Boron: Fiziologie Medical

ntrebri pentru evaluare

1. A 47-year-old woman with a longstanding history of heartburn complains of severe

heartburn. You make the diagnosis of gastroesophageal reflux disease (GERD). An upper
endoscopy study is positive for Barretts esophagus. Which of the following correctly
describes Barretts esophagus?

a) Replacement of the squamous epithelium of the esophagus with columnar epithelium;

b) Replacement of the columnar epithelium of the esophagus with squamous epithelium;
c) The presence of moderate-to-high grade dysplasia in the esophagus;
d) The presence of low-to-moderate grade dysplasia in the esophagus;
e) The presence of any stricture within the esophagus.

2. A 65-year-old woman with a history of congestive heart failure, osteoarthritis, and

hypertension presents with pain and tenderness, which is relieved by food or antacids. Upper
endoscopy reveals a gastric ulcer. Her current medications include digoxin, metoprolol,
lisinopril, aspirin, and hydrochlorothiazide. Which of her medications is most likely to have
contributed to her peptic ulcer disease?

a) Digoxin;
b) Metoprolol;
c) Lisinopril;
d) Aspirin;
e) Hydrochlorothiazide.

3. A 45-year-old woman complains of episodic epigastric pain. She denies fevers, chills,
diaphoresis, flushing, chest pain or shortness of breath. An upper endoscopy, reveals severe
and atypical peptic ulcer disease. Biopsy results are Helicobacter pylori negative and she
denies taking NSAIDs. Continued workup should include serum levels of which of the
following?

a) Serotonin;
b) Gastrin;
c) Vasoactive intestinal peptide (VIP);
d) Cholecystokinin (CCK);
e) Histamine.
4. A 67-year-old man presents with mild dysphagia and throat discomfort that has slowly
progressed over the past 5 years. He reports waking up at night choking and regurgitating
undigested food. He has been troubled by halitosis and has noticed a small protrusion in his
neck over the past year. He denies weight loss or heartburn. Which of the following is most
consistent with his symptoms?

a) Achalasia;
b) Zenkers diverticulum;
c) Gastroesophageal reflux disease;
d) Schatzkis ring;
e) Esophageal cancer.

5. A 56-year-old retired schoolteacher presents with progressive dysphagia, substernal pain

with eating, and weight loss over the course of 1 year. He has never traveled outside the
United States. Barium esophagography reveals esophageal dilation, lack of esophageal
peristalsis, and a birds beak tapering of the distal esophagus. Which of the following is a
likely cause of this patients condition?

a) Achalasia;
b) Zenkers diverticulum;
c) Barretts esophagus;
d) Chagas disease;
e) Increased pressure of the upper esophageal sphincter.

6. A 79-year-old woman presents to the emergency department with right lower quadrant
abdominal pain of several hours duration. She has a temperature of 101.7F and has
tenderness to palpation in the right lower quadrant of her abdomen. Abdominal computed
tomography (CT) scan reveals diverticulitis of the colon. Where are diverticula most
frequently found in the colon?

a) Cecum;
b) Ascending colon;
c) Transverse colon;
d) Descending colon;
e) Sigmoid colon.

7. A 30-year-old woman with severe Crohns disease is taken to surgery for an ileal resection.
What nutritional deficiency does this woman risk in the future?

a) Folate deficiency;
b) Niacin deficiency;
c) Thiamine deficiency;
d) Iron deficiency;
e) Vitamin B12 deficiency.
8. A 60-year-old man presents to your office with facial flushing and abdominal cramps and
diarrhea. The workup reveals an elevated level of urinary 5-hydroxyindoleacetic acid (5-
HIAA), and subsequently, elevated levels of 5-HIAA in a 24-hour urine collection. What is
the most likely diagnosis?

a) Zollinger-Ellison syndrome;
b) Cushings syndrome;
c) Malignant carcinoid syndrome;
d) Vipoma;
e) Glucagonoma.

9. A 58-year-old woman with type II diabetes mellitus was diagnosed approximately 1 year
ago. Her labs show no improvement in blood glucose control over the ensuing months despite
treatment. What test should you order to examine her average blood sugar levels over the past
few months?

a) Fasting blood glucose;

b) Two-hour glucose tolerance test;
c) Hemoglobin;
d) Hemoglobin A1c;
e) Hemoglobin S.

10. You see a 78-year-old man in clinic for his annual physical. He reports excellent health.
During your review of systems, he admits to having difficulty initiating his urine stream,
nocturia, and occasionally feels as if he does not completely empty his bladder. Routine lab
tests show a normal level of prostate-specific antigen (PSA). Analysis shows no hematuria or
crystalluria. What related finding might you anticipate when you move on to his physical
exam?

a) Testicular atrophy;
b) Urinary calculi (stones) blocking the urethra;
c) Hypospadias;
d) Irregular prostatic nodularity;
e) Uniformly smooth prostatic enlargement.
11. A 14-year-old male soccer player complains of occasional shortness of breath, particularly
during practice or games. You decide to initially treat his asthma with a 2 agonist inhaler to
be used when symptoms appear. By which mechanism will this agent improve his ability to
breathe?

a) Bronchodilation via smooth muscle relaxation;

b) A decrease of pro-inflammatory cells;
c) Prevention of histamine release;
d) Inhibition of leukotriene synthesis;
e) Leukotriene-l receptor antagonism.

12. A middle-aged obese man complains of increasing frequency of headaches and worsening
visual acuity. Although his headache pain is usually relieved by over-the-counter pain
relievers, the discomfort returns after a few hours. An ophthalmoscopic examination reveals
bilateral flame hemorrhages and cotton-wool spots. What laboratory measurement would
confirm the likely cause of this mans headaches and worsening sight?

a) Serum glucose level;

b) Hemoglobin A1c;
c) Toxicology screen including methanol;
d) Serum vitamin A level;
e) Blood pressure.

13. Which if the following is true about voltage-gated Na+ channels in the axon?

a) They remain open as long as the membrane is sufficiently hyperpolarized;

b) They remain open as long as the membrane is sufficiently depolarized;
c) They remain open for only a short period of time after the cell is sufficiently depolarized;
d) They belong to a family of channels that are made of five subunits;
e) They have about the same relative permeability ratio (PNa/PK) as ACh channels.

14. Lidocaine, a use-dependent blocker of voltage-gated Na+ channels, is an effective

antiarrhythmic because its blocking effect becomes greater:

a) When the drug is repeatedly used;

b) When Na+ channels are activated repeatedly at a high frequency;
c) When Na+ channels are activated repeatedly at a low frequency;
d) When Na+ channels are closed;
e) When the extracellular Na+ concentration is high.
15. In skeletal muscle during a contraction cycle:

a) MyosinATP complex has a high affinity for actin;

b) Tropomyosin binds calcium;
c) The rigor complex is broken by the binding of ADP to myosin;
d) ATP hydrolysis provides the energy required for myosin flexure in the hinge regions;
e) The T tubules take up calcium via an active transport mechanism.

16. A 18-year-old male complains about continuous growth, lack of facial hair, small genitalia
and lack of muscle development. Laboratory values include total testosterone 125 ng/dL
(normal 300-1100 ng/dL) and luteinizing hormone (LH) < 2 mIU/mL (normal 623 mIU/mL).
A major causal factor in some cases of hypogonadism is:

a) Increased number of follicle stimulating hormone (FSH) receptors in the testis;

b) Hypersecretion of pituitary LH and FSH as the result of increased gonadotropin-releasing
hormone (GnRH);
c) Excess secretion of testicular activin by Sertoli cells;
d) Failure of the hypothalamus to respond to testosterone;
e) Reduced secretion of GnRH.

17. A 17-year-old girl comes to see an endocrinologist because of primary amenorrhea. Breast
development started several years ago, and she has otherwise been well. On examination
breast development and height is in the tenth percentile, but she has no pubic or axillary hair.
A pelvic examination reveals a blind vagina. These findings are most consistent with which of
the following:

a) Turners syndrome;
b) Hypopituitarism;
c) Androgen insensitivity;
d) Klinefelters syndrome;
e) Adrenogenital syndrome.

18. Your 55-year-old female patient suffers from osteoporosis. For treatment you decide to use
an antiresorptive agent currently used for treatment of osteoporosis:

a) Increasing parathyroid hormone (PTH) secretion;

b) Inhibiting calcitonin release;
c) Decreasing the remodeling space of bone;
d) Stimulating estrogen synthesis;
e) Blocking 1-hydroxylase activity.
19. Your 74-year-old male patient suffers from hyperthyroidism. Hyperthyroid individuals
characteristically exhibit:

a) Heat tolerance;
b) A low basal metabolic rate (BMR);
c) Decreased peripheral resistance;
d) Dry, yellowish skin;
e) High plasma cholesterol levels.

20. In an elite marathon runner, performance in a marathon race is limited by a number of

factors. Among world class marathon runners, which of the following factors is considered to
be critical for a high level of performance?

a) Muscle ATP content;

b) Adequate fat stores;
c) High muscle glycogen content;
d) High muscle oxidative capacity;
e) High percentage of type II muscle fibers.

