Histidine E Bilirubin glucuronide
31. Vitamins: 37. Insulin:

A Vitamin A is water soluble A Is a polypeptide with a molecular weight
B Vitamin A deficiency predisposes to more than 5000
xerophthalmin B Requires magnesium for its
C Vitamin BI is teratogenic crystallisation
D Pellagra is due to deficiency in vitamin B2 C Is stored in quantities up to 250 units at any
E Vitamin B6 (pyridoxine) is fat soluble one time
D Is produced in alpha-cells
32. Vitamins: E Is required for entry of glucose into hepatic
A Folic acid is stored in the liver cells
B Folic acid levels can only be measured in
plasma 38. The hypothalamus:
C Vitamin C deficiency results in a microcytic A Is found below the cavernus sinus
anaemia B Has posterior boundaries for the mamillary
D Vitamin B6 (pyridoxine) deficiency results bodies
in a macrocytic anaemia C Is medial to the tuber cinereum
E Vitamin D can be found in egg yolk D In the supraoptic area contains the
dorsomedial nuclei
33. Vitamin D: E Is connected to the posterior pituitary by the
A Is required forcalcium absorption from the gut pituitary portal system
B Deficiency causes rickets
C Is water soluble 39. The pituitary gland:
D 1,25 (OH)2 cholecalciferol concentrations A Oxytocin is produced in the paraventricular
are approximately doubled in pregnancy nucleus of the hypothalamus
E Excess causes hypercalcaemia B TRH is a decapeptide
C PIF is dopamine
34. In pregnancy: D the superior hypophyseal artery is a branch
A 1.2 mg of calcium is required per day of the internal carotid artery
B 15 mg of iron is required/day E the inferior hypophyseal artery is a branch of
C The requirements of sodium are increased the external carotid artery
D The requirements of iodine are the same
E The requirements of potassium are increased 40. The pituitary:
A The pars intermedia is derived from the
35. In the liver: posterior pituitary
A Galactokinase converts galactose into B The pituitary gland lies medial to the
glucose cavernus sinus
B Triglycerides are synthesised from fatty C Prolactin is secreted by the posterior
acids and glycerol pituitary
C Cephalins are lipoproteins D The alpha unit is the same in all pituitary
D Urea is formed from four molecules of glycoproteins
ammonia E Hypoglycaemia inhibits the release of
E 95% of the body's globulin is synthesised growth hormone
324
41. Prolactin secretion is stimulated by: 46.At puberty:

ADopamine AGenerally pubic hair appears after the
BTRF initiation of breast growth
CDiazepam BAt menarche the uterine: cervical ratio is 1:1 CThe
DCoitus age of menarche is unrelated to the
E, Venepuncture standard of living
DThe earliest changes in puberty are
42. Posterior pituitary: increased adrenal androgens
AVasopressin is a nonapeptide. EThe pituitary and hypothalamus become
BOxytocin sensitivity of the uterus varies with less sensitive to negative feedback
gestation
COxytocinase is found in the uterus 47.After the menopause:
DOestrogen prevents the action of oxytocin AFSH levels remain high for longer than 2-4
on the breast alveoli years
EOxytocin stimulates production of milk by BThe urinary calcium creatinine ratio slowly
the alveoli falls
COvarian follicles do not respond to pituitary
43. In the menstrual cycle: stimulation
AThe discus proligerous is found outside the DLH is increased
granulosa cells EUrinary P04-3 creatinine ratio is raised
BSubnuclear vacuole formation occurs in the
proliferative phase 48.Steroid hormones:
CAs the cycle proceeds the spiral arteries AAre all synthesised from cholesterol
become less coiled BDHAS is a substrate for oestriol
DArborisation of the cervical mucus can be CACTH stimulates the secretion of
seen at the time of ovulation aldosterone
EWhen progesterone is present a vaginal slide DCorticosteroid metabolites are 17
shows large numbers of superficial cells oxosteroids
ECortisol secretion shows diurnal
44. Steroid hormones: variation
ABefore passing into the nucleus a steroid
hormone binds to a cytosol receptor 49.Adrenaline
BAndrogens are excreted in the urine as 17 AHas VMA as its principle metabolite
oxo-steroids BStimulates insulin release
COvulation occurs 6 hours after the LH peak CStimulates glycogen formation
DMaximum progesterone levels occur 5 days DIncreases cyclic AMP levels in the liver
after the LH peak EIs the principle catecholamine affecting the
EProgesterone is secreted by the testis heart
45. Gonadotrophins: 50. Thyroid hormones:

