A healthy adult participating in a clinical research study increases his daily sodium intake greatly, but his plasma

sodium remains at a constant level. Which of the following substances is most responsible for this constancy in plasma sodium concentration when large amounts of sodium are ingested? A. B. C. D. E. Aldosterone Angiotensin II Antidiuretic hormone (ADH) Atrial natriuretic factor (ANF) Epinephrine

The correct answer is C. A 5-fold increase in sodium intake causes the plasma sodium concentration to increase by less than 1%, indicating the existence of a powerful mechanism for maintaining extracellular sodium concentration at a constant level. However, when the ADH-thirst mechanism is blocked, a 5fold increase in sodium intake causes the plasma sodium concentration to increase by more than 10%. Therefore, the major mechanism for controlling extracellular sodium concentration (as well as extracellular osmolarity) is the ADHthirst mechanism. You should recall that ADH increases the permeability of the late distal tubule and collecting duct to water, which allows water to be retained by the body and a concentrated urine to be excreted. Aldosterone (choice A) and angiotensin II (choice B) are powerful salt-retaining hormones. They regulate the total amount of sodium in the body, but have relatively little effect on plasma sodium concentration under normal conditions for the following reasons: (1) they increase reabsorption of sodium and water to an equal extent, and (2) any tendency for sodium concentration to change is immediately compensated for by changes in ADH levels, which return sodium concentration to a normal value. Atrial natriuretic factor (choice D) is released from the atria when blood volume increases. It acts on the kidneys to increase the excretion of sodium and water. However, ANF does not have an important role in regulating plasma sodium concentration because any tendency for sodium concentration (as well as osmolarity) to change is immediately compensated for by changes in ADH levels, as discussed above. Epinephrine (choice E) does not have an important role in regulating extracellular sodium concentration.

 Diagrams A-E show the relative osmolarity (Y-axis) and volume (Xaxis) of the intracellular and extracellular fluid compartments during normal conditions (solid line) and following various disturbances in the body fluids (shaded area, dashed line). Which of the following diagrams depicts a woman who runs a marathon on a hot summer day and replaces all volume lost in sweat by drinking water during the race?

A.

B.

C.

D.

E.

The correct answer is C. Diagram C shows a disturbance in body fluid balance commonly referred to as "hypotonic contraction" which is characteristic of sodium chloride loss from the body. Because the fluid lost as sweat was replaced entirely with water and because sweat contains sodium chloride (as well as other electrolytes), the body fluid osmolarity has decreased and the total volume of water in the body has remained at a normal level, as shown in diagram C. The extracellular fluid volume has decreased (because the electrolytes were lost from the extracellular fluid compartment) and the intracellular fluid volume has increased due to movement of water into the cells. (The astute student will note that this question can be answered very quickly because the total body water volume is unchanged only in diagram C.) Choice A (isotonic contraction) can be caused by diarrhea. Choice B (hypertonic expansion) can be caused by excessive intake of sodium chloride without water supplementation. Choice D (hypertonic contraction) can be caused by sweating (without water replacement) and other perturbations in which a hypotonic fluid is lost from the body. Choice E (hypotonic expansion) can be caused by retention of water by the kidneys, e.g., inappropriate secretion of antidiuretic hormone.

 The usefulness of the technique of transcutaneous electrical nerve stimulation is explained by which of the following? A. B. C. D. E. Allodynia Central pain Gate theory of pain Referred pain Thalamic pain

The correct answer is C. Transcutaneous electrical nerve stimulation is a method used to lessen severe, chronic pain by overly stimulating the involved neurons. This is thought to trigger inhibitory interneurons in lamina II of the spinal cord, thereby partially blocking the transmission of pain impulses. These interneurons are considered to be "gate-keepers," that can, to some degree, isolate the peripherally generated signals from the brain. Allodynia (choice A) is the term used for the perception of pain following a normally innocuous stimulation of a mechanoreceptor. Central pain (choice B), such as that caused by thalamic lesions (choice E), is pain that originates at the level of the brain rather than in the periphery. Referred pain (choice D) is the perception of pain initiated in one body site (typically an internal organ) as being localized to another body site (frequently on the more superficial parts of the body). An example is that of diaphragmatic pain, which may be referred to the top of the shoulder. The phenomenon occurs because both internal organs and more superficial structures may arise from, and consequently be innervated by, the same dermatome.