21. An individual has arterial hypoxemia; PaO2 = 50 mmHg. Which possible cause of this
hypoxemia would cause the largest elevation in arterial PCO2?

a) High altitude;
b) Diffusion impairment;
c) Physiological shunt;
d) Pulmonary embolism;
e) Hypoventilation.

22. A 26-year-old man comes to the emergency room complaining of lethargy, headache,
nausea and extreme, weakness. His skin has a cherry-red color. He has a normal arterial PO2,
but a low venous PO2 of 20 mmHg (normal is 40 mmHg). You believe this situation is caused
by:

a) Cyanide poisoning;
b) Absolute right-to-left cardiopulmonary shunt;
c) A right-shifted hemoglobin;
d) Hypoventilation;
e) Carbon monoxide poisoning.
23. A 59-year-old morbidly obese female patient is diagnosed with a restrictive lung disease
that causes lung compliance to be half the normal value. If tidal volume and breathing rate are
normal, then:

a) Total work of breathing is twice normal;

b) Airway resistance is twice normal;
c) Pleural pressure at end-inspiration is more negative than normal;
d) Alveolar pressure at end-inspiration is positive;
e) The functional reserve capacity (FRC) is increased.

24. Your patient has normal function of the diaphragm but has a spinal injury that completely
prevents any activity of abdominal or intercostal muscles. In this patient you expect to find
that:

a) Residual volume is smaller than normal;

b) Vital capacity equals total lung capacity;
c) Intrapleural pressure is positive during expiration;
d) Transpulmonary pressure is negative during expiration;
e) Alveolar pressure is positive during expiration.

25. A sudden ascent to high altitude (e.g. atmospheric pressure half that at sea level) will, in
the first several hours, cause:

a) Hypoxic stimulation of central chemoreceptors;

b) A decrease in the pH of the fluid surrounding the central chemoreceptors;
c) An increase in alveolar to arterial PO2 difference;
d) Hypoxic stimulation of carotid body chemoreceptors;
e) A decrease in pulmonary arterial blood pressure.

26. A patient presents with a urine flow (V), of 12 L/day. You find that plasma osmolality
(POSM) is above normal and that plasma AVP levels are very low. Based on this information,
and given the following choices, what is your best diagnosis for this patient?

a) Hypothalamic (central) diabetes insipidus;

b) Nephrogenic diabetes insipidus;
c) Diabetes mellitus;
d) Polydipsic diabetes insipidus;
e) Diabetes macula densa.
27. Al and Zack are twins with end-stage renal failure due to Alport syndrome. Both are on
chronic dialysis and make no urine. Following dialysis, they both weigh the same and have
identical serum osmolalities. On the way home from a dialysis session, they stop at Vinos for
lunch. Al drinks 1 liter of pale ale and eats a pepperoni calzone (sodium content 140 mEq).
Zack, the designated driver, isnt hungry but drinks 2 liters of lager.

When (if) they arrive home, which of the following statements would be true?

a) Zacks total body water is less than Als;

b) Zacks serum osmolality is greater than Als;
c) Zacks intracellular fluid (ICF) volume is greater than Als;
d) Zacks extracellular fluid (ECF) volume is greater than Als;
e) Zacks plasma sodium level is greater than Als.

28. A 68-year-old man is brought to your emergency room in July after concerned neighbors,
who had not seen him for several days, found him collapsed on his living room floor. The
temperature inside the house was about 105F. The patient was barely arousable. His body
temperature is 40C, his skin and mucus membranes are dry, and his blood pressure is low.
Which of the following laboratory results would you expect to find?

a) Elevated aldosterone level;

b) Decreased renin level;
c) Elevated urine Na+ concentration;
d) Decreased antidiuretic hormone (ADH) levels;
e) Low urine osmolality.

29. A 56-year-old man presents with a 4-day history of impaired vision. On physical exam,
you note a loss of vision of his left visual field in both eyes. The patient most likely has a
lesion involving the:

a) Right optic nerve;

b) Optic chiasm;
c) Right optic tract;
d) Right temporal lobe;
e) Right parietal lobe.
30. A 49-year-old male presents to the emergency department with intermittent abdominal
pain and nausea for the past week. He is worried that he has a duodenal ulcer. Which of the
following is correct regarding duodenal ulcers?

a) Characterized by epigastric pain that worsens with eating;

b) Less than 20% are associated with Helicobacter pylori infection;
c) Incidence is greater in smokers;
d) It is unrelated to consumption of nonsteroidal anti-inflammatory drugs (NSAIDs);
e) Peak incidence is at 60 years of age.

31. A 19-year-old male presents to the emergency department with headache, neck stiffness
and fever. You are concerned about bacterial meningitis. What are the classical laboratory
findings for CSF in bacterial meningitis?

a) Decreased glucose; decreased protein; many polymorphonuclear leukocytes;

b) Normal glucose; elevated protein; many polymorphonuclear leukocytes;
c) Elevated glucose; decreased protein; many polymorphonuclear leukocytes;
d) Decreased glucose; elevated protein; many polymorphonuclear leukocytes;
e) Elevated glucose; elevated protein; many lymphocytes.

32. A 30-year-old female with a past medical history of having a baby born with a
myelomeningocele plans to become pregnant. She is concerned about the possibility of having
another child with this condition and asks what she can do to help prevent the defect from
occurring again. Which of the following dietary supplements would you recommend?

a) Vitamin A;
b) Vitamin B12;
c) Folic acid;
d) Iron;
e) Vitamin K.

33. A 1-year-old infant is brought to the pediatrician with lethargy, a poor suck, and feeding
reflux days after eating home-canned peaches. You suspect Clostridium botulinum poisoning.
What is the mechanism of the toxin responsible for this childs symptoms?

a) Toxin causes convulsive contractions of skeletal muscle;

b) Toxin blocks release of acetylcholine at synapses;
c) Exfoliative toxin causes separation of granular epidermal cells;
d) Enterotoxin causes stimulation of ADP ribosylation;
e) Protein causes pore formation in epithelial cell membranes.
34. A 2-year-old Caucasian boy is brought to the pediatric clinic for failure to gain weight.
The childs mother states that he has frequent foul-smelling stools, with a greasy appearance,
and has had three hospitalizations for pneumonia. Which of the following defects is
responsible for this childs symptoms?

a) Lack of phenylalanine hydroxylase;

b) Deficiency of galactokinase;
c) Defective epithelial chloride transport;
d) Amino acid substitution on the hemoglobin beta chain;
e) Defect in hypoxanthine-guanine phosphoribosyltransferase.

35. A 24-year-old pregnant woman complains of right-sided facial drooping, particularly of

her right eyelid and the corner of her mouth. She describes herself as being healthy. What
cranial nerve has most likely been affected?

a) Trigeminal nerve (CN V);

b) Abducens nerve (CN VI);
c) Glossopharyngeal nerve (CN IX);
d) Facial accessory nerve (CN XI);
e) Facial nerve (CN VII).

36. You see a 52-year-old markedly obese man in clinic who complains of arthritic pain in the
knees, but otherwise reports no significant health problems. On physical exam you notice a
darkening of his skin along the back of his neck, at the folds of his axillary skin, and faintly in
the groin area and behind his knees. He states that he has had these darker areas for quite a
long time. What laboratory test would be most helpful in confirming your suspicions of his
metabolic disorder?

a) Serum blood glucose;

b) Thyroid stimulating hormone (TSH);
c) Parathyroid hormone (PTH);
d) Uric acid;
e) Urine vanillylmandelic acid (VMA).

37. A 7-year-old patient with cystic fibrosis (CF) has a 4-week history of greasy, foul smelling
diarrhea. In which of the following vitamins or minerals would he be most likely to be
deficient?

a) Iron;
b) Vitamin B6;
c) Vitamin C;
d) Vitamin K;
e) Folic acid.
38. A 55-year-old homeless man presents to the emergency room and is noted to have
bleeding gums. He has several ecchymoses over his shins and forearms. A complete blood
count shows hemoglobin of 11 g/dL and an elevated mean corpuscular volume (MCV). Which
vitamin deficiency is responsible for his symptoms?

a) Vitamin A;
b) Vitamin B12;
c) Vitamin C;
d) Vitamin D;
e) Vitamin E.

39. An 70-year-old man complains of lower back pain that is accompanied with strong muscle
spasms. He is otherwise healthy. Which of the following drugs might be effective in reducing
the magnitude of the spasms?

a) A drug that inhibits Ca2+ release from the sarcoplasmic reticulum;

b) A drug that inhibits myosin light chain kinase;
c) A drug that blocks Ca2+ channels in the cell membrane;
d) An acetylcholinesterase inhibitor;
e) An inhibitor of skeletal muscle glucose uptake.

40. Certain tumor cells are known to have a plasma membrane Na+ channel that is activated
by acidic extracellular pH. In these cells, if acid is added to the extracellular medium, the:

a) Membrane potential will hyperpolarize;

b) Rate of ATP utilization will increase;
c) Cells will shrink;
d) Na+ K+-ATPase will become inactivated;
e) K+ efflux will decrease.