AFSH controls the formation of androgen- AT3 is more potent than T4
binding protein in Sertoli cells BIodine is better absorbed from the gut as
BInhibin stimulates the secretion of GnRH iodine
CThe LH surge is in response to the feedback CReverse T3 is more potent than T3
of oestrogen DCarbimazole prevents conversion of iodide
DTestosterone secretion is controlled by FSH to iodine
EGonadotrophin LH is secreted in 14-minute ELarge doses of iodine suppress thyroid
pulses activity
325
51. Thyroid:
CPhenylephrine is a beta-agonist
AIodine-131 may cause fetal hypothyroidism
DBeta sympathetic agonists stimulate the uterus
BIn pregnancy plasma levels of iodide rise
ELabetalol is a (3-blocker
CThe fetal thyroid glands are inactive until
the third trimester
56.Iron:
DCarbimazole does not cross the placenta
AThe fetus dervies its iron mainly in the last 4
ECarbimazole is safe for breastfeeding
weeks of pregnancy
BIron in eggs is well absorbed
52. Calcium metabolism in pregnancy:
CTea enhances the absorption of iron
AFetal calcium levels are less than maternal
DIn pregnancy the percentage saturation of
BParathyroid hormone crosses the placenta
the total iron-binding capacity increases
by active transport
EFerritin is a high molecular weight lipoprotein
CVitamin D3 crosses the placenta via a
binding protein
57. Iron:
DThe levels of parathyroid hormone increase
AHaemoglobin comprises less than 15% of
in pregnancy
total body iron
EIn pregnancy there is an increased turnover
BAggregates of transferrin form haemosiderin CThe
of vitamin D
total iron body content of the adult
female is about 38 mg/kg
53. Somatic nervous system:
DIron is best absorbed in the ferrous form
AEfferent fibres pass through the ventral roots
EHaem iron is more effectively absorbed than
of the spinal cord
non-haem iron
B 20% of the descending fibres of the motor
cortex lie in the lateral corticospinal tract
58.Iron:
CPain and temperature ascend in the lateral
AThe red blood cell's lifespan is 70 days
spinothalamic tract
BIn iron deficiency anaemia microcytosis
DEfferent fibres synapse in the substantia
appears before hypochromia
gelatinosa
CA normal diet contains 40 mg/day
EFibres for proprioception ascend in dorsal
DIs absorbed in the terminal small bowel
columns to the medulla
EParenteral iron is more effective than oral
iron in correcting severe anaemia
54. The autonomic nervous system:
AParasympathetic outflow is via cranial
59. Coagulation:
nerves IV, VIII and IX
AProstacyclin prevents platelet adhesion
BSympathetic nerves pass through the grey
BProstacyclin synthetase is found in highest
rami communicantes to the collateral
concentrations in the lamina externa of the
ganglia
blood vessels
CPreganglionic sympathetic fibres run all the
CProstacyclin production is increased in pre-
way to the uterus
eclampsia
DAtropine blocks transmission at
DLow platelet count may be associated with
parasympathetic ganglia
intrauterine growth restriction
EAtropine blocks transmission at sympathetic
EAdenosine diphosphate stimulates
ganglia
aggregation of platelets
55. The autonomic nervous system:

60.Coagulation:
ASympathetic neurones to sweat glands are
AThromboplastin activates the intrinsic
cholinergic
system
BSympathetic neurones to vasodilatory
BThe intrinsic pathway is quicker than the
smooth muscle are nicotinic
extrinsic pathway
326
CAnti-thrombin III is an a -2-globulin 7. AT 15. AF 23. AF

DIn pregnancy factors XI and XII are BF BT BT
increased CT CT CF
EHeparin potentiates the action of anti-Xa DF DF DF
ET ET EF
61. Fibrinolysis:
APlasminogen activator is found in raised 8. AT 16. AF 24. AF
concentrations in the placenta BF BF BF
BEpsilon-amino-caproic-acid stimulates CT CT CT
plasminogen activator DF DT DF
CStreptokinase stimulates plasminogen EF ET EF
activator
D Plasma fibrinolytic activity returns to
9. AT 17. AT 25. AF
normal within 1 hour of placental delivery EThe
BF BF BF
placenta contains inhibitors which
CF CT CT
block fibrinolysis DT DT DF
EF EF EF
62. Disseminated intravascular coagulation
may result from:
A Pre-eclampsia 10. AT 18. AT 26. AF
BFactor VIII deficiency BF BT BF
CIdiopathic thrombocytopaenic purpura CT CT CT
DF DF DF
DAmniotic fluid embolism
EAbruptio placentae EF EF EF
63. Rhesus incompatibility: 11. AF 19. AT 27. AF