 A 30-year-old female presents with tender cervical lymphadenopathy. She has had low-grade fever on and off for a few weeks. A biopsy performed shows a normal lymph node with multiple germinal centers. Many macrophages containing debris from ingested lymphocytes are present (tingible body macrophages). This supports which of the following diagnoses? A. B. C. D. E. Benign reactive lymphadenitis Hodgkin's disease Malignant histiocytosis Non-Hodgkin's lymphoma Szary syndrome

The correct answer is A. Tingible body macrophages are characteristic of a reactive follicular center in benign reactive lymphadenitis. Within the lymph node, the germinal center is the major site of antigen-dependent B-lymphocyte selection and maturation. Certain B cells are selected, and those that are less suited for a particular antigen are eliminated by apoptosis. The apoptotic debris is ingested by macrophages that then appear as "tingible body macrophages." The tenderness is also suggestive of benignity. Hodgkin's disease (choice B) is a type of lymphoma that spreads from node to node in contiguity. There are four main subtypes of the disease. Histologically, the characteristic cell finding is the Reed-Sternberg cell. Hodgkin's disease usually presents with painless cervical adenopathy and fever, chills, night sweats, and weight loss. Malignant histiocytosis (choice C) is a common subtype of nonHodgkin's lymphoma. The characteristic cell appears large with a vesicular nucleus and prominent nucleolus. The disorder can present with nodal enlargement (usually non-tender) or with extranodal involvement. Non-Hodgkin's lymphoma (choice D) is the name for a varied group of lymphomas that are not associated with ReedSternberg cells. They usually present with lymphadenopathy and splenomegaly. They do not spread in contiguity and 30% present extranodally. The histologic presentation varies, but all contain atypical lymphocytes. Szary syndrome (choice E) is a type of cutaneous T-cell lymphoma. Neoplastic T cells are found in the upper dermis and also within the peripheral blood. Patients present with lymphadenopathy, pruritic erythroderma, and exfoliation.

 During a fast, a brief phase of intense sequential contractions begins in the stomach and gradually migrates to the ileum. Release of which of the following intestinal hormones is most likely responsible for this observed effect? A. B. C. D. E. F. Cholecystokinin Gastrin Gastrin-releasing peptide Motilin Secretin Somatostatin

The correct answer is D. Motilin is a hormone released by the small intestine during the fasting state. Its waxing and waning blood levels correlate with the initiation and ending of migrating motor complexes (MMC). Furthermore, injection of motilin has been shown to evoke MMC activity. The MMC typically begins in the stomach, and over a 90-120 minute period, migrates to the ileum, where it dies out. As one complex dies out in the ileum, another complex begins in the stomach provided the fasting state continues. Eating a meal interrupts the MMC activity. Cholecystokinin (choice A) is released during the intestinal phase of the digestive period (not during a fast). Its secretion is evoked by the presence of fat and protein digestion products in the duodenum. It induces contraction of the gall bladder and relaxation of the sphincter of Oddi. Gastrin (choice B) is released from G cells in the antrum, mostly during the gastric phase of the digestive period (not during a fast). It tends to increase stomach motility, although the rate of emptying is decreased because gastrin also causes the pyloric sphincter to contract. It also may contribute to the increase in ileal and colonic motility as part of the gastroileal and gastrocolic reflexes, respectively. Gastrin-releasing peptide (choice C) mediates the neural release of gastrin. Antral enteric neurons that are activated by vagal efferents or by local reflexes release gastrin-releasing peptide, which stimulates the G cells to secrete gastrin. Secretin (choice E) is a duodenal hormone that is released during the intestinal phase of the digestive period (not during a fast). Its secretion is evoked by a duodenal pH less than 4.5. Secretin tends to decrease the rate of stomach emptying. Somatostatin (choice F) is released by delta cells in the stomach mucosa. It mediates the inhibition of gastrin secretion that occurs when the pH of the gastric juice falls below 3. It also acts directly on the parietal cell to decrease acid secretion.

 Which of the following hormones is most important in initiating gall bladder contraction? A. B. C. D. E. Cholecystokinin (CCK) Gastric inhibitory peptide (GIP) Gastrin Secretin Vasoactive intestinal polypeptide (VIP)

The correct answer is A. Cholecystokinin, or CCK, is synthesized in the duodenal and jejunal mucosa and stimulates gall bladder contraction and pancreatic enzyme secretion. Other functions include slowing of gastric emptying, an atrophic effect on the pancreas, and secretion of antral somatostatin, which in turn, decreases gastric acid secretion. Gastric inhibitory peptide, or GIP (choice B), stimulates pancreatic insulin secretion at physiologic doses and inhibits gastric acid secretion and gastric motility at pharmacologic doses. Gastrin (choice C) prepares the stomach and small intestine for food processing, including stimulating secretion of HCl, histamine, and pepsinogen. It also increases gastric blood flow, lower esophageal sphincter tone, and gastric contractions. Secretin (choice D) stimulates secretion of bicarbonatecontaining fluid from the pancreas and biliary ducts. Vasoactive intestinal polypeptide, or VIP (choice E), relaxes intestinal smooth muscle and stimulates gut secretion of water and electrolytes.

