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USMLE WORLD STEP 1

PHYSIOLOGY
Question List
Physiology Q No: 1 Renal Physiology Q No:
4
3 Cardiology
Physiology Q No: 2 Renal Physiology Q No:
4
4 Neurology
Physiology Q No: 3 Pulmonology Physiology Q No:
4
5 Musculoskeletal
Physiology Q No: 4 Blood vessels Physiology Q No:
4
6 Pulmonology
Physiology Q No: 5 Neurology Physiology Q No:
4
7 Cardiology
Physiology Q No: 6 Pulmonology Physiology Q No:
4
8 Cardiology
Physiology Q No: 7 Musculoskeletal Physiology Q No:
4
9 Pulmonology
Physiology Q No: 8 Cardiology Physiology Q No:
5
0 Cardiology
Physiology Q No: 9 Cardiology Physiology Q No:
5
1 Cardiology
Physiology Q No:
1
0 Cardiology Physiology Q No:
5
2 Renal
Physiology Q No:
1
1 Pulmonology Physiology Q No:
5
3 Pulmonology
Physiology Q No:
1
2 Pulmonology Physiology Q No:
5
4 Renal
Physiology Q No:
1
3 Cardiology Physiology Q No:
5
5 Pulmonology
Physiology Q No:
1
4 Gastrointestinal system Physiology Q No:
5
6 Blood vessels
Physiology Q No:
1
5 Pulmonology Physiology Q No:
5
7 Pulmonology
Physiology Q No:
1
6 Renal Physiology Q No:
5
8 Pulmonology
Physiology Q No:
1
7 Endocrinology Physiology Q No:
5
9 Renal
Physiology Q No:
1
8 Neurology Physiology Q No:
6
0 Endocrinology
Physiology Q No:
1
9 Cardiology Physiology Q No:
6
1 Neurology
Physiology Q No:
2
0 Musculoskeletal Physiology Q No:
6
2 Pulmonology
Physiology Q No:
2
1 Pulmonology Physiology Q No:
6
3 Cardiology
Physiology Q No:
2
2 Renal Physiology Q No:
6
4 Endocrinology
Physiology Q No:
2
3 Renal Physiology Q No:
6
5 Endocrinology
Physiology Q No:
2
4 Cardiology Physiology Q No:
6
6 Dermatology
Physiology Q No:
2
5 Endocrinology Physiology Q No:
6
7 Endocrinology
Physiology Q No:
2
6 Pulmonology Physiology Q No:
6
8 Gastrointestinal system
Physiology Q No:
2
7 Pulmonology Physiology Q No:
6
9 Musculoskeletal
Physiology Q No:
2
8 Renal Physiology Q No:
7
0 Gastrointestinal system
Physiology Q No:
2
9 Pulmonology Physiology Q No:
7
1 Endocrinology
1
USMLE WORLD STEP 1
PHYSIOLOGY
Physiology Q No:
3
0 Cardiology Physiology Q No:
7
2 Cardiology
Physiology Q No:
3
1 Gastrointestinal system Physiology Q No:
7
3 Endocrinology
Physiology Q No:
3
2 Pulmonology Physiology Q No:
7
4 Musculoskeletal
Physiology Q No:
3
3 Cardiology Physiology Q No:
7
5 Renal
Physiology Q No:
3
4 Pulmonology Physiology Q No:
7
6 Musculoskeletal
Physiology Q No:
3
5 Renal Physiology Q No:
7
7 Blood vessels
Physiology Q No:
3
6 Endocrinology Physiology Q No:
7
8 Pulmonology
Physiology Q No:
3
7 Cardiology Physiology Q No:
7
9 Pulmonology
Physiology Q No:
3
8 Renal Physiology Q No:
8
0 Hematology
Physiology Q No:
3
9 Neurology Physiology Q No:
8
1 Endocrinology
Physiology Q No:
4
0 Renal Physiology Q No:
8
2 Pulmonology
Physiology Q No:
4
1 Pulmonology Physiology Q No:
8
3 Hematology
Physiology Q No:
4
2 Musculoskeletal Physiology Q No:
8
4 Cardiology
2
USMLE WORLD STEP 1
PHYSIOLOGY
Physiology Q No: 85 Renal Physiology Q No: 108 Renal