AThere are three Rhesus antigens BF BT BF
BABO antibodies are IgG CF CF CT
CIn haemolytic disease of the newborn, the DT DF DF
haemolytic process is maximal at the time of ET ET EF
birth in live-born infants
D Severe Rhesus sensitisation causes recurrent 12. AF 20. AF 28. AF
1st trimester abortions BF BT BT
ECauses hydrops fetalis CT CF CT
DT DF DT
EF ET ET
Answers
1. AF 3. AF 5. AF 13. AT 21. AT 29. AT

BT BT BT BT BT BF
C F CF CT CT CT CT
D F D F D F DT DT DT
E T E F E F ET EF EF
2. AF 4. AF 6. AF 14. AT 22. AF 30. AT

B F B T B T BF BT BF
CT C F C F CF CF CF
D F D F D F DF DT DT
E F E F E F EF ET ET
327
31. AF 37. AT 43. AF 49. AT 55. AT 61. AF

BT BF BF BF BF BF
CF CT CF CF CF CT
DF DF DT DT DF DT
EF EF EF ET ET ET
32. AT 38. AF 44. AT 50. AT 56. AT 62. AT

BF BT BT BT BF BF
CF CF CF CF CF CF
DF DF DF DT DF DT
ET EF ET ET EF ET
33. AT 39. AT 45. AT 51. AT 57. AF 63. AF

BT BF BF BF BF BF
CF CT CT CF CT CT
DT DT DF DF DT DF
ET EF ET EF ET ET
34. AF 40. AF 46. AT 52. AF 58. AF

BT BT BT BF BT
CF CF CF CT CF
DF DT DT DT DF
EF EF ET ET EF
35. AT 41. AF 47. AT 53. AT 59. AT

BT BT BF BF BF
CF CT CT CT CF
DF DT DT DF DT
EF ET ET ET ET
36. AF 42. AT 48. AT 54. AF 60. AF

BT BT BT BF BF
CT CT CF CT CF
DF DF DF DF DF
ET EF ET EF ET
328
C Atenolol - fetal overactivity

DRUGS AND DRUG THERAPY
D 17 hydroxy-progesterone - virilisation of
female fetus
Questions
E Lithium - Epstein's malformation
1. The following are alkylating agents:
A Cyclophosphamide 6. The half life of the drug will be increased
B Bleomycin by:
C Thiotepa A Increased volume of distribution
D Treosulphan B Increased rate of clearance
E Melphalan C Increased age, for drugs eliminated mainly by
the kidney
2. Cyclophosphamide: D Pregnancy for drugs metabolised in the liver E
A Is activated by liver enzymes Shortening the time between doses
B May cause haematuria
C Frequently causes profound 7. In pregnancy:
myelosuppression A The concentration of globulins falls
D May cause alopecia B Highly ionised drugs are metabolised more
E Has four alkylating arms than non-ionised drugs
C Barbiturates decrease the capacity of the liver
3. These side-effects are recognised to metabolise drugs
complications of the following drugs: D Antacids enhance drug absorption
A Vinblastine - neurotoxicity E Anticonvulsants are more slowly eliminated
B Vincristine - marrow depression
C Adriamycin - cardiomyopathy Answers
D Methotrexate - diarhhoea
E 5-fluorouracil - renal failure 1. AT 4. A F 7. A F
B F B F B F
4. The following statements are true: C T C T C F
A Naloxone is a partial opiate agonist B DT D F D F
Azathioprine is teratogenic E T E T E F
C Nalidixic acid may interfere with bilirubin
conjugation 2. AT 5. AT
D Oral hypoglycaemic agents are safe in B T B T
pregnancy CF C F
E Ganglion-blockers may be associated with D T D F
50% fetal loss E F E T
5. These side-effects are recognised 3. AF 6. AT

complications of the following drugs: B F B F
A Methyldopa - positive Coomb's test in the C T CT
baby D T D F
B Methyldopa - neonatal ileus E F E F
329
Appendix to statistics and
evidence-based health care
values and n is the sample size. While the sample