 In which type of blood vessel is the mean linear velocity of a red blood cell the lowest? A. B. C. D. E. F. Aorta and large arteries Arterioles Capillaries Small arteries Vena cavae and large veins Venules and small veins

The correct answer is C. The same volume of blood flows through each of the different types of blood vessels each minute. Because the capillaries have the largest cross-sectional area (averaging 2500-5000 cm2), and because the velocity of blood flow is inversely related to cross-sectional area, it is clear that the mean linear velocity of a red blood cell is lowest in the capillaries. Under resting conditions, the mean linear velocity of a red blood cell in the capillaries is 0.3-0.6 mm/sec, whereas, the velocity in the aorta (choice A) is about 200 mm/sec. This low velocity of red blood cells in the capillary network allows plenty of time for oxygen to diffuse to the tissues. The velocity of blood flow is ranked from highest to lowest as follows: aorta (choice A) > vena cavae (choice E) > large veins (choice E) > small arteries (choice D) > arterioles (choice B) > small veins (choice F) > venules (choice F) > capillaries. This ranking assumes the vena cavae have a larger cross-sectional area than the aorta; however, when the vena cavae are partially collapsed (which occurs often) they have a lower cross-sectional area and a higher velocity of blood flow compared to the aorta.

 A 26-year-old man participates in an exercise study. He is appropriately classified as sedentary, since his VO2max (maximum oxygen consumption) measured during conventional cycle ergometer exercise is 35 mL/kg/min. The exercise study he participates in utilizes a knee-extensor ergometer that limits exercise to the quadriceps muscles. The subject is given a 5-minute unloaded warmup, followed by a graded maximal exercise test, and then by 30 minutes of knee-extensor exercise at 50% of the maximum work load. A biopsy is taken from the exercising muscle using a 5 mm diameter biopsy needle sixty minutes after termination of the exercise routine. Which of the following would most likely be increased in the muscle sample? A. B. C. D. E. Basic fibroblast growth factor mRNA Intracellular pO2 Mitochondrial volume density Myoglobin oxygen saturation Vascular endothelial growth factor mRNA

The correct answer is E. Vascular endothelial growth factor (VEGF) is a heparin binding glycoprotein that increases endothelial cell proliferation in vitro and capillary growth (i.e., angiogenesis) in vivo. Unlike most other growth factors, VEGF has unique target cell specificity for vascular endothelial cells, i.e., it does not directly stimulate growth of other types of cells. VEGF mRNA expression is increased in human skeletal muscle within an hour following intensive exercise. This increase in VEGF mRNA expression is followed by increased VEGF protein levels, which can initiate angiogenesis in the muscles. Growth of new blood vessels decreases diffusion distances between capillaries and muscle fibers, thereby improving oxygen transport to the tissues. Basic fibroblast growth factor (bFGF) (choice A) is a heparinbinding growth factor capable of stimulating angiogenesis. However, bFGF mRNA expression is not increased following an exercise routine such as that described in the vignette. Exercise decreases myoglobin oxygen saturation (choice D) as well as intracellular pO2(choice B). Endurance exercise training can stimulate growth of mitochondria in human skeletal muscle and thereby increase mitochondrial volume density (choice C) (i.e., volume of mitochondria per unit volume of muscle); however, growth of new mitochondria will not occur within an hour after exercise.

 A 70-year-old woman with a history of multiple small strokes reports to her physician that she has had multiple recent experiences that something or someone seemed very familiar, when in reality they were not familiar to her. This type of experience is called which of the following? A. B. C. D. E. Anterograde amnesia Confabulation Deja vu Jamais vu Retrograde amnesia

The correct answer is C. This is deja vu ("seen before"), which is the experience of an event, person, or thing as familiar, even though it has never previously been experienced. Severe cases often accompany an underlying neurologic problem. Anterograde amnesia (choice A) is the inability to learn new facts. Most commonly, it involves both verbal and nonverbal material, but it can involve one or the other. In confabulation (choice B), a patient reports "memories" of events that did not take place at the time in question. In jamais vu (choice D), a patient fails to recognize familiar events that have been encountered before. In retrograde amnesia (choice E), a patient fails to remember facts or events that occurred before the onset of amnesia.

 Which of the following hormones is most important in the initiation of gallbladder contraction following a fatty meal? A. B. C. D. E. CCK Gastrin GIP Secretin VIP

The correct answer is A. Cholecystokinin, or CCK, is synthesized in the duodenal and jejunal mucosa and stimulates gallbladder contraction and pancreatic enzyme secretion. Other functions include slowing of gastric emptying, an atrophic effect on the pancreas, and secretion of antral somatostatin, which in turn, decreases gastric acid secretion. Gastrin (choice B) prepares the stomach and small intestine for food processing, including stimulating secretion of HCl, histamine, and pepsinogen, increasing gastric blood flow, lower esophageal sphincter tone, and gastric contractions. Gastric inhibitory peptide, or GIP (choice C), stimulates pancreatic insulin secretion at physiologic doses and inhibits gastric acid secretion and gastric motility at pharmacologic doses. Secretin (choice D) stimulates secretion of bicarbonatecontaining fluid from the pancreas and biliary ducts. Vasoactive intestinal polypeptide, or VIP (choice E), relaxes intestinal smooth muscle and stimulates gut secretion of water and electrolytes.