41. Some tumor cells have a large number of Cl channels on the plasma membrane. This
makes the Cl permeability higher than that of any other ion and therefore:

a) Causes the cell to swell when suspended in isotonic NaCl;

b) Causes the cell to shrink when suspended in isotonic NaCl;
c) Increases the steady state intracellular osmolality;
d) Decreases the steady state intracellular osmolality;
e) Causes the membrane potential to be near the equilibrium potential for Cl.
42. A particular epithelium has a paracellular (between the cells) pathway permeable to water
and chloride. In order to enhance the net movement of NaCl and water from apical to
basolateral portions of the cell, the epithelium needs:

a) Basolateral Na+K+-ATPase, basolateral K+ channels, and apical Na+ channels;

b) Apical Na+K+-ATPase, apical K+ channels, and basolateral Na+ channels;
c) Basolateral Na+K+-ATPase, apical K+ channels, and basolateral Na+ channels;
d) Apical Na+K+-ATPase, basolateral K+ channels, and apical Na+ channels;
e) Basolateral Na+K+-ATPase, basolateral K+ channels, and basolateral Na+ channels.

43. An epithelial cell layer bathed in physiological saline solution on both apical and
basolateral surfaces starts out in a steady state in which there is constant absorption of Na+,
Cl, and H2O. The addition of ouabain to the basolateral side will cause:

a) Intracellular Na+ to rise and intracellular K+ to remain constant;

b) Intracellular Na+ to fall and intracellular K+ to rise;
c) Intracellular Na+ to rise and intracellular K+ to fall;
d) Intracellular Na+ to remain constant and intracellular K+ to fall;
e) Intracellular Na+ to remain constant and intracellular K+ to remain constant.

44. Which statement is true about a 5 kg infant and his 50 kg mother?

a) The rate (mL/day) of insensible water loss is ten times as high in the mother as in the
infant;
b) The water turnover rate (% total body water [TBW]/day) is the same in the infant and the
mother;
c) The water turnover rate (%TBW/day) is higher in the mother than in the infant;
d) The mother has a TBW of about 42 kg;
e) The mother has an intracellular water of about 20 kg.

45. A 30-year-old woman complains of extreme fatigue following even mild exercise. These
symptoms become worse throughout the day. You diagnose this patient with myasthenia
gravis (MG). In most patients with MG autoantibodies cause a decrease in:

a) Presynaptic action potential threshold;

b) Postsynaptic action potential threshold;
c) Postsynaptic (endplate) potential;
d) Excitationcontraction (EC) coupling;
e) Neurotransmitter release from the nerve terminal.
46. Lambert-Eaton Syndrome (LES) is similar to myasthenia gravis. In LES, which of the
following is most affected during neuromuscular transmission?

a) The driving force for Ca2+ influx in the nerve terminal;

b) The synthesis of acetylcholine (ACh) in the nerve terminal;
c) The release of ACh from the nerve terminal;
d) The degradation of ACh in the synaptic cleft;
e) The response to ACh in the muscle membrane.

47. Given the following data from a patient urine output 1.5 L/day; plasma creatinine 1.0
mg/dL; urinary creatinine 1.2 mg/mL; plasma phosphate 0.002 mEq/mL; urinary phosphate
0.05 mEq/mL what can you reliably conclude about the renal handling of phosphate?

a) There is net secretion of phosphate;

b) There is net reabsorption of phosphate;
c) Phosphate is neither secreted nor reabsorbed;
d) Phosphate is fractionally filtered;
e) The extraction ratio of phosphate is greater than 1.

48. A 36-year-old male patient with a recent head injury complains of polyuria. You suspect
central diabetes insipidus. How could you confirm the diagnosis?

a) Restrict water intake and treat with insulin and see if urinary volume is decreased;
b) Restrict water intake and treat with angiotensin II and see if urinary volume is decreased;
c) Restrict water intake and treat with arginine vasopressin (AVP) and see if urinary volume
declines;
d) Restrict water intake and treat with a loop diuretic to determine if urinary flow rates
decrease;
e) Compare urinary production rates following consumption of 3 L of water and 3 L of
isotonic saline to determine whether they differ.

49. A 44 year-old male presents to the emergency department with severe back pain radiating
to the left flank. A radiological exam reveals a kidney stone partially blocking the ureter of
one kidney. Based on your knowledge of renal physiology, which of the following statements
is correct?

a) The patient will have problems with salt and water balance due to a loss of 50% of renal
function;
b) Glomerular filtration rate (GFR) in the affected kidney will decrease;
c) Urinary flow will be reduced by approximately 50%;
d) Hydrostatic pressure in the tubules will be decreased;
e) Renal failure will occur.
50. A 25-year-old female medical student from out of state wants to drive home over the 4th
of July holiday. She hates to use public facilities and would prefer to minimize her urinary
flow rate. Unfortunately, the air conditioning in her car is broken so she knows that she will
have to consume 2-3 L of fluids to replace that lost due to sweating. What is her best choice to
drink during the 8-hours to result in a minimum of rest room breaks?

a) Bottled water;
b) Coffee;
c) Sports drinks;
d) Soda;
e) Sweetened tea.

51. A patient complains of excessive urine output and constant thirst. Laboratory tests show
an elevated plasma sodium concentration (151 mEq/L) and elevated plasma osmolality (320
mOsm/L). The urine osmolality is only 75 mOsm/L. Which of the following could explain the
patients problem?

a) Defective epithelial sodium channel (ENaC);

b) Defective ROMK proteins;
c) Defective V2 receptor proteins;
d) Excessive antidiuretic hormone (ADH) secretion;
e) Defective atrial natriuretic peptide (ANP) secretion.

52. A medical student complains of severe vomiting and diarrhea for 2 days since eating at the
Roadkill Caf. His blood pressure is 120/70 mmHg supine and 90/50 mmHg standing. His
skin and mucous membranes are dry. Which of the following laboratory finding would you
expect to find?

a) Low serum aldosterone concentration;

b) High atrial natriuretic peptide (ANP) levels;
c) Low plasma renin activity;
d) Low urinary sodium concentration;
e) High urine volume.

53. A 30-year-old female patient with hypercapnia that is not the result of compensation for an
acidbase disturbance is seen in the clinic. Thus, this patient is suffering from:

a) Nothing, the patient has normal acidbase balance;

b) Respiratory acidosis;
c) Respiratory alkalosis;
d) Metabolic acidosis;
e) Metabolic alkalosis.
54. In a patient recovering from cholera, pH = 7.; [HCO3] = 16 mEq/L; PCO2 = 30 mmHg.
What is the acidbase status of the patient?

a) Compensated metabolic alkalosis;

b) Compensated metabolic acidosis;
c) Compensated respiratory alkalosis;
d) Compensated respiratory acidosis;
e) Uncompensated respiratory alkalosis.

55. Consider a patient with pH = 7.33; [HCO3] = 36 mEq/L; PCO2 = 70 mmHg. What is the
acidbase status of the patient?

a) Compensated metabolic alkalosis;

b) Compensated metabolic acidosis;
c) Compensated respiratory alkalosis;
d) Compensated respiratory acidosis;
e) Uncompensated respiratory alkalosis.

56. Which of the following is correct for male sex differentiation?

a) The male phenotype is determined by the presence of either X or Y chromosomes;

b) Stimulation and development of the indifferent gonad is initiated by the sex-determining
region of the Y chromosome (SRY) gene;
c) The mllerian ducts develop into the male reproductive tract;
d) Sertoli cells are stimulated to produce testosterone;
e) Testes have descended into the scrotum by 9 weeks gestation.

57. You determine that your 1-year-old male patient has cryptorchidism. Cryptorchidism is the
term used to describe non-descent of the testes. Which of the following statements is correct
in connection with this process?

a) Fertility is unaffected in males with undescended testes;

b) Hormone treatment is not effective to induce descent;
c) Leydig cell function is reduced in boys with undescended testes;
d) There is an increased rate of testicular malignant change in cryptorchidism;
e) Klinefelters syndrome may be responsible for testicular non-descent.
58. Insulin binding to its receptor tyrosine kinase leads to:

a) Activation of Janus kinase-signal transducer and activator of transcription (JAK-STAT);

b) Mitogen-activated protein kinase (MAPK) extracellular signal-regulated kinase (ERK)
activation;
c) Insulin-receptor binding to the MAPK promoter;
d) Gs activation and substrate phosphorylation by PKA;
e) Gi activation of phosphodiesterase (PDE).

59. Suppose the plasma membrane of a particular mammalian cell is much more permeable to
water and urea than to any other solute. The water permeability is higher than the urea
permeability. The cell is initially in a normal physiological saline solution and then is
suddenly moved into a solution consisting of 600 mM urea as the only solute. The cell will:

a) Swell initially and continue to swell until lysis;

b) Swell initially until it reaches osmotic equilibrium with the medium;
c) Shrink initially and then swell until lysis;
d) Shrink initially and stay shrunken;
e) Swell initially and then shrink back to normal volume.

60. Two people have the same total body mass (70 kg) but one has a much higher percentage
of body fat than the other. They both habitually ingest 2.5 L of water per day.

The individual with the higher percentage of fat will have a:

a) Higher extracellular fluid (ECF) volume than the other individual;

b) Lower rate of water turnover than the other individual;
c) Higher rate of water turnover than the other individual;
d) Positive water balance;
e) Negative water balance.