This appendix gives a more formal approach to mean is a measure of the overall magnitude of
statistical analysis that is still the subject of some part
the observations, the standard deviation, denoted by the
1 MRCOG exam questions. Many of the formulae do
not need to be committed to memory, particularly symbol s, is a measure of the variability of the observations
given the availability of modern computing about their mean value. The algebraic formula for the
software. standard deviation is:
E(x _ 2
n-1
DATA COLLECTION AND PRESENTATION
which, with some algebraic juggling, can be
Statistical data are usually oftwo types, either quan-
rearranged to ease calculation to give:
titative or qualitative. Data derived from quantita-
tive variables have numerical values; examples are
birthweight (kilograms) or age at menarche (years), S - EX2 - g)2 In
while qualitative variables indicate the presence or n-1
absence of a characteristic; for example, a woman is
either pregnant or not pregnant, a baby is either
Nowadays, the calculation is programmed into
born alive or born dead. The first stage in sum-
many electronic calculators. To interpret the mag-
marising any data is to construct a frequency distri-
nitude of the standard deviation a simple rule is that
bution such as those shown in Table A. 1.
the interval x ± 2s should include about 95% of all
There are situations where it is not particularly use-
the observations. The interval mean ± two standard
ful to construct frequency distributions, for example the
deviations is often called the normal range of values.
sample size might be very small; then it is usual to summarize
For comparison x ± s includes 68% of all the obser-
the data even further by concentrating on just one or two vations. Y ± 3s includes over 99% of all the observa-
measures. For quantitative data, it is usual to calculate the tions.
sample mean and the standard deviation, while for
Other terms that are often confused with mean are
qualitative data it is usual to calcu-
mode and median. The mode is the value that has the
late the sample proportion p which has the character-
largest frequency distribution, i.e. the value that includes the
istic or equivalently the percentage.
peak in a unimodal frequency distribu-
The sample mean or, as it is often called, the aver-
tion or the values for both peaks in a bimodal fre-
age value is calculated by adding up all the observa-
quency distribution. The median is the value above and below
tions and dividing by the total number of
which half of the values lie. It is also the 50th centile. The
observations. Algebraically this calculation would
75th centile is the value that
be written as:
includes 75% of all the values when they are ranked in
_ Ex increasing order of size and so on.
x= n
In a so-called normal distribution the mean mode
and median all have the same value but this is not so
where x is the symbol used to denote the for skewed or other distributions that deviate from
sample mean, Ex means the sum of all the observed normal.
331
BASIC SCIENCE IN OBSTETRICS AND GYNAECOLOGY
Table A.1 Example of fr

equency distributions
(a) A qualitative variable. Outcome of 1827 pregnancies
Outcome Frequency ova
Spontaneous abortion 54 2.95

Induced abortion 148 8.10
Stillbirth 22 1.20
Live birth 1603 87.74
Total 1827 99.99
(b) A quantitative variable. Parity distribution of mothers of 1 469 086 births of which 18 847 were stillbirths.
England and Wales
1969-70
Parity Total births

Stillbirths % Stillbirth rate/ 1000
0 564 003 38.39
1 482 074 32.81 8032 42.62 14.24
2 234 732 15.98 4707 24.97 9.76
2853 15.14 12.15
3 101 167 6.89
4 44 553 3.03 1494 7.93 14.77
819 4.35 18.38
5-9 41 144 2.80
887 4.71 21.56
10 1 413 0.10
55 0.29 38.92
Total 1 469 086 100.00
18 847 100.01 12.83
POPULATIONS AND SAMPLE equal exactly the population mean or population