 During the passage of an intravenous catheter, numerous endothelial cells are dislodged from the lining of the popliteal vein. What substance allows platelet adhesion to the exposed collagen fibers? A. B. C. D. E. Factor VIII Factor IX Fibronectin Tissue factor Von Willebrand factor

The correct answer is E. Von Willebrand factor (vWF) is a selfpolymerizing clotting protein present in the serum and the subendothelial basal lamina, which has binding sites for collagen, platelets, and fibrin. At a site of injury, vWF forms the bridge between the exposed collagen fibers and platelets in circulation, stimulating platelet degranulation and initiating the cellular component of the clotting cascade. An equally important role for vWF is binding platelets to the newly formed fibrin strands in a blood clot. Factor VIII (choice A) and Factor IX (choice B) are clotting proteins of the intrinsic pathway. Factor VIII acts in concert with activated Factor IX (IXa) to cleave Factor X to Xa. Xa is the prothrombin activator central to both the intrinsic and extrinsic pathways. Fibronectin (choice C) is a serum protein that acts as an opsonin for phagocytic cells in clots. Fibronectin binds nonspecifically to bacteria and other materials in the newly forming clots, and draws the cell membrane of phagocytes into contact with these substances. Tissue factor (choice D) is a protein released from injured tissues that works in concert with Factor VII to initiate the extrinsic pathway of coagulation. Like Factors VIII and IX, tissue factor and Factor VII cleave Factor X to Xa.

 Two normal, healthy subjects volunteer for a study on insulin secretion. In Patient 1, blood glucose is increased to 150 mg/dL by direct intravenous infusion. In Patient 2, blood glucose is increased to 150 mg/dL by ingestion of oral glucose. The peak plasma insulin concentration produced in Patient 1 is 70 U/mL while in Patient 2, it is 95 U/mL. Which of the following best explains the higher insulin concentration in Patient 2? Ingested glucose activates a sympathetic reflex that increases cell release of insulin Ingested glucose increases duodenal secretion of gastric B. inhibitory peptide (GIP), increasing cell release of insulin Intravenous glucose increases islet cell secretion of C. somatostatin, inhibiting cell release of insulin Intravenous glucose increases islet cell secretion of glucagon, D. inhibiting cell release of insulin A.

The correct answer is B. Ingestion of glucose results in secretion of a "gut factor" into the blood that subsequently increases insulin secretion by cells. The most likely candidate for this action is the intestinal peptide known as gastric inhibitory peptide (GIP), which obviously was named for its effects on the stomach. GIP secretion is increased during ingestion of glucose and the blood level produced is sufficient to stimulate insulin secretion. Because of this effect on insulin secretion, GIP is sometimes referred to as glucose-dependent insulinotropic peptide. Activation of the sympathetic innervation to the pancreas inhibits insulin secretion via an 2-adrenergic mechanism. Hence, any sympathetic reflexes activated during ingestion of glucose would decrease (not increase, choice A) insulin secretion. While paracrine release of somatostatin (choice C) by cells in the islets does inhibit insulin secretion by cells, there is no reason to suspect that intravenous versus ingested glucose would have a differential effect on somatostatin release. The same holds true for glucagon secretion by cells. Furthermore, glucagon has a paracrine effect to increase (not decrease, choice D) insulin secretion.

 Which of the following vascular structures contains the largest proportion of the total blood volume in a normal individual? A. B. C. D. E. F. G. Aorta and large arteries Arterioles Capillaries Chambers of the heart Pulmonary vasculature Vena cavae Venules and veins

The correct answer is G. The total blood volume of the body is about 5000 mL. The systemic veins contain about 64% of this volume or about 3200 mL. The vena cavae (choice F) contain a small fraction of the total venous volume. No other segment of the circulation comes close to the amount of blood contained by the systemic veins: the pulmonary vasculature (choice E) contains about 450 mL; the chambers of the heart (choice D) contain about 350 mL; the aorta and large arteries (choice A) together contain about 650 mL; and the arterioles and capillaries (choices B and C) together contain about 350 mL. Although the capillaries contain less than 7% of the total blood volume, they have a very large surface area which facilitates diffusion exchange of nutrients and metabolites between the blood and tissue spaces.

A 24-year-old student generates the series of flow-volume curves shown above. Curve W was generated, when the student was healthy, by inhaling as much air as possible and then expiring with maximum effort until no more air could be expired. Curve X is most likely to be caused by which of the following? A. B. C. D. E. An asthma attack Aspiration of meat into the trachea Heavy exercise Normal breathing at rest Pneumonia

The correct answer is C. The tidal volume has increased from a normal value of 0.5 liter (indicated by curve Z) to nearly 2.5 liters during heavy exercise, as indicated by curve X. The expiratory air flow rate has reached a maximum value of over 5 L/sec during the heavy exercise because respiratory rate has increased greatly and a maximum expiratory effort is required to move the ~2.5 liter tidal volume out of the lungs. Curve Y was recorded during mild exercise. An asthma attack (choice A) would not be expected to increase tidal volume greatly, certainly not to ~2.5 liters. An asthma attack would also increase the resistance to air flow from the lungs, making it unlikely that expiratory air flow rate could approach its maximum value at a given lung volume. Aspiration of meat into the trachea (choice B) would increase the resistance to air flow from the lungs, making it unlikely that the expiratory air flow rate could approach its maximum value. Normal breathing at rest (choice D) is represented by curve Z, as discussed above. The tidal volume should not increase greatly with pneumonia (choice E), and because the lungs are difficult to expand with pneumonia, the patient breathes at lower than normal lung volumes (the curve would be shifted to the left on the diagram).