61. Your patient has been diagnosed with malignant hyperthermia after a surgical procedure.
The most common cause of malignant hyperthermia in humans is an abnormal response to
general anesthetics involving the:

a) Na+Ca2+ exchanger;
b) Sarcoplasmic reticulum Ca2+ release channel;
c) IP3 receptor;
d) Na+K+-ATPase;
e) Central nervous system (CNS).
62. The primary source of estriol (E3) during pregnancy is the:

a) Maternal ovary;
b) Fetal ovary;
c) Fetal adrenal and placenta;
d) Endometrium;
e) Corpus luteum.

63. Which of the following statements best describes ARDS (acute respiratory distress
syndrome):

a) It occurs only in adults;

b) It is best described as a diffuse pulmonary process with decreased thickness of the
pulmonary membrane;
c) A direct pulmonary insult is required for ARDS to develop;
d) Hypercarbia is the most common finding in the early stages of ARDS;
e) Mortality rate has been decreasing over the past 5 years.

64. Which of the following when administered to a normal individual produces effects similar
to that observed in patients with myasthenia gravis?

a) Black widow spider toxin;

b) Neostigmine;
c) Curare;
d) Nerve gas;
e) Edrophonium.

65. A 45-year-old woman arrives at the clinic and exhibits athetoid movements. She probably
has a:

a) Cerebellar lesion;
b) Lesion in the basal ganglia;
c) Thalamic lesion;
d) Frontal eye field lesion;
e) Lesion in the cerebral cortex.
66. Which one of the following statements is correct regarding salivary secretion?

a) The secretion of saliva is essential for the complete digestion of starch;

b) It is primarily under hormonal control;
c) It does not prevent decalcification of the teeth;
d) It is an acidic solution that begins the digestion of protein in the mouth;
e) It is the only hypotonic gastrointestinal secretion.

67. A 58-year-old woman develops a fever and dyspnea approximately 24 h after undergoing
a laparoscopic cholecystectomy. Physical examination shows decreased percussion, increased
tactile fremitus, and decreased breath sounds in the right lower lobe. Which of the following
is the most likely diagnosis?

a) Atelectasis;
b) Lobar pneumonia;
c) Lung abscess;
d) Pulmonary infarction;
e) Spontaneous pneumothorax.

68. A 56-year-old right-handed woman states that her right hand shakes when she tries to open
a door. Her physician does not observe a tremor when the patients hands are resting in her
lap. She further states that she falls frequently, usually to the right side. The most likely cause
of these findings is a lesion in the:

a) Left internal capsule;

b) Left precentral gyrus;
c) Right caudal medulla;
d) Right cerebellum;
e) Right lateral corticospinal tract.

69. In aging, if osteoclast activity is constant, but osteoblast activity progressively decreases,
which disease will likely develop?

a) Osteoclastoma;
b) Osteomalacia;
c) Pagets disease;
d) Osteoporosis;
e) Scurvy.
70. A 1-day-old neonate with acute respiratory distress syndrome (ARDS) has moderately
severe hypoxemia. Physical examination reveals, dry inspiratory crackles in the lungs and a
continuous harsh murmur heard over the entire precordium. Which of the following sets of
oxygen saturation (SaO2) values in the cardiac chambers and vessels most likely match those of this
patient?

Normal SaO2 (%)

Right atrium (RA) 75
Right ventricle (RV) 75
Pulmonary artery (PA) 75
Pulmonary vein (PV) 95
Left ventricle (LV) 95
Aorta (A) 95

a) RA 75%, RV 80%, PA 80%, PV 95%, LV 95%, A 95%;

b) RA 80%, RV 80%, PA 80%, PV 95%, LV 95%, A 95%;
c) RA 75%, RV 75%, PA 80%, PV 95%, LV 95%, A 95%;
d) RA 75%, RV 75%, PA 75%, PV 95%, LV 80%, A 80%;
e) RA 75%, RV 75%, PA 75%, PV 95%, LV 95%, A 95%.

71. 45-year-old woman experiences blurred vision and difficulty swallowing after eating some
home-canned vegetables. These symptoms are followed by respiratory distress and flaccid
paralysis. The symptoms of her illness are most associated with which of the following?

a) Black widow spider toxin;

b) Botulinum toxin;
c) Organophosphate poisoning;
d) Benzodiazepine ingestion;
e) -Bungarotoxins.

72. A 23-year-old woman, who complains of chronic cough, shortness of breath, and chest
tightness is diagnosed with asthma. Which of the following is the best clinical indicator of
significant pulmonary obstruction in patients with asthma?

a) Arterial hypoxemia;
b) Dyspnea;
c) Forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) ratio of less
than 75%;
d) Large anatomic dead space volume;
e) Rapid respirations.

73. A 25-year-old woman complains of chronic constipation and progressive weight gain over
the past 6 months despite maintaining a pure vegan diet. Physical examination reveals a
fatigued woman with brittle hair, face and eyelid puffiness, a symmetrically enlarged, non-
tender thyroid gland, prolonged relaxation phase of deep tendon reflexes, and proximal
muscle weakness in her lower extremities. Which set of the following results of thyroid
function studies shown below would you expect in this patient?

a) Low Serum thyroxine (T4); Low Serum thyroid-stimulating hormone (TSH); Low
(radioactive iodine) uptake 131I;
b) Low Serum thyroxine (T4); High Serum thyroid-stimulating hormone (TSH); Normal
(radioactive iodine) uptake 131I;
c) High Serum thyroxine (T4); Low Serum thyroid-stimulating hormone (TSH); Low
(radioactive iodine) uptake 131I;
d) High Serum thyroxine (T4); Low Serum thyroid-stimulating hormone (TSH); High
(radioactive iodine) uptake 131I;
e) Normal Serum thyroxine (T4); Normal Serum thyroid-stimulating hormone (TSH);
Normal (radioactive iodine) uptake 131I.

74. An 8-year-old healthy boy is concerned about his very short stature. His growth hormone
level is within normal limits despite the fact that his growth rate and bone age are below the
norm for children of the same chronologic age. The level of which of the following hormones
is most likely to be abnormal?

a) Fibroblast growth (FGF);

b) Insulin;
c) Insulin-like growth factor I (IGF-I);
d) Somatostatin;
e) Somatotropin.

75. A 5-year-old boy has a history of growth retardation, pulmonary infections, and bulky,
oily, malodorous stools. Which of the following test results would be expected in this patient?

a) Abnormal sweat chloride test;

b) Low C3 complement level;
c) Abnormal nitroblue tetrazolium (NBT) dye test;
d) Positive wheal and flare reaction with antigen scratch testing;
e) Sputum with Gram-positive diplococci.

76. A 56-year-old obese woman suffering from heartburn and regurgitation of acid saliva after
large meals is treated with cimetidine. During cimetidine treatment, her serum creatinine
concentration increases significantly. The increase in serum creatinine with cimetidine
treatment is most likely due to:

a) Being reabsorbed by the nephron in exchange for creatinine;

b) Blocking synthesis of creatinine by skeletal muscle;
c) Causing acute renal failure;
d) Competing with creatinine for renal tubular secretion;
e) Inhibiting uptake of creatinine ingested with food.

77. A 50-year-old homeless man with a 30-year history of alcoholism complains of painful
lesions on the mucous membranes of his mouth and tongue and has pigmented keratotic
scaling lesions on his face and hands. In addition, he is weak, forgetful, and has burning
sensations in various parts of the body and diarrhea. A deficiency of which of the following is
most likely to account for these findings?

a) Biotin;
b) Folic acid;
c) Niacin;
d) Riboflavin;
e) Vitamin C.

78. A healthy 16-year-old man experiences severe hemorrhaging following an automobile

accident. He is conscious and aware upon arrival at the emergency department, but
hypotensive, and tachypneic. Which of the following is associated with the hemodynamic
response to hemorrhage?

a) Decreased coronary blood flow;

b) Decreased sympathetic tone to the venous system;
c) Increased blood flow to the skin, intestines, and kidneys;
d) Increased cholinergic vasoconstrictor tone of skeletal muscle arterioles;
e) Normal cerebral blood flow.

79. A 45-year-old woman is concerned by a history of episodes of confusion and fainting over
the past year that occur either on first arising in the morning or after exercising. The episodes
are preceded or accompanied by shaking, sweating, and palpitations. The womans husband
has noticed that eating can prevent the onset of symptoms. Which of the following is the most
likely cause of this patients symptoms?

a) Autonomic insufficiency leading to orthostatic hypotension;

b) Benign insulin-secreting tumor causing periodic hypoglycemia;
c) Glucagon-secreting tumor causing periodic hypoglycemia;
d) Meningioma in the region of the frontal cortex;
e) Norepinephrine-secreting tumor causing periodic hyperglycemia.

80. A 30-year-old woman in her first trimester of pregnancy complains of easy fatigability,
heat intolerance, and palpitations. Physical examination shows a slightly enlarged, nontender
thyroid gland. Thyroid function studies show an increased total serum thyroxine (T4) level,
but normal serum thyroid-stimulating hormone (TSH) levels. Which of the following best
explains the results of these studies?

a) Decreased thyroid-binding globulin (TBG);

b) Increased synthesis of T4;
c) Increased synthesis of triiodothyronine (T3);
d) Thyroiditis-induced release of T4;
e) Normal finding in pregnancy.