proportion.
In sampling, a part of a population is chosen to pro- It is useful to distinguish between two sorts of
vide information which can be generalised to the error: sampling error and bias. Sampling errors arise
whole population. In this context, the population is because only a part of the population has been
any defined group of individuals which is of interest observed. Sampling errors get less important as sam-
in a particular study. It may be a population of peo- ple size increases. In contrast, a bias does not neces-
ple, for example pregnant women living in a defined sarily get less important as sample size increases. A
geographical area at a particular time, but in general bias arises if the sample is systematically unrepresen-
the population might be hospitals, medical records tative of the population. Non-random sampling is
of stillbirths. Sampling is adopted to reduce labour perhaps the most important cause of bias, but there
and hence costs, but by taking a sample rather than may be many other sources of bias in any particular
studying the whole population, there is a loss of study. For example, a tendency to forget early spon-
precision. taneous abortions may bias a study involving repro-
In general, a parameter of the population is to be ductive histories; a patient's refusal to participate in a
estimated using the information provided by the study may cause a bias if the reasons for refusal are
sample. This population parameter could be, for related to the interests of the study.
example, the mean value of some measurement or While bias may be important in a particular
the proportion of the population with some charac- study, the causes and control of bias are dependent
teristic. If a sample is used, the conclusions about on the study itself and, apart from emphasising the
the population parameter may involve error; that is, importance of random selection for the sample,
a sample mean or sample proportion is unlikely to general rules cannot be laid down. In contrast,
although sampling error cannot be calculated for a
sample estimate, it is possible to estimate the maxi-
332
APPENDIXTO STATISTICS
mum likely value of sampling error. If, for example, The estimated standard error of (x 1 - x2) is:
a population mean µ is to be estimated from a sam-
ple of size n, the sample mean .x =£x/n is calculated.
The actual sampling error is x - µ and this cannot be T-1 + sz
calculated because p is clearly unknown. The vnj nz
standard error of a sample estimate is a measure of where
the precision of the estimate and, in general, the 1)S2
S _ (nI- (n 2 -
1 1)s;+
,
maximum likely value of x - p is twice the standard nj +n,-2
error. In this context likely corresponds to a proba- and
z z
bility (P) of about 0.95 or 95%. X�-X2±2x n +n z
Thus, if an interval, defined by the value of an
estimate ± twice the standard error of the estimate,
is calculated, this interval is called a 95% confid-
ence interval and has a 95% chance of including the is a 95% confidence interval for the difference between two
value of the population parameter. Some examples population means. It is assumed that n1 + n2 is greater
are: than about 30.
4. Estimation of the difference between two
1. Estimation of a population mean. Take a
population proportions. Take a sample of n1 individuals
random sample of n individuals and calculate the
from the first population and n2
sample mean x and the standard deviations. The
individuals from the second population and
estimated standard error of the sample mean is
calculate the two sample proportions p1 = r1/n1
s/ Jand x ± 2 x s/ fis a 95% confidence interval
and p2 = r2/n2 and the overall proportion p =
for the population mean. It is assumed that n is
(r1
greater than about 30. + r2)/(n1 + n2). Then p1 -p2 is the estimate
of the difference between the two population
2. Estimation of a population proportion. Take a
random sample of n individuals, count the number with proportions. The standard error of (p1 -p2) is:
the characteristic of interest r and the sample proportion

p = r/n. The estimated standard error of the sample
proportion is: P(1 -P) (n,+n�)
and
1 1
PI - Pz± 2 x p(1-P) n , +n2
is a 95% confidence interval for the difference between

and
the two population proportions.
p-2x P(1 n P)
SIGNIFICANCE TESTS
is a 95% confidence interval for the population A significance test is a test of a hypothesis which
proportion with the characteristic. specifies a value of a population parameter. In its
3. Estimation of the difference between two simplest form a significance test is achieved by con-
population means. Take a random sample of n1 sidering a confidence interval. For example, if the
individuals from the first population and n2 hypothesis were that the mean value of some vari-
individuals from the second population and able in a population were say, µ0, then if the 95%
calculate their means x1 and x2 and standard confidence interval included the value t0 it would be
deviations s 1 and s2. Then x 1 - x2 is the estimate of argued that the sample provided no strong evidence
the difference between the two population means. against the value .to. If, on the other hand, µ0 were
333
xr
outside the limits of the confidence interval, it would If the points lie fairly closely on a straight line, it
be stated that t0 is an unlikely value for the popula- may be adequate to fit the line by eye, but an object-
tion mean, and the difference between the value go ive method of fitting a straight line through the set of points
proposed by the hypothesis and the sample mean x is on the scatter diagram should be used for a full analysis.
significant at the P < 0.05 or 5% level. The 0.05 or 5% A straight line can be described algebraically in the form:
here is the probability that the confidence inter- y=a+(3x.
val does not include the population mean R.
By a similar argument, two sample means can be The problem is to find estimates of a and R
compared. Here the hypothesis is that the differ- (which will be called a and b) from the data such
ence between the two population means is zero. If that the line fits the points on the scatter diagram as
the 95% confidence interval for the difference closely as possible. Suppose the scatter diagram and
between the two population means includes zero, the closest-fitting line looks like that in Figure A. 1.
then it would imply that the samples provide no If the vertical distance of the points from the line
strong evidence of a difference between the popula- is called d, estimates of E and E are chosen which
tion means. If the interval does not include zero, minimise Ede. These estimates are called least
then it is concluded that the difference between x 1 squares estimates.
and x, is significant at the P <0.05 or 5% level (see The use of differential calculus shows that the
(3) on p.333). expressions for a and b, the sample estimates of a and (3,
The same arguments can be applied to signifi- which satisfy this condition, are:
cance tests of a single sample proportion and the Sxy x
difference between two sample proportions. a = y -
The t test and the x2 tests of these hypotheses are
and
refinements of the test procedures outlined above and
further details can be found in standard textbooks.
where
LINEAR REGRESSION AND S xx = E(x - z)2 = Ex2 -(Ex)2