 An inexperienced resident physician is asked to draw arterial blood gases from a patient with severe chronic obstructive pulmonary disease, who is not yet on oxygen therapy. The resident attempts to draw blood from the femoral artery at the groin, but actually draws blood from the femoral vein. When compared to the arterial sample that should have been obtained, this venous sample will show which of the following differences? p02 pC02 pH A. Decreased Increased Decreased B. Decreased Increased Increased C. Increased Decreased Decreased D. Increased Decreased Increased E. Increased Increased Increased

The correct answer is A. The tissues use oxygen, so venous blood has decreased p02 compared to arterial blood. The tissues produce C02, which makes carbonic acid, and thus causes the venous blood to be slightly more acidic (decreased pH) than arterial blood, although both values can still be within normal limits because of the effects of blood buffering. Arterial puncture for blood gas collection is considered sufficiently difficult that some hospitals only allow physicians to collect the blood. At other institutions, specially trained non-physician personnel may be allowed to do the blood collections. Remember that in the groin, the femoral vein lies medial to the femoral artery, and the femoral nerve lies lateral to the artery.

 An asymptomatic, 24-year-old African-American woman in her second trimester of pregnancy has the following laboratory findings:

Based

on the laboratory data, which of the following tests is necessary for further evaluation of this patient? A. B. C. D. E. Creatinine clearance Oral glucose tolerance test Serum ferritin Sickle cell preparation No further study is necessary

The correct answer is E. All of the laboratory data in this pregnant woman are normal, hence no further study is necessary. In a normal pregnancy, both the plasma volume and RBC mass are increased with a greater increase in the plasma volume than RBC mass (2:1 ratio). This has a dilutional effect on many laboratory tests. Increasing plasma volume in pregnancy increases the creatinine clearance (choice A) due to the expected elevation in the glomerular filtration rate (GFR). The reference intervals for serum blood urea nitrogen and creatinine are lower than normal, due to the dilutional effect of increased plasma volume and increased clearance of both analytes in the urine caused by the rise in the GFR. The threshold for glucose is reduced in pregnancy, so patients can have a positive dipstick test for glucose in the presence of a normal serum glucose. Therefore, an oral glucose tolerance test (choice B) is not indicated. The hemoglobin (Hb) concentration in pregnancy is normally decreased because of the dilutional effect of increased plasma volume. Since the Hb is normal (for a pregnant woman) in this patient, a serum ferritin (choice C) to rule out iron deficiency is unnecessary. Furthermore, iron deficiency is usually associated with a low MCV (microcytic anemia), and her MCV is normal. Although sickle disease is the most common genetic hemoglobinopathy among African Americans, the patient is not anemic, so there is no reason to order a sickle cell preparation (choice D).

 A healthy 20-year-old man deprived of water for several days has an arterial pressure of 118/78 mm Hg and a plasma concentration of antidiuretic hormone (ADH) 5 times above normal. Which of the following is the most likely explanation for the increase in ADH concentration? A. B. C. D. E. Decreased plasma aldosterone Decreased plasma renin activity Increased extracellular fluid volume Increased left atrial pressure Increased plasma osmolality

The correct answer is E. An obligatory loss of water from the body continues to occur even when a person is deprived of water. This loss of water from the body tends to concentrate the extracellular fluid, causing it to become hypertonic. Both the decrease in extracellular fluid (compare with choice C) and the increase in osmolarity act as stimuli for increased thirst and increased secretion of ADH. The decrease in extracellular fluid volume also tends to decrease arterial pressure, which in turn increases plasma renin activity (compare with choice B) as well as aldosterone levels in the plasma (compare with choice A). Water deprivation tends to decrease left atrial pressure (compare with choice D).

 A 72-year-old woman with insomnia participates in a sleep study. As part of the study protocol, she has EEG leads attached, then goes to sleep. At one point during the evening, 12-16 Hz sleep spindles and Kcomplexes are observed. Which of the following stages of sleep is associated with this pattern? A. B. C. D. E. REM Stage 1 Stage 2 Stage 3 Stage 4

The correct answer is C. Stage 2 has more theta waves than stage 1 and is associated with sleep spindles (short bursts of 1216 Hz activity) and K-complexes (high amplitude slow waves with superposed sleep spindles) on the electroencephalogram Transient large amplitude potentials in the occipital areas (pontogeniculo-occipital [PGO] spikes) are associated with REM sleep (choice A). Stage 1 (choice B), or drowsiness, is characterized by the attenuation of alpha rhythm (8-13 Hz) and the appearance of 4-7Hz theta waves. Stages 3 (choice D) and 4 (choice E), or slow wave sleep, are characterized by high amplitude slow waves, especially in the delta (< 4 Hz) frequency range.