81. A 70-year-old man complains of weakness in his right leg. Physical examination is notable
for hyperactive muscle stretch reflexes, a positive Babinski sign, and diffuse areas of
weakness in his right leg. Although he can accurately distinguish sharp and dull pain in the
right leg he is unable to distinguish these types of pain in his left leg. The most likely cause of
these findings is a lesion in the:

a) Cerebellum;
b) Internal capsule, left anterior limb;
c) Left lateral funiculus;
d) Reticular formation;
e) Right frontal lobe.

82. A tall, obese 14-year-old boy with long arms has bilateral gynecomastia, decreased
testicular size for his age, and sparse axillary and pubic hair. A buccal smear preparation
shows a single Barr body extending off the nuclear membrane of many squamous cells.
Which of the following sets of laboratory studies would be expected in this patient?
 a) High Serum follicle stimulating hormone (FSH); High Serum luteinizing hormone (LH);
Low Serum testosterone;
b) High Serum follicle stimulating hormone (FSH); Normal Serum luteinizing hormone
(LH); Normal Serum testosterone;
c) Low Serum follicle stimulating hormone (FSH); Low Serum luteinizing hormone (LH);
Low Serum testosterone;
d) Normal Serum follicle stimulating hormone (FSH); High Serum luteinizing hormone
(LH); Low Serum testosterone;
e) Low Serum follicle stimulating hormone (FSH); Low Serum luteinizing hormone (LH);
High Serum testosterone.

83. A 30-year-old man with a family history of sudden cardiac death has a systolic murmur
that increases in intensity when he is sitting up. An echocardiogram shows abnormal
movement of the anterior mitral valve leaflet against an asymmetrically thickened
interventricular septum. The mechanism for sudden cardiac death in this patients family is
most closely attributed to which of the following conditions?

a) Acute myocardial infarction (MI);

b) Congenital bicuspid aortic valve;
c) Conduction system defect;
d) Dissecting aortic aneurysm;
e) Mitral valve prolapse (MVP).

84. A 24-year-old bicyclist severely injures his right leg after colliding with an automobile. He
is hemorrhaging from the wound but is stabilized, with a blood pressure of 90/40 mmHg and a
heart rate of 100/min. He was not wearing protective head gear at the time of the accident, but
shows no evidence of head trauma. His breathing is rapid and shallow. Blood pressure and
urine flow could best be improved in this patient by:

a) Oral administration of diuretic;

b) Administration of physiologic saline solution;
c) Blood transfusion;
d) Indirect cardiac massage;
e) Intravenous injection of norepinephrine.

85. The glomerular filtration rate (GFR) can be determined from:

RPF = (UPAH/ PPAH) x V (urine flow)

 a) Urinary flow rate (V), plasma P-aminohippuric acid (PAH) concentration (PPAH) and
urinary PAH concentration (UPAH);
b) Urinary flow rate (V), plasma arginine vasopressin (AVP) concentration (PAVP) and urinary
AVP concentration (UAVP);
c) Urinary flow rate (V), plasma creatinine concentration (Pcreatinine) and urinary creatinine
concentration (Ucreatinine);
d) Urinary flow rate (V), plasma urea concentration (Purea) and urinary urea concentration
(Uurea);
e) Urinary flow rate (V), plasma insulin concentration (Pinsulin) and urinary insulin
concentration (Uinsulin).

86. A 32-year-old female undergoes an appendectomy without complications, but has

markedly reduced bowel sounds and an absence of flatus or defecation during the immediate
postoperative period. Which of the following mechanisms best explains this decrease in bowel
sounds?

a) Decreased sympathetic activity to the gut;

b) Increased activity of the gastrocolic reflex;
c) Increased parasympathetic activity to the gut;
d) Increased plasma acetylcholine concentration;
e) Increased plasma norepinephrine concentration.

87. A 58-year-old woman has left hemiparesis and right ptosis (droopy eyelids). She cannot
adduct, elevate, or depress her right eye. The most likely cause of these findings is a lesion in
which of the following sites?

a) Cavernous sinus;
b) Cerebral cortex;
c) Left genu of the internal capsule;
d) Mesencephalon;
e) Right occipital lobe.

88. A 16-year-old boy has become totally deaf in his left ear after a motor vehicle accident
even though hearing in his right ear is normal. A lesion at which of the following sites is the
most likely cause of this finding?

a) Left dorsal and ventral cochlear nuclei;

b) Left inferior colliculus;
 c) Left superior colliculus;
d) Right medial geniculate nucleus;
e) Right temporal lobe.

89. A 74-year-old comatose man, exhibits flexion of the left upper extremity with passive
movement of the head to the right, and flexion of the right upper extremity when the head is
moved to the left. His legs are fixed in extension during all movements. Which of the
following is the most likely explanation of these findings?

a) Alternating hemiplegia syndrome;

b) Brown-Squard syndrome;
c) Decerebrate rigidity;
d) Decorticate rigidity;
e) Transection of the spinal cord below vertebra TV.

90. Which of the following causes of brain hypoxia would most strongly stimulate the aortic
and carotid chemoreceptors?

a) Carbon monoxide poisoning;

b) Severe anemia;
c) Formation of methemoglobin;
d) A marked decrease in pulmonary diffusing capacity;
e) Acute respiratory alkalosis.

91. A 46-year-old man complains of progressive muscle weakness. Laboratory studies show a
serum pH of 7.6, HCO3 of 32 mEq/L, and an elevated plasma aldosterone concentration. The
most likely cause of muscle weakness in this patient is:

a) Hyperchloremia;
b) Hyperkalemia;
c) Hypocalcemia;
d) Hypokalemia;
e) Hyponatremia.

92. If a healthy 70 kg man loses 2 L of sweat while doing yard work and simultaneously
drinks 2 L of pure water, which of the following body fluid changes would be expected?

a) An increase in extracellular osmolarity;

b) An increase in extracellular fluid (ECF) volume;
c) An increase in intracellular osmolarity;
d) An increase in intracellular fluid (ICF) volume;
 e) An increase in plasma Na+ concentration.

93. A 60-year-old man develops an acute onset of confusion, ataxia, nystagmus, and
hypothermia shortly after the administration of an intravenous solution containing 5% glucose
and normal saline. The pathogenesis of this patients neurologic disorder is most closely
related to which of the following conditions?

a) Central pontine myelinolysis;

b) Purkinje cell atrophy;
c) Thiamine deficiency;
d) Viral encephalitis;
e) Vitamin B12 deficiency.

94. A 25-year-old woman has had secondary amenorrhea for the past 8 months. She plans to get
married soon, and states that she has been trying to lose weight for her upcoming wedding. A urine
pregnancy test is negative. The patient is given an intramuscular injection of progesterone. Ten days
later she reports that she has had no withdrawal bleeding. Laboratory studies show the following
serum levels:

Normal range
Prolactin 10 ng/ mL 5-10 ng/ mL
Follicle-stimulating hormone (FSH) 3 mlU/ mL 5-15 mlU/ mL
Luteinizing hormone (LH) 2 mlU/ mL 5-22 mlU/ mL
Thyroid-stimulating hormone (TSH) 4.1 U/ mL 10 U/ mL
Estradiol 1 ng/ 24 h 0-14 ng/ 24 h
Cortisol (a.m.) 35 g/ dL
Growth hormone 10 ng/ mL

a) Acromegaly;
b) Cushings syndrome;
c) Hypopituitarism;
d) Primary ovarian disease;
e) Weight loss syndrome.

95. A middle-aged woman has had asthma since childhood and has been a heavy smoker since
her early teens. During the past few years, she has experienced progressive dyspnea
(breathing difficulty) and somnolence (sleepiness). Physical examination reveals a cachectic
(general ill health and malnutrition) female with shortness of breath, prolonged expirations,
and frequent coughing. Laboratory data are as follows: arterial pH 7.35; arterial HCO3 32
mEq/L; arterial PCO2 60 mmHg; and arterial PO2, 60 mmHg. Which of the following is a
likely diagnosis?
 a) Acute metabolic acidosis with renal compensation;
b) Acute respiratory acidosis without renal compensation;
c) Chronic metabolic acidosis with considerable renal compensation;
d) Chronic respiratory acidosis with considerable renal compensation;
e) Respiratory acidosis with metabolic acidosis.

96. A 50-year-old woman has diminished sensation in the left part of her face and eyelid. She
feels no pain in her left cornea and has no tearing in that eye. A lesion in which of the
following areas is most likely to cause these findings?

a) Left frontal lobe;

b) Left motor nucleus of the trigeminal nerve (CN V);
c) Left ventral posterolateral (VPL) nucleus of the thalamus;
d) Ophthalmic division of the left trigeminal nerve;
e) Right nucleus of the trigeminal nerve.