CORRELATION n
and
If often happens, in modern surveys, that more Sxy= E(x-..)(y-y) = Exy- (Ex)(Ey)
than one measurement is made on each individ- �n
ual. For example, in a study of diastolic blood We will also use, later,
pressure in pregnant women, for each woman
examined there may be several measurements Syy = E (y -.Y)2 = Eye -(E.Y)2
n
apart from blood pressure, such as gestational
stage, age, weight, weekly tobacco consumption. Thus a and b can be calculated and the straight line drawn
One object of such a study might be to see how the on the scatter diagram.
response or dependent variable, blood pressure, The quantity a (the sample estimate of (x) is
varies with the explanatory or independent vari- called the intercept because it is the value ofy when the line
ables, age, weight. crosses they axis (i.e. since y = a + bx, y = a when x = 0.
Consider the simplest situation in which there is See figure A. 1.
one response or dependent variable conventionally The quantity b (the sample estimate of (3) is called
denoted byy, and one explanatory or independent the estimated regression coefficient and is very impor-
variable x, and assume the relationship between tant because it measures the average increase my per
them is linear. unit increase inx, i.e. b is the estimated slope of the line.
If there are n pairs of observations (xl,yl), (x2,y2) The concept of correlation arises in attempting to
(xn, yn), to see how y varies with x a scatter dia- measure the association which exists between quan-
gram should be drawn withy on the vertical axis and x on the
horizontal axis.
334
APPENDIX TO STATISTICS
Y Y
r =-1
b is negative
x x
Fig. A.1 An example of a scatter diagram with the Fig. A.3 Perfect negative correlation.
best-fitting straight line.
titative variables. The degree and kinds of correla- certainty about the increase. All we can say is that the
tion are best illustrated diagrammatically in the case average value ofy for a given value of x tends to increase as
of two variables conventionally denoted by x and y. x increases, and vice versa. There is
Figure A. 2 shows a perfect linear relation between some degree of positive correlation.
x and y in which y increases as x does and vice versa. Figure A.5 shows the same sort of situation as Figure
This situation is an ideal one, but close approxima- A.4, but the tendency here is for one variable to decrease as the
tions to it occur in some experiments in the physical other increases. There is some degree of negative correlation
sciences. It rarely, if ever, occurs in biological work. and the average value ofy for a given value ofx decreases as x
The situation in Figure A.3 is similar to that in increases.
Figure A.2 but, in this case, as one variable increases Figure A.6 shows the situation where there is no
the other decreases. Figure A.2 shows perfect posi- association at all. As x increases there is no tendency for the
tive correlation and Figure A.3 shows perfect nega- average value ofy to increase or decrease, i.e. neither variable
tive correlation. This is again an ideal case occurring sheds any light on the behaviour of the other, as it does in
in the same restricted situations as in Figure A. 2. Figures A.2-A.5.
Figure A.4 with Figures A.5 and A.6 shows the Figure A.7 shows a fairly strong association, but
type of association which is usually encountered in the relationship between x and y is non-linear. This
practice. In Figure A.4 there is a tendency for one situation is important when interpreting zero values
variable to increase as the other does, but there is no of the correlation coefficient, shortly to be defined.
Y
Y
r = +1
b is positive
x x
Fig. A.2 Perfect positive correlation. Fig. A.4
Some degree of positive correlation.
335
Y Y
r 0
b 0
•
•
•
• • •
-1 <r<o •
b is negative
x x
Fig. A.5 Some degree of negative correlation. Fig. A.7 No linear association between x and y.
Y perfect positive correlation and r = - 1 to perfect