 A patient develops a form of lung cancer that spreads to occlude the thoracic duct. Edema involving which of the following sites might be expected as a potential complication? A. B. C. D. E. Entire left side and right leg Entire right side and left leg Left arm only Right arm and right half of head only Right arm only

The correct answer is A. The right lymphatic duct drains the right arm, the right side of the chest, and the right side of the head. The thoracic duct drains the rest of the body. Both the right lymphatic duct and the thoracic duct dump into the large venous channels at the base of the neck. Occlusion of this drainage can produce intractable edema in sites feeding these ducts. The left side and right leg would be affected, rather than the right side and left leg (choice B). The entire left side (rather than just the left arm, choice C) and right leg drain into the thoracic duct. The right arm and the right half of the head (choices D and E) drain to the right lymphatic duct.

 A human subject takes part in a nutritional research study. After ingesting a very fatty meal, serum samples are taken for research studies at 1 hour and 3 hours. These studies measure the average diameter of the chylomicrons, showing an average chylomicron diameter of 500 nm at 1 hour, which drops to an average diameter of 150 nm at 3 hours. Where is the enzyme responsible for this change located? A. B. C. D. E. Adipocytes Endothelial cells Enterocytes Hepatocytes Myocytes

The correct answer is B. Chylomicrons are produced by enterocytes (intestinal epithelial cells), using gut luminal triglycerides for the source of the lipid. The chylomicrons are secreted into the gut lymphatic system, and from there drain eventually into the systemic venous system from the thoracic duct, and hence into the serum portion of the blood. They are initially large and have a very high triglyceride content. With time, lipoprotein lipase releases triglycerides from the chylomicron core by hydrolyzing them to more easily absorbed fatty acids. The enzyme is located on the external surface of the vascular endothelium of tissues with triglyceride needs such as skeletal muscle, cardiac muscle tissue, and lactating breast. The result of lipoprotein lipase activity is that the chylomicrons shrink in size. While adipose tissue can utilize chylomicrons, lipoprotein lipase is located on the endothelial cells rather than adipocytes (choice A). Adipocytes have an adipose tissue lipase, which is an intracellular enzyme that can cleave triglycerides to glycerol and fatty acids, allowing them to be released into the circulation when chylomicrons are low. Enterocytes (choice C) have the ability to pick up mixed micelles from the gut lumen for repackaging in the smooth endoplasmic reticulum as chylomicrons. Hepatocytes (choice D) pick up the chylomicron remnants after the lipoprotein lipase shrinks them. Myocytes (choice E) are not involved in chylomicron metabolism.

 A patient with a pheochromocytoma is secreting large amounts of norepinephrine into the blood stream. In a normal individual, this compound is usually released from the adrenal medulla in response to which of the following? A. B. C. D. E. Acetylcholine Epinephrine Metanephrine Normetanephrine Vanillylmandelic acid

The correct answer is A.In the normal individual, release of the catecholamine norepinephrine is under neuroendocrine control, with acetylcholine serving as the local neurotransmitter that triggers its release. This normal control is disrupted in patients with pheochromocytoma. The catecholamine epinephrine (choice B) is also secreted by the adrenal medulla, but does not regulate norepinephrine secretion. Metanephrine (choice C), normetanephrine (choice D), and vanillylmandelic acid (choice E) are all catecholamine degradative products that may become elevated if catecholamine production is increased by a pheochromocytoma.

 A healthy, 25-year-old female medical student has an exercise stress test at a local health club. Which of the following is most likely to occur in this woman's skeletal muscles during exercise? A. B. C. D. E. Decreased blood flow Decreased metabolite concentrations Increased arteriolar diameter Increased oxygen concentration Increased vascular resistance

The correct answer is C. Blood flow can increase as much as 20-fold in exercising skeletal muscle, which is a greater increase than in any other tissue in the body. This tremendous increase in blood flow results almost entirely from the actions of local vasodilator substances on the muscle arterioles. During exercise, the muscles use oxygen more rapidly than it can be delivered by the blood, which decreases the oxygen concentration (choice D) in the tissues. The oxygen deficiency causes vasodilator metabolites (choice B) such as adenosine, carbon dioxide, lactic acid, and others to accumulate in the tissues. The vasodilator metabolites acting on the arterioles lead to a reduction in vascular resistance (choice E) and an increase in blood flow (choice A).