Physiology Q No: 86 Blood vessels Physiology Q No: 109 Renal
Physiology Q No: 87 Endocrinology Physiology Q No: 110 Pulmonology
Physiology Q No: 88 Endocrinology Physiology Q No: 111 Gastrointestinal system
Physiology Q No: 89 Cardiology Physiology Q No: 112 Hematology
Physiology Q No: 90 Renal Physiology Q No: 113 Pulmonology
Physiology Q No: 91 Neurology Physiology Q No: 114 Gastrointestinal system
Physiology Q No: 92 Endocrinology Physiology Q No: 115 Pulmonology
Physiology Q No: 93 Pulmonology Physiology Q No: 116 Pulmonology
Physiology Q No: 94 Endocrinology Physiology Q No: 117 Cardiology
Physiology Q No: 95 Reproductive system Physiology Q No: 118 Cardiology
Physiology Q No: 96 Endocrinology Physiology Q No: 119 Renal
Physiology Q No: 97 Cardiology Physiology Q No: 120 Cardiology
Physiology Q No: 98 Pulmonology Physiology Q No: 121 Endocrinology
Physiology Q No: 99 Endocrinology Physiology Q No: 122 Cardiology
Physiology Q No: 100 Cardiology Physiology Q No: 123 Pulmonology
Physiology Q No: 101 Renal Physiology Q No: 124 Cardiology
Physiology Q No: 102 Musculoskeletal Physiology Q No: 125 Musculoskeletal
Physiology Q No: 103 Renal Physiology Q No: 126 Musculoskeletal
Physiology Q No: 104 Renal Physiology Q No: 127 Endocrinology
Physiology Q No: 105 Genitourinary Physiology Q No: 128 Pulmonology
Physiology Q No: 106 Hematology Physiology Q No: 129 Renal
Physiology Q No: 107 Renal Physiology Q No: 130 Gastrointestinal system
3
USMLE WORLD STEP 1
PHYSIOLOGY
A.
Proximal collecting t!le !r"# !or$er en%&me acti'it&
(. Intracelllar )roximal collecting t!le #&$rogen ion generation
*. +a,R,-* cotran")ort in t#e t#ic. a"cen$ing lim!
D. H&$rogen ion "ecretion /rom t#e intercalate$ cell" o/ t#e collecting t!le"
E. Urea rea!"or)tion in t#e collecting t!le"
Explanation:
Al$o"terone i" a mineralocorticoi$ #ormone "&nt#e"i%e$ an$ relea"e$ !& t#e %ona
glomerlo"a cell" o/ t#e a$renal cortex. Al$o"terone relea"e i" "timlate$ !&
angioten"in II0 #ig# "erm )ota""im ion concentration"0 an$ 1to a "mall $egree2
A*TH.
Al$o"terone i" a com)onent o/ t#e renin,angioten"in,al$o"terone "&"tem0 3#ic# i"
normall& acti'ate$ in time" o/ lo3 !loo$ )re""re0 lo3 'i"ceral )er/"ion an$ lo3
)la"ma 'olme. Al$o"terone increa"e" "o$im an$ 3ater rea!"or)tion in t#e
collecting $ct" o/ t#e ne)#ron0 t#" increa"ing circlating 'olme. A "teroi$
#ormone al$o"terone cro""e" t#e cell mem!rane $irectl&0 !in$" a c&to"olic )rotein
rece)tor an$ "!"e4entl& mo'e" into t#e ncle" to mo$i/& gene ex)re""ion. It"
net e//ect i" to increa"e t#e nm!er o/ +a56,ATPa"e )rotein" an$ "o$im c#annel" in
t#e cell mem!rane" o/ t#e .i$ne&7" cortical collecting $ct". Un$er t#e in/lence o/
al$o"terone0 "o$im an$ 3ater are remo'e$ /rom t#e t!lar /li$ acti'el& an$
)a""i'el&0 re")ecti'el&. A" a con"e4ence0 )ota""im an$ #&$rogen ion" are lo"t into
t#e t!lar /li$. T#"0 al$o"terone )romote" )ota""im ion an$ #&$rogen ion
"ecretion /rom t#e intercalate$ cell" o/ t#e renal collecting t!le".