negative correlation.
•
4. If r = 0 this can mean that there is no
association between the two variables but this
• •
• • is not necessarily the case. Given that r = 0 we
• • can deduce nothing about the extent of
association between x and y.
r =0
b=0
INTERPRETATION OF REGRESSION COEFFICIENT AND
COEFFICIENT OF CORRELATION
x
Fig. A.6 No association between y and x. The regression coefficient b is a measure of the aver-
age change my for a unit change in x. If all the points
Supposing n pairs (x1,yi) ... (xn,yn) form a sam-
on the scatter diagram lay on the regression line, it
ple of size n. Then the (product-moment) correla-
would be reasonably certain that y would increase
tion coefficient of x and y in the sample is denoted by rand defined by:
by exactly b for a unit increase in x. There would be
an exact or perfect relationship between x and y. In
Sx Y practice this is not the case, and y can vary inde-
r S
`Sxx YY pendently of x, so that two observations of the same
x could produce differing values of y. Given any
particular value of x, however, the expected value ofy
can be calculated but, since factors other than x may
The properties of this coefficient are as follows (NB
affecty, the observed value ofy cannot be predicted
always take the positive square root in the
exactly.
denominator) :
Thus the regression equation expresses only the
1. The sign of r is the same as the sign of Sxy. If average relationship between x and y. It does not
Sxy is positive, so is r, if Sxy is negative, so is r. measure the closeness of the association between
2. r can never be less than - 1 or greater than + 1. the two variables. When the points lie close. to the
3. If r = ± 1 then all the pairs lie on a line. This has regression line, a strong association is implied, but if
a positive slope if r = +1 and a negative slope if they are scattered widely about the line, the regres-
r = - 1. In other words, r = +1 corresponds to sion line will still show the average relationship
336
APPENDIX TO STATISTICS
between the two variables, but the association is alpha = 5% and this gives Zalpha/2 = 1.96. If beta =
weaker. 10% (for a power of 90%), then Z
The coefficient of correlation is a measure of the beta = 1.28. These
closeness of association between the two variables. values may be taken as constants in the formula.
Suppose the object of appraisal was a study involv-
ing a treatment for hypertension which might rea-
sonably be expected to make a difference of 5 mmHg
DERIVING THE FORMULA FOR A POWER CALCULATION
of diastolic blood pressure compared with a placebo.
This could be taken as the worthwhile difference to
n per group = 2 x (Z alpha/2 +Zbeta)2 X 6 be detected (8). In the population of interest, the
2/82 standard deviation might be 10 mmHg - this will be
This intimidating formula consists of four parts. The the 6. The aim is to show this difference as statistical-
worthwhile difference and the estimate of vari- ly significant at the 5% level with 90% power. Thus:
n per group = 2 x (1.96 + 1.28)2 x 102/52 = 84.
ability have already been referred to on p. 288. For a
quantitative variable, 8 is the worthwhile difference in If it was noted that the authors of the study had
mean value (of blood pressure, say). r is the included only 20 patients per group, we would
estimate of variability; specifically it is the standard know that the study was underpowered.
deviation of the blood pressure. The above formula needs to be modified a little if the
The other two elements are Z alpha/2 and Zbeta• outcome of interest is an event. The percentage of subjects
These refer to the Type I error and Type II error who would experience the event in the control group (n1)
which any study has the possibility of making. The must first be estimated, and also the percentage for the
Type I (alpha) error is where one wrongly rejects the group receiving the new
null hypothesis (i.e. concludes that the treatment treatment (7t2). The 6 would now represent the dif-
makes a difference to blood pressure when in fact it ference in these two percentages, = 7t1-7t2.
does not do so). This is related to the significance However, the notion of a standard deviation is
level of the test often set at 5%. The Type II (beta) less intuitive for a variable representing an event. In
error is where one concludes the treatment does not fact, instead of 62, it is n 1 x (1-7t 1) + 7E2 x (1-7t2) .
affect blood pressure when in fact it does do so. The Thus, the whole formula for a power calculation when the
Type II error rate is related to the power of the study; outcome is an event becomes:
if beta = 20%, then the power of the study is 80%. A
study that has a power of less than 80% runs more n per group = 2 x (Z alpha/2 + Zbeta) 2
than a one-in-five chance of failing to detect a worth- x[711x(1-711)+712x(1-
712)]/82
while difference between the groups if one exists.
The letter Z that precedes alpha and beta in the Fortunately, even statisticians rarely have to
formula refers to numbers derived from the normal commit such formulae to memory, but if you are planning
distribution. It is usual practice to require a power a research study yourself you should make a point of
of 80% or 90%, and a significance level of 5%. Thus consulting this text or a statistician before deciding how many
subjects to recruit!
337