 A healthy, 37-year-old, recently divorced woman loses her job at the auto factory. She picks up her three young children from the factory day care center and gets into an automobile accident on the way home. Her 5-year-old son, who was not wearing a seat belt, sustains a severe head injury. The woman was not hurt in the accident, but is hyperventilating as she sits in the waiting room at the hospital. She complains of feeling faint and has blurred vision. Which of the following is decreased in this woman? A. B. C. D. E. Arterial oxygen content Arterial oxygen tension (PO2) Arterial pH Cerebral blood flow Cerebrovascular resistance

The correct answer is D. The key symptom is hyperventilation. Hyperventilation results in hypocapnia, alkalosis, increased cerebrovascular resistance, and decreased cerebral blood flow. Carbon dioxide plays an important role in the control of cerebral blood flow. An increase in arterial PCO2 dilates blood vessels in the brain and a decrease in PCO2 causes vasoconstriction. The anxious, hyperventilating woman is "blowing off" carbon dioxide, which lowers her arterial PCO2. This decrease in PCO2 has caused the cerebrovascular resistance (choice E) to increase, thereby decreasing cerebral blood flow. The decrease in cerebral blood flow has caused the woman to feel faint and to have blurred vision. Other symptoms commonly associated with the hyperventilation of anxiety states are feelings of tightness in the chest and a sense of suffocation. Hyperventilation increases the arterial oxygen content (choice A) and PO2(choice B) in a normal person. A decrease in arterial PCO2 causes the arterial pH (choice C) to increase, i.e., the patient becomes alkalotic.

 A healthy 22-year-old female medical student with normal kidneys decreases her sodium intake by 50% for a period of 2 months. Which of the following parameters is expected to increase in response to the reduction in sodium intake? A. B. C. D. E. Arterial pressure Atrial natriuretic peptide release Extracellular fluid volume Renin release Sodium excretion

The correct answer is D. A reduction in sodium intake leads to a decrease in extracellular fluid volume (choice C) and therefore a decrease in arterial pressure (choice A). The decrease in arterial pressure stimulates renin release, which in turn leads to an increase in the formation of angiotensin II. The angiotensin II increases the renal retention of salt and water (ie, decreases sodium excretion, choice E), which returns the extracellular fluid volume nearly back to normal. Atrial natriuretic peptide (choice B) is released from the two atria of the heart as a result of an increase in the extracellular fluid volume. Therefore, a decrease in sodium intake would tend to decrease the release of atrial natriuretic peptide.

 A 65-year-old male visits his family practitioner for a yearly examination. Measurement of his blood pressure reveals a systolic pressure of 190 mm Hg and a diastolic pressure of 100 mm Hg. His heart rate is 74/min and pulse pressure is 90 mm Hg. A decrease in which of the following is the most likely explanation for the high pulse pressure? A. B. C. D. E. Arterial compliance Cardiac output Myocardial contractility Stroke volume Total peripheral resistance

The correct answer is A. A decrease in arterial compliance indicates that the arterial wall is stiffer (i.e., less distensible). When the compliance of the arterial system decreases, the rise in arterial pressure becomes greater for a given stroke volume pumped into the arteries. In the normal young adult, the systolic blood pressure is about 120 mm Hg and the diastolic blood pressure is about 80 mm Hg. Because the pulse pressure is the difference between the systolic and diastolic blood pressures, the normal pulse pressure is about 40 mm Hg in a healthy young adult. However, in older adults the pulse pressure sometimes increases as much as two times normal because the arteries become hardened by arteriosclerosis. The cardiac output (choice B) itself has no direct effect on the pulse pressure; however, if a decrease in cardiac output is associated with a decrease in stroke volume, the pulse pressure would be expected to decrease. A decrease in myocardial contractility (choice C) would be expected to decrease stroke volume, and therefore cause the pulse pressure to decrease. A decrease in stroke volume (choice D) causes the pulse pressure to decrease because a smaller amount of blood enters the arterial system with each heartbeat, and the rise and fall of pressure during systole and diastole is decreased. A decrease in total peripheral resistance (choice E), i.e., vasodilation, does not have a significant effect on the pulse pressure of the major arteries under normal conditions.

 A research physiologist is performing an experiment in which he stimulates sympathetic cholinergic neurons. Which of the following responses is expected? A. B. C. D. E. Bradycardia Bronchoconstriction Diaphoresis Increased gastrointestinal motility Increased peripheral vascular resistance

The correct answer is C. The vast majority of sweat glands in the body are innervated by sympathetic cholinergic neurons. Sympathetic cholinergic neurons are sympathetic postganglionic neurons that happen to release acetylcholine instead of norepinephrine. Bradycardia (choice A), bronchoconstriction (choice B), and increased gastrointestinal motility (choice D) would all result from stimulating parasympathetic cholinergic neurons. Increased peripheral vascular resistance (choice E) would result from stimulating sympathetic adrenergic neurons.