97. A middle-aged man is evaluated for polydipsia and polyuria. His 24-hour urine volume is
7.0 L with a low osmolality, and is negative for red blood cells, leukocytes, protein, and
glucose. His blood pressure and heart rate are both normal. Which of the following is a likely
cause of polyuria in this patient?

a) Acute attack of diabetes mellitus without glucosuria;

b) Acute renal failure with a severe decrease in glomerular filtration rate (GFR);
c) Cerebrovascular accident damaging the anterior pituitary gland;
d) Renal supersensitivity to the effects of antidiuretic hormone (ADH);
e) Suppression of ADH secretion due to polydipsia.

98. A newborn presents with somewhat ambiguous external genitalia. The genitalia appear as
an enlarged clitoris and a scrotum-like structure that appears to result from labial fusion. An
ultrasound reveals normal ovarian development. The karyotype is 46 XX. The findings are
most likely due to a deficiency in which one of the following enzymes:

a) 11-hydroxylase;
b) 16-hydroxylase;
c) 17-hydroxylase;
d) 21-hydroxylase;
 e) 3-hydroxysteroid dehydrogenase.

99. A 30-year-old man complains of progressive muscle weakness and double vision
(diplopia) and some difficulty in swallowing solid foods. Neurologic studies show a
neuromuscular conduction defect, and diagnostic studies with an intravenous injection of
edrophonium are found to rapidly increase his muscle strength. When the patient is treated
with neostigmine, his status improves. The most probable target molecule in this treatment is:

a) Acetylcholinesterase;
b) Choline acetyltransferase;
c) Monoamine oxidase;
d) Muscarinic acetylcholine (ACh) receptor;
e) Nicotinic ACh receptor.

100. A 60-year-old man comes to your office complaining of dyspnea (difficult breathing). His
laboratory values are as follows:

Breathing Breathing 100%

air O2 for 7 minutes
Arterial PO2 (mmHg) 76 500
Arterial PCO2 (mmHg) 55 65
Arterial Hb (g/ 100 mL) 18 18
Arterial O2 saturation 85 100
(%)
Arterial pH 7.35 7.20

a) Patent ductus arteriosus;

b) Patent foramen ovale;
c) Complete obstruction of the right bronchus;
d) Thickened alveolar membrane impairing diffusion;
e) Pulmonary fibrosis restricting lung movement.

101. A 60-year-old woman complains of persistent breathing difficulties. Her laboratory

studies show: pH 7.36; [H+] 44 nmol/L; PaCO2 55 mmHg; [HCO3] 30 mmol/L. Which of the
following is the most likely diagnosis?

a) Combined metabolic acidosis and respiratory acidosis;

b) Primary respiratory acidosis, secondary metabolic alkalosis, full pH compensation;
c) Primary respiratory acidosis, secondary metabolic alkalosis, partial pH compensation;
d) Pure metabolic acidosis without pH compensation;
e) Pure respiratory acidosis.
102. A 58-year-old man complains of tinnitus that is loudest in his right ear and a decreased
sense of taste in the anterior portion of his tongue. His symptoms have become progressively
worse during the past 6 months. His physical examination is within normal limits. Which of
the following is the most likely diagnosis?

a) Acoustic neuroma;
b) Lacunar stroke in the internal capsule;
c) Lesion in the caudal medulla;
d) Lesion in the mesencephalic tegmentum;
e) Lesion in the tectum.

103. A 14-year-old boy complains of a 3-week history of weight loss, excessive thirst, and
urination. Type 1 diabetes mellitus is suspected. Laboratory testing of blood samples will
most likely show:

a) Increased erythrocyte sedimentation rate;

b) Increased serum creatinine level;
c) Presence of anti-pancreatic amyloid antibodies;
d) Presence of anti-pancreatic islet cell antibodies;
e) Presence of anti-streptolysin O antibodies.

104. A 60-year-old hypertensive man is diagnosed with stenosis of a major renal artery. To
compensate for decreased blood perfusion of the affected kidney, he produces an excess of the
compound labeled X in the figure below. Which of the following best characterizes compound
X?

Figura

a) It causes arteriolar vasoconstriction;

b) It is produced by juxtaglomerular cells of the kidney;
c) It is secreted in response to infusions rich in Na+;
d) It is under tight control of adrenocorticotropic hormone (ACTH);
e) It promotes sodium retention and potassium excretion in the distal tubules of nephrons.

105. The fundamental benefit of applying positive end-expiratory pressure (PEEP) to an 80-
year-old patient with a large closing volume would be that PEEP:

a) Increases the area available for gas exchange by opening closed alveoli;
b) Increases compliance, making it easier to breathe;
c) Promotes an increase in pulmonary blood flow;
d) Significantly increases the PaO2 when the patient is breathing air;
 e) Stimulates breathing by tonically activating pulmonary stretch receptors.

106. Upon awakening one morning, a 62-year-old man, is unable to use his right hand. In
addition, he recently experienced conjugate deviation of the eyes to the left and paralysis of
voluntary gaze to the right; 5 days later, however, his eye movements returned to normal. This
patient probably has had a stroke involving the:

a) Left frontal cortex;

b) Left mesencephalic tegmentum;
c) Left occipital cortex;
d) Right lateral geniculate nucleus;
e) Right occipital cortex.

107. A 23-year-old girl complains of a 3-month history of malaise and generalized muscle
cramps. Laboratory results reveal: serum sodium 144 mmol/L; serum potassium 2.0 mmol/L;
serum bicarbonate 40 mmol/L; arterial pH 7.5. Which of the following is the most likely
cause of this patients hypokalemic alkalemia?

a) Hyperaldosteronism;
b) Hyperventilation;
c) Persistent diarrhea;
d) Renal failure;
e) Diabetes mellitus.

108. A 47-year-old male arrives in the emergency department with acute anterior chest pain,
which radiates to the left arm and back and has lasted for 1 h. He is 80 in tall and weighs 190
lbs. His blood pressure is 115/70 mmHg, pulse 116/min, and respiratory rate 20/min. The
lungs are clear and an electrocardiogram (ECG) shows no abnormalities. Which of the
following is the most likely diagnosis?

a) Angina pectoris;
b) Myocardial infarction (MI);
c) Aortic dissection;
d) Cervical disc disease;
e) Pericardial tamponade.

109. A 67-year-old man suffering from metastatic prostate cancer arrives at your emergency
department 2 h after the sudden onset of anterior chest pain and shortness of breath. The pain
is enhanced by deep breathing movements. He is hypotensive and exhibits a rapid pulse and
respiration rate. His blood pressure is 100/56 mmHg, pulse 136/min and respiration rate
28/min. Although the lungs are clear, an electrocardiogram (ECG) shows a right axis
deviation not observed before. Which of the following is the most likely diagnosis?

a) Pneumonia;
b) Pulmonary embolism;
c) Pneumothorax;
d) Lung cancer;
e) Esophageal spasm.

110. A 56-year-old female complains of generalized weakness and a 20 lb weight loss over the
past 6 months. Blood pressure is 136/80 mmHg and pulse is 88/min. Laboratory values reveal
a hematocrit of 31% (normal 40-45%), hemoglobin level of 10 g/dL (normal 14 g/dL), and a
blood smear shows hypochromic microcytic cells. A stool test for occult blood is positive.
Which of the following would be the most likely cause of the findings?

a) Acute blood loss;

b) Folic acid deficiency;
c) Hemochromatosis;
d) Iron deficiency;
e) -thalassemia trait.

111. A 44-year-old woman complains of increased hairiness that has developed over her face
and body over the past 2 years. Physical exam reveals increased hair growth over the upper
lip, chin, chest, and abdomen, but no truncal obesity or purple striae. Laboratory values of
which hormones would provide the most pertinent diagnostic information?

a) Cortisol and thyroxine (T4);

b) Estrogen and progesterone;
c) Follicle stimulating hormone (FSH) and luteinizing hormone (LH);
d) 17-alpha-hydroxyprogesterone;
e) Testosterone and dehydroepiandrosterone (DHEA) sulphate.

112. A 15-year-old girl is brought to her doctor because of increased irritability, restlessness,
weight loss and learning problems over the past 2 months. Physical examination reveals no
abnormalities. Laboratory studies reveal increased triiodothyronine (T3) and thyroxine (T4)
levels. Which of the following is the most likely diagnosis?

a) Hypoglycemia;
b) Diabetes mellitus;
 c) Hyperthyroidism;
d) Pituitary adenoma;
e) Thyroid cancer.

113. An 8-year-old girl developed rosy cheeks while playing outside on a chilly day. What is
thought to be the cause of this vasodilation?

a) Paralysis of vascular smooth muscle;

b) A decreased thermoregulatory set point;
c) Increased prostaglandin E2 (PGE2) production;
d) Increased parasympathetic activity;
e) Secretion of progesterone.

114. A 69-year-old man is diagnosed with benign prostatic hypertrophy (BPH). Which of the
following hormones is primarily responsible for prostatic enlargement in BPH?

a) Testosterone;
b) Androstenedione;
c) Dihydrotestosterone (DHT);
d) Estrone;
e) Estradiol.