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14 Multiple choice questions

B Accumulation of abnormal products is

Questions D Bones are radiosensitive

1. AT 4. AT 7. AT 10. AT 13. AF 16. AF

2. AT 5. AT 8. AF 11. AT 14. AT 17. AT

3. AT 6. AT 9. AT 12. AT 15. AT 18. AT

7. AF 11. AT 15. AT 19. AF 23. AT

8. AT 12. AF 16. AT 20.AF 24. AF

9. AF 13. AT 17. AT 21. AT 25. AT

10. AT 14. AT 18. AF 22.AT

THE-FETUS E Chemoreceptors in the carotid body

4. Nervous system: C In low oxygen tensions fetal Hb has lesser

11. Placental structure: 14. The placenta produces the following

ANATOMY 5. In the anterolateral group of abdominal

3. Abdominal fascia: 7. The diaphragm:

4.In the inguinal ligament: 8. The coeliac trunk:

DMiddle colic artery

DThere may be accessory arteries in up to

DFourth part of duodenum 36.The following are branches of the

41. Lymphatics: E Is closed by a true valve, where it enters the

C The posterior border of the triangular

61. The following statements are true:

1. AF 9. AF 17. AT 25. AT 33. AT 41. AT

2. AT 10. AT 18. AT 26. AT 34. AF 42. AT

3. AT 11. AT 19. AF 27. AF 35. AF 43. AF

4. AT 12. AT 20. AF 28. AT 36. AT 44. AF

5. AF 13. AF 21. AF 29. AF 37. AT 45. AF

6. AF 14. AF 22. AF 30. AT 38. AF 46. AT

7. AF 15. AF 23. AF 31. AT 39. AT 47. AF

8. AF 16. AF 24. AT 32. AT 40. AF 48. AF

49. AF 53. AF 57. AF 61. AF 65. AF

50. AF 54. AF 58. AT 62. AT 66. AF

51. AT 55. AT 59. AT 63. AT 67. AT

52. AT 56. AF 60. AT 64. AT

CMild arteritis is common

5. In primary syphilis: 11. Wound healing is delayed by

6. In secondary syphilis: 12. Surface epithelium give rise to:

13. Syphilis serology:

10. AF 13. AT 16.AT 19.AF 22.A F

11.AF 14.AT 17.AF 20.AT

12.AT 15.AT 18.AF 21.AT

C IgE can `fix' complement

Questions E IgA crosses the placenta

1. HLA-system: 4. Hypersensitivity reactions:

CGalactose is a pentose monosaccharide

3. Nutrition: 8. The following hormones lower the

5. In carbohydrate metabolism: 10. In the tricarboxylic acid (TCA) cycle:

CEach pair of hydrogen atoms yields three

C Th e p at w c Hhih 50% of a buffer is

10. Local control of blood flow:

E The loop of Henle is concerned with the 25. In pregnancy:

31. Vitamins: 37. Insulin:

41. Prolactin secretion is stimulated by: 46.At puberty:

45. Gonadotrophins: 50. Thyroid hormones:

55. The autonomic nervous system:

CAnti-thrombin III is an a -2-globulin 7. AT 15. AF 23. AF

63. Rhesus incompatibility: 11. AF 19. AT 27. AF

1. AF 3. AF 5. AF 13. AT 21. AT 29. AT

2. AF 4. AF 6. AF 14. AT 22. AF 30. AT

31. AF 37. AT 43. AF 49. AT 55. AT 61. AF

32. AT 38. AF 44. AT 50. AT 56. AT 62. AT

33. AT 39. AT 45. AT 51. AT 57. AF 63. AF

34. AF 40. AF 46. AT 52. AF 58. AF

35. AT 41. AF 47. AT 53. AT 59. AT