 A patient's airway pressure is being measured while he is breathing into a spirometer. Which of the following lung volumes would be associated with an airway pressure of +30 cm H2O? A. B. C. D. E. Functional residual capacity Minimal volume Residual volume Tidal volume Total lung capacity

The correct answer is E. For this question, you need not worry about the actual value of the airway pressure. There is only one listed answer that would produce a positive airway pressure, and that is total lung capacity. To measure the airway pressure, a patient inspires or expires from a spirometer, and then relaxes while his airway pressure is measured. It is easy to determine whether the airway pressure would be negative or positive by practicing on yourself. Inhale to total lung capacity and relax. You will feel the sensation of wanting to blow air out--this creates a positive pressure in your airways. Any volume above functional residual capacity (FRC) will create a positive airway pressure, and any volume below FRC will create a negative airway pressure. The functional residual capacity (choice A) is the volume of air that remains in the lung after a normal expiration. The FRC is the equilibrium volume when the elastic recoil of the lungs is balanced by the tendency of the chest to spring out. Because this is the volume when the patient is "at rest," the airway pressure is zero. Breathe out normally (to reach FRC) and notice that there is no pressure in your airways. Minimal volume (choice B) can only be achieved with an excised lung. It is the volume of air remaining in an excised lung that is maximally deflated. It is smaller than the residual volume because the chest wall is not there to help draw the lung open. The residual volume (choice C) is the volume of air remaining in the lungs after maximal expiration. At volumes less than FRC, like residual volume, the airway pressure would be less than 0 cm H2O. Exhale all the way (to residual volume), and relax--you will feel the sensation of wanting to draw air in--this creates a negative pressure in your airways (like a vacuum). Tidal volume (choice D) is the volume of air that is inhaled or exhaled with each normal breath.

 A surgeon performs an exploratory laparotomy, producing a large incision in the patient's abdomen. Poor blood supply to which of the following is most likely to cause problems during the healing process? A. B. C. D. E. Adipose tissue Aponeuroses Loose connective tissue Muscle Skin

The correct answer is A. Surgeons worry about their obese patients more than their skinny ones, because a thick layer of relatively poorly vascularized subcutaneous fatty tissue is both mechanically unstable (it holds stitches poorly) and heals very slowly. These patients have a frequent rate of dehiscence (tearing open of the incisional site) with subsequent, difficult-tocontrol infection (access by antibiotics, leukocytes, and serum antibodies are all hampered by the poor blood supply). Aponeuroses (choice B) are strong thickenings of muscle sheath that usually suture and heal well after surgery. Loose connective tissue (choice C) is well vascularized and surgeons do not usually worry much about it during the healing process. Muscle (choice D) usually heals well after surgery. Skin (choice E) usually heals well, unless it becomes infected.

 A pulmonologist is testing a patient's lung volumes and capacities using simple spirometry. Which of the following lung volumes or capacities cannot be measured directly using this technique? A. B. C. D. E. Expiratory reserve volume Functional residual capacity Inspiratory reserve volume Tidal volume Vital capacity

The correct answer is B. The functional residual capacity is the amount of air left in the lungs after a normal expiration. Because this volume cannot be expired in its entirety, it cannot be measured by spirometry. Essentially, lung volume that contains the residual volume, which is the amount of air remaining after maximal expiration (e.g., functional residual capacity and total lung capacity), cannot be measured by spirometry. These volumes can be determined using helium dilution techniques coupled with spirometry or body plethysmography. The expiratory reserve volume (choice A) is the volume of air that can be expired after expiration of a tidal volume. The inspiratory reserve volume (choice C) is the volume of air that can be inspired after inspiration of a tidal volume. Tidal volume (choice D) is the amount of air inspired or expired with each normal breath. Vital capacity (choice E) is the volume of air expired after a maximal inspiration.

 In the transition from a Graafian follicle to a functional corpus luteum, which of the following cellular events occurs? A. B. C. D. E. Granulosa cells begin to express aromatase Granulosa cells begin to express FSH receptors Granulosa cells begin to express LH receptors Theca cells begin to express LH receptors Theca cells begin to express side-chain cleavage enzyme

The correct answer is C. The secretion of estrogen by the developing follicle can best be explained using the "two cell" hypothesis. Theca cells are stimulated by LH (theca cells express LH receptors prior to formation of the corpus luteum, choice D) to secrete the androgens androstenedione and testosterone. The androgens then diffuse into the granulosa cells, where they are aromatized to estrogens. Hence, theca cells express side-chain cleavage enzyme (first step in steroidogenesis) prior to the formation of the corpus luteum (choice E). FSH stimulates aromatase activity in the granulosa cells (receptors for FSH and aromatase enzyme are present prior to the formation of the corpus luteum, choices A and B). The granulosa cells apparently have the ability to produce steroids (progesterone), but lack 17-hydroxylase activity and cannot synthesize estrogen themselves. Only as the follicle approaches ovulation do LH receptors begin to be expressed by the granulosa cells. Estrogen and FSH probably are responsible for the change. After ovulation, the scar of the follicle undergoes luteinization. The theca cells decrease 17-hydroxylase activity and secrete more progesterone. The granulosa cells decrease aromatase activity and also secrete more progesterone.