1*#oice A2 T#e !r"# !or$er en%&me acti'it& o/ t#e )roximal collecting t!le" i"
re")on"i!le /or rea!"or!ing o/ -58 o/ t#e "o$im an$ 3ater /iltere$ /rom t#e
4
Q NO 1: A ne3 agent #a" !een "#o3n to !loc. al$o"terone7" interaction 3it# it"
rece)tor". W#ic# o/ t#e /ollo3ing i" mo"t li.el& to !e $ecrea"e$ !& t#e acti'it& o/
t#i" ne3 $rg9
USMLE WORLD STEP 1
PHYSIOLOGY
glomerlar ca)illarie" into (o3man7" ca)"le. T#e"e en%&me" are al"o re")on"i!le
/or rea!"or!ing /iltere$ glco"e0 amino aci$"0 )#o")#ate an$ lactate !& cotran")ort
3it# "o$im.
1*#oice (2 Intracelllar #&$rogen ion generation in t#e )roximal collecting t!le
occr" !& t#e action o/ car!onic an#&$ra"e. *ar!onic an#&$ra"e "&nt#e"i%e" H*O
an$ H /rom *O- an$ H-: 3it#in t#e cell" o/ t#e earl& )roximal t!le. T#e H*O i"
tran")orte$ into t#e !loo$ an$ t#e H i" tran")orte$ into t#e t!lar /li$ in exc#ange
/or "o$im. *ar!onic an#&$ra"e in#i!itor $rg" li.e aceta%olami$e in#i!it t#i"
en%&me. T#e"e $rg" are "e$ a" $iretic" an$ in t#e treatment o/ montain
"ic.ne"".
1*#oice *2 +a,R,-*1 cotran")ort in t#e t#ic. a"cen$ing lim! i" t#e target o/ t#e
)otent cla"" o/ $iretic" .no3n a" loo) $iretic" 1e.g. /ro"emi$e0 et#acr&nic aci$2.
T#e"e agent" $ecrea"e t#e acti'it& o/ t#e +a,6,-*1 cotran")orter lea$ing to
)ota""im lo"" an$ $ire"i".
1*#oice E2 ADH 1'a"o)re""in2 increa"e" rea rea!"or)tion in t#e collecting t!le"
!& contri!ting to t#e /ormation o/ t#e cortico )a)illar& renal inter"titial o"motic
gra$ient.
E$cational O!;ecti'e<
Al$o"terone i" a com)onent o/ t#e renin,angioten"in,al$o"terone "&"tem t#at act"
on t#e intercalate$ cell" o/ t#e renal collecting t!le" to ca"e re"or)tion o/ "o$im
an$ 3ater an$ lo"" o/ )ota""im an$ #&$rogen ion".
5
USMLE WORLD STEP 1
PHYSIOLOGY

A. Urea0 !icar!onate
(. Inlin0 PAH
*. Pota""im c#lori$e
D. Inlin0 "o$im
E. (icar!onate0 "o$im
Explanation:
T#e t!lar /li$ )la"ma ltra /iltrate 'ale in t#e gra)# a!o'e i" calclate$ !&
ta.ing t#e t!lar /li$ concentration o/ a gi'en "!"tance in t#e )roximal t!le
an$ $i'i$ing t#at 'ale !& t#e initial concentration o/ t#at "!"tance 3it#in
(o3man7" ca)"le. T#"0 an )3ar$ 1)o"iti'e2 "lo)e in$icate" an increa"ing
concentration o/ t#at "!"tance a" /li$ mo'e" to3ar$ $i"tal )art" o/ t#e t!le
3#ic# i" "all& t#e re"lt o/ "ecretion or non,rea!"or)tion o/ t#at "!"tance. A
$o3n3ar$ "lo)e in$icate" re"or)tion o/ t#at "!"tance in t#e )roximal t!le.