115. An 18-year-old patient with trisomy 21 has an unrepaired complete atrioventricular (AV)
canal defect and pulmonary hypertension. She is complaining of headache and dizziness.
Which of the following tests would be most likely to reveal the etiology of these complaints?

a) Electrocardiography (ECG);
b) Electroencephalography (EEG);
c) Hematocrit;
d) Sinus radiography;
e) Urinalysis.

116. An 8-year-old girl has headache, vomiting, and hypertension. She appears adequately
hydrated. Laboratory values are: serum sodium concentration 110 mEq/L (normal 135-145
mEq/L); blood urea nitrogen 10 mg/dL (normal 7-22 mg/dL); serum creatinine, 0.4 mg/dL
(normal 0.3-0.7 mg/dL). The sodium concentration of a random sample of urine is 100 mEq/L
(normal 130-260 mEq/24 h). An increase in which of the following hormones is the most
likely cause of these findings?
 a) Antidiuretic hormone (ADH);
b) Atrial natriuretic peptide (ANP);
c) Estrogen;
d) Glucocorticoid;
e) Mineralocorticoid.

117. A 15-year-old boy complains of vomiting, anorexia, and weight loss. Laboratory studies
reveal: serum calcium 13 mg/dL (normal 8.7-10.6 mg/dL); blood urea nitrogen 36 mg/dL
(normal 7-22 mg/dL); serum creatinine, 1.8 mg/dL (normal 0.3-0.7 mg/dL). He has been
taking several high-potency vitamin supplements daily for the past year as part of a body-
building program. An excess of which of the following vitamins is the most likely cause of
these findings?

a) Vitamin A;
b) Vitamin B;
c) Vitamin C;
d) Vitamin D;
e) Vitamin E.

118. A previously healthy 2-year-old girl who developed a sudden onset of persistent
coughing is brought to the pediatric clinic. She has no fever and now is coughing up bright
red, frothy blood. What is the most likely cause of this childs problem?

a) Arteriovenous malformation of the lung;

b) Cystic fibrosis;
c) Foreign body in the bronchus;
d) Pneumonia;
e) Tuberculosis.

119. A 6-week-old boy is brought to his pediatrician by his mother because of progressively
worsening projectile vomiting over the past 2 weeks. Physical examination reveals a wasted,
dehydrated infant who is avidly sucking on a nipple. Which of the following laboratory values
is most consistent with this childs problem?

a) Sodium (mEq/L) 160, Potassium (mEq/L) 3.0 , Chloride (mEq/L) 125 , and
Bicarbonate (mEq/L) 12 ;
b) Sodium (mEq/L) 140 Normal, Potassium (mEq/L) 3.8 Normal, Chloride (mEq/L) 110 ,
and Bicarbonate (mEq/L) 23 Normal;
c) Sodium (mEq/L) 138 Normal, Potassium (mEq/L) 2.5 , Chloride (mEq/L) 110 , and
Bicarbonate (mEq/L) 23 Normal;
 d) Sodium (mEq/L) 130 , Potassium (mEq/L) 2.8 , Chloride (mEq/L) 80 , and
Bicarbonate (mEq/L) 35 ;
e) Sodium (mEq/L) 123 , Potassium (mEq/L) 3.2 , Chloride (mEq/L) 93 , and
Bicarbonate (mEq/L) 10 .

120. While on a rotation in India, you encounter a 10-year-old patient who is suffering cholera
and is severely dehydrated. You are asked to prepare an oral rehydration solution. What, in
addition to water, would the most important components of the solution be?

a) Bicarbonate and potassium;

b) Chloride and potassium;
c) Lactate and potassium;
d) Sodium and bicarbonate;
e) Sodium and glucose.

121. A 23-year-old weightlifter lifts 325 lbs. over his head and holds it there for 5 s, after
which he suddenly drops it to the floor. Which of the following receptors is responsible for
this sudden muscle relaxation?

a) Free nerve ending;

b) Golgi tendon organ;
c) Muscle spindle;
d) Merkels disk;
e) Pacinian corpuscle.

122. A 42-year-old obese woman experiences episodic upper right quadrant abdominal pain.
She notes that the pain increases after the ingestion of a fatty meal. The action of which of the
following hormones is responsible for the postprandial intensification of her symptoms?

a) Cholecystokinin (CCK);
b) Gastrin;
c) Pepsin;
d) Secretin;
e) Somatostatin.

123. A 44 year old woman with severe cardiac failure caused by coronary artery disease was
treated by cardiac transplantation. Three months after surgery, she developed a bleeding
duodenal ulcer and lost approximately 600 ml of blood in one hour. She was treated with
dietary changes and antibiotics and the ulcer was healed in about two weeks. The acute blood
loss from the patients duodenal ulcer would be expected to:

a) Decrease central venous pressure and increase cardiac output;

b) Increase central venous pressure and decrease mean arterial pressure;
c) Decrease central venous pressure and decrease cardiac output;
d) Increase mean arterial pressure and decrease cardiac output;
e) Decrease central venous pressure and increase aortic pulse pressure.

124. A 33-year-old man complained about chest pain on exertion. He was referred to a
cardiologist, who carried out a number of studies, including right- and left-sided
catheterization. Among the data obtained during these studies were the findings that at the
time of his initial examination the patients mean aortic pressure was 93 mm Hg and his mean
pulmonary artery pressure was 20 mm Hg.

These findings can be explained as follows:

a) The patients systemic vascular resistance was much greater than his pulmonary vascular
resistance;
b) The patients aortic compliance was much greater than his pulmonary artery compliance;
c) The patients left ventricular stroke volume was much greater than his right ventricular
stroke volume;
d) The total cross-sectional area of the patients pulmonary artery was much greater than the
total cross-sectional area of the aorta;
e) The duration of rapid ejection phase of the patients left ventricle exceeded the duration of
the rapid ejection phase of the right ventricle.

125. A 9-year-old child has suffered severe lacerations and blood loss in an automobile
accident. What is the most likely cause of increased vasopressin secretion in this child?

a) Secretion is stimulated when the plasma volume decreases;

b) Vasopressin decreases fluid loss by inhibiting aquaporin-2 (AQP2) water channel activity;
c) Secretion increases as plasma osmolality decreases;
d) Decreased K+ transport by increasing protein kinase A (PKA) activity in kidney cells;
e) Secretion is increased when blood pressure increases.

126. You wish to determine the ability of thyrotropin-releasing hormone (TRH) to stimulate
the release of pituitary hormones in a group of volunteer subjects. In addition to measuring
thyroid stimulating hormone (TSH), which of the following hormones could you also
measure?
 a) Growth hormone (GH);
b) Prolactin;
c) Luteinizing hormone (LH);
d) Adrenocorticotropic hormone (ACTH);
e) Antidiuretic hormone (ADH).

127. You determine that a 45-year-old female patient with kidney stones is suffering from
primary hyperparathyroidism. What is the most likely reason for an increase in her plasma
ionized calcium?

a) Increased bone resorption;

b) Enhanced 24,25(OH)2-vitamin D3 production;
c) Increased kidney tubule reabsorption of phosphate;
d) Decreased osteoclast formation;
e) Decreased urinary phosphate.

128. Your 54-year-old female patient is suffering from myocardial ischemia. One drug that
you suggest to improve her cardiac function is a -blocker. What would be the myocardial
effect of a -blocker?

a) Dilation of peripheral blood vessels, particularly the veins;

b) Prevention of pulmonary conversion of angiotensin I to angiotensin II;
c) Increased L-type calcium channel activity in ventricular muscle;
d) Increase in the dP/dt during ventricular isovolumetric contraction;
e) Decreased heart rate and contractility of the myocardium.

129. A neonate is brought to the endocrinologist with ambiguous external genitalia. It is

determined that the infant has ovaries and internal female genitalia, but external virilization
(ambiguous genitalia). Which of the following diagnoses is the most likely?

a) Turners syndrome (45, XO);

b) Klinefelters syndrome (47, XXY);
c) Congenital adrenal hyperplasia;
d) Deficient estrogens during fetal life;
e) 5-reductase mutation.
130. A 31-year-old woman attempting to become pregnant after several months sees her
gynecologist who diagnoses her with luteal insufficiency, even though ovulation does occur.
Which of the following is most likely responsible?

a) High serum levels of periovulatory luteinizing hormone (LH);

b) Elevated levels of periovulatory gonadotropin releasing hormone (GnRH);
c) Insufficient priming of the corpus luteum by follicle stimulating hormone (FSH);
d) Inadequate LH surge to luteinize the corpus luteum;
e) High levels of follicular phase estrogen.

131. Your 21-year-old female patient presents with a history of secondary amenorrhea, acne,
hyperpigmentation, clitoral enlargement, and physical and mental fatigue. Her blood pressure
is 160/105 mmHg and laboratory values indicate hypokalemia, low fasting blood glucose, and
hypernatremia. What, in the light of these findings, is the most likely cause of her symptoms?

a) An adrenocorticotropic hormone (ACTH)-secreting tumor;

b) 11-hydroxylase deficiency;
c) Absence of androgen receptors;
d) 21-hydroxylase deficiency;
e) Primary hypercortisolism.

132. In addition to treating a diabetic patient (type 1) for ketoacidosis with insulin, why is a
potassium salt often administered?

a) Insulin directly increases the excretion of potassium by the kidney;

b) Return of plasma pH and glucose to normal will lower the total body potassium content;
c) Return of plasma pH and glucose to normal is accompanied by a shift of potassium into
cells;
d) Plasma potassium is usually low in diabetic ketoacidotic patients;
e) Return of plasma glucose to normal will cause a decrease in the plasma volume.

133. Walking on a treadmill increased the body temperature of a 67-year-old male patient
from 98.1F to 103.2F. What will the increase in body temperature cause?

a) Inhibition of postganglionic sympathetic cholinergic activation;

b) Increased thyroid stimulating hormone (TSH) secretion;
c) A shift to the left in the O2 dissociation curve;
d) Vasodilation of cutaneous vasculature;
e) A decrease in the basal metabolic rate (BMR).
134. In a healthy subject, running is usually associated with a decrease in the end-systolic
volume of the right and left ventricles and with an increase in their stroke volume. What is the
probable mechanism for this response?

a) A decrease in catecholamine release;

b) An increase in sympathetic tone to the ventricles;
c) An increase in parasympathetic tone to the ventricles;
d) A decrease in venous return of blood to the heart;
e) An increase in pulmonary and systemic resistance.

135. Your 20-year-old female patient has the following laboratory values: arterial blood pH
7.50; HCO3 40 mEq/L; PCO2 51 mmHg. What is the acidbase status of this patient?

a) Partially compensated metabolic alkalosis;

b) Partially compensated metabolic acidosis;
c) Partially compensated respiratory alkalosis;
d) Partially compensated respiratory acidosis;
e) Uncompensated respiratory alkalosis.

136. A 10 year-old boy is admitted through the emergency department where he was brought
after receiving a wasp sting while on a family outing. During a previous wasp sting, he
experienced respiratory problems, itching, and urticaria, and he fainted. Upon admission he
was obviously suffering from a generalized systemic inflammatory condition (anaphylaxis).
What will anaphylactic shock cause?

a) Increased renal fluid output;

b) Hypertension;
c) Decreased blood volume;
d) Decreased interstitial fluid pressure;
e) Increased level of atrial natriuretic peptide.

137. Your 49-year-old male patient is admitted to the heart hospital suffering the classic
symptoms of myocardial ischemia. His electrocardiogram (ECG) at admission shows an
elevated ST segment with an inverted T wave. What is the most likely cause of the inverted
T wave?

a) Ventricular repolarization occurring from endocardium to epicardium;

 b) Ventricular repolarization occurring from epicardium to endocardium;
c) Ventricular depolarization occurring from epicardium to endocardium;
d) Ventricular depolarization occurring from endocardium to epicardium;
e) An abnormal delay in atrioventricular (AV) nodal conduction.

138. A 49-year-old woman with coronary artery disease is prescribed a calcium channel
blocker to facilitate coronary vasodilatation. Because of their myocardial side-effects, drugs
that block L-type calcium channels would be expected to do which of the following?

a) Increase heart rate by enhancing the firing rate of the sinoatrial (SA) node;
b) Trigger vasoconstriction;
c) Lower blood pressure;
d) Increase the force of contraction of the heart;
e) Lengthen the plateau phase of the ventricular action potential.

139. A 58-year-old female patient with type II diabetes mellitus decides to discontinue insulin
treatment because she believes she can control the disease with diet alone. What would you
expect to happen to this patient shortly after insulin is discontinued?

a) Blood glucose concentration decreases;

b) Excretion of nitrogen increases;
c) Glycogen content in the liver increases;
d) Extracellular concentration of potassium decreases;
e) Rate of conversion of alanine to glucose decreases.

140. A 10-year-old boy has a low plasma ionized Ca2+ and an increased parathyroid hormone
level. He has a high plasma alkaline phosphatase, exhibits muscle weakness, and has skeletal
areas that are poorly calcified. You prescribe vitamin D3, but see no improvement. However,
treatment with 1,25(OH)2-vitamin D3 causes the patients ionized Ca2+ level to increase. What
would the most likely diagnosis be?

a) Type 1 vitamin D-dependent rickets;

b) Rickets due to vitamin D deficiency;
c) Inability to form 24(OH)-vitamin D3;
d) Receptors for dehydrocholesterol are absent;
e) Inability to form vitamin D3 in the skin.
141. Which of the following causes of brain hypoxia would most strongly stimulate the aortic
and carotid chemoreceptors?

a) Carbon monoxide poisoning;

b) Severe anemia;
c) Formation of methemoglobin;
d) A marked decrease in pulmonary diffusing capacity;
e) Acute respiratory alkalosis.

142. A patient is given a drug that prolongs the PR interval of the electrocardiogram (ECG).
What is the most likely action of the drug?

a) Reduced conduction velocity of the atrial fibers;

b) Delayed repolarization of the ventricular fibers;
c) Reduced conduction velocity of atrioventricular (AV) nodal fibers;
d) Increased conduction velocity of the atrial fibers;
e) Increased force of contraction of the right ventricle.

143. In a patient with a fractured pelvis, requiring a 3-week period of bed rest which of the
following physiologic changes would be expected to occur?

a) Decreased blood volume;

b) Increased plasma concentration of aldosterone;
c) Increased plasma volume;
d) Increased activity of the sympathetic nervous system;
e) Decreased plasma concentration of sodium.

144. If the venous return to the right atrium should increase from a normal value of about 5
L/min (in the adult) to about 10 L/min, what would a normal heart most likely develop?

a) An increase in atrial and end-diastolic ventricular pressure with decreased stroke volume;
b) A decrease in atrial and end-diastolic ventricular pressure with decreased contractility;
c) An increase in atrial and end-diastolic ventricular pressure with increased stroke volume;
d) Bradycardia and cardiac shock;
e) Bradycardia and very low end-diastolic pressure of the right ventricle.

145. A 69-year-old man complains of episodes of squeezing substernal chest pain, that
occur when he physically exerts himself. He sometimes feels the pain in his jaw, and it often
radiates down his left arm. After thorough evaluation, he is diagnosed with chronic stable
angina (exertional angina) and instructed to take nitroglycerin. The mechanism by which
nitroglycerin exerts its beneficial effects in angina is by:

a) Blocking 1-adrenergic receptors and reducing myocardial oxygen consumption by

decreasing cardiac pre-load and afterload;
b) Blocking 1-adrenergic receptors and reducing myocardial oxygen consumption by
preventing an increase in heart rate and contractility;
c) Blocking slow Ca2+ channels and reducing myocardial oxygen consumption by decreasing
cardiac contractility, heart rate, and arterial pressure;
d) Causing smooth muscle relaxation by stimulating the formation of nitric oxide, thereby
causing an increase in the level of cyclic guanosine monophosphate (cGMP);
e) Preventing platelet aggregation by inhibiting platelet cyclooxygenase activity.

146. Your 15-year-old dizzy patient arrives at the emergency department after winning a
breath holding contest. Her laboratory values are as follows: pH 7.10; HCO3 4 mEq/L; PCO2
17 mmHg. What is the acidbase status of this patient?

a) Partially compensated metabolic alkalosis;

b) Partially compensated metabolic acidosis;
c) Partially compensated respiratory alkalosis;
d) Partially compensated respiratory acidosis;
e) Uncompensated respiratory alkalosis.

147. A 73-year-old patient in the cardiology clinic suffers from an arrhythmia, which prevents
the electrical impulse from slowing down at the atrioventricular (AV) node. Which of the
following would be a direct result of this type of arrhythmia?

a) Insufficient time for ventricular filling;

b) Augmentation of ventricular contraction;
c) Increase in venous return;
d) Insufficient time for atrial filling;
e) Increased aortic pressure.

148. A 70-year-old male with edema and congestive heart failure has diastolic dysfunction
characterized by decreased ventricular filling due to reduced ventricular muscle compliance.
Which one of the following proteins determines the normal stiffness of ventricular muscle?

a) Calmodulin;
 b) Troponin;
c) Tropomyosin;
d) Titin;
e) Myosin light chain kinase.

149. A 30-year-old man develops adult respiratory distress syndrome (ARDS) after near-
drowning due to a boating accident. Conventional mechanical ventilation and inhaled nitric
oxide (NO) do not provide sufficient oxygenation. The partial pressure of arterial carbon
dioxide (PaCO2) and fraction of inspired oxygen (FIO2) ratio as well as shunt fraction (Qs/Qt)
improve greatly after bronchial instillation of surfactant. The improvements in respiratory
function occurred because surfactant decreased which of the following?

a) Bronchiolar smooth muscle tone;

b) Arterial bicarbonate concentration;
c) Lung compliance;
d) The work of breathing;
e) Functional residual capacity (FRC).

150. A 12-year-old girl is seen in your practice for weight loss and diarrhea, with bowel
movements described as large, soft, greasy and foul smelling, occurring about ten times a day.
After serologic testing and mucosal biopsy of the duodenum, you confirm your diagnosis and
the patients condition improves on a gluten-free diet. What is the most likely diagnosis of this
patients condition?

a) Cystic Fibrosis;
b) Diverticulosis;
c) Gastrinoma;
d) Celiac sprue;
e) Chagas disease.