Line on t#e a!o'e gra)# in$icate" a "!"tance 3it# a ra)i$l& increa"ing
concentration in t#e t!lar /li$. S!"tance" t#at !e#a'e in t#i" /a"#ion are /reel&
6
Q NO 2: T!lar /li$5)la"ma ltra/iltrate concentration ratio" /or "e'eral
"!"tance" are "#o3n on t#e "li$e !elo3. W#ic# o/ t#e /ollo3ing "!"tance" are
mo"t li.el& to )ro$ce cr'e" - an$ =0 re")ecti'el&9
USMLE WORLD STEP 1
PHYSIOLOGY
/iltere$ /rom t#e glomerlar ca)illarie" an$ are )oorl& rea!"or!e$ /rom t#e )roximal
t!le. (eca"e 3ater i" rea!"or!e$ /a"ter t#an t#e"e "!"tance"0 t#eir
concentration in t#e )roximal t!le increa"e". *#emical" t#at !e#a'e in t#i"
manner incl$e creatinine0 inlin0 an$ )ara,amino#i))ric aci$ 1PAH2.
Line - i" in$icati'e o/ t#e !e#a'ior o/ rea in t#e )roximal t!lar /li$. Urea i"
/reel& /iltere$ /rom t#e glomerlar ca)illarie" an$ i" )oorl& rea!"or!e$ /rom t#e
)roximal t!le0 !t le"" "o t#an PAH or inlin. Urea i" ltimatel& "ecrete$ in 'eri
#ig# concentration"0 a" i" it a 3a"te )ro$ct o/ meta!oli"m.
Line 8 in$icate" no concentration c#ange along t#e )roximal t!le. T#i" line col$
re)re"ent t#e o"molalit& o/ t#e t!lar /li$ in t#i" "egment0 a" 3ell a" t#e "o$im
or )ota""im concentration> "o$im an$ )ota""im are rea!"or!e$ in concentration"
e4al 3it# 3ater in t#e )roximal t!le.
Line = re)re"ent" t#e !e#a'ior o/ !icar!onate in t#e )roximal t!le. (icar!onate i"
rea!"or!e$ in t#e )roximal t!le $e to t#e acti'it& o/ car!onic an#&$ra"e 3it#in
)roximal t!lar cell". T#i" rea!"or!ing /orce ca"e" t#e concentration o/
!icar!onate to $ecrea"e a" /li$ rn" along t#e )roximal t!le.
Line ? in$icate" "olte" t#at are a'i$l& rea!"or!e$ in t#e )roximal t!le. Mo"t
nota!l&0 t#e"e incl$e glco"e an$ amino aci$".
T#"0 line" - an$ = re)re"ent t#e !e#a'ior o/ rea an$ !icar!onate0 re")ecti'el&0 in
t#e )roximal t!le.
E$cational O!;ecti'e<
T#e concentration" o/ PAHI creatinine0 inlin0 an$ rea increa"e a" /li$ rn" along
t#e )roximal t!le0 3#ile t#e concentration" o/ !icar!onate0 glco"e0 an$ amino
aci$" $ecrea"e.
7
USMLE WORLD STEP 1
PHYSIOLOGY
A.
Lng com)liance
(. PAO-,P@O- $i//erence
*. Ti""e ::- )ro$ction
D. Lng $i//"ing ca)acit&
E. Le/t,to,rig#t car$iac "#nting
A. Mixe$ 'eno" !loo$ ox&gen content
Explanation:
T#e al'eolar,arterial ox&gen gra$ient 1A,a gra$ient2 i" t#e $i//erence !et3een t#e
)artial )re""re o/ ox&gen in t#e al'eoli an$ t#e )artial )re""re o/ ox&gen in t#e
arterial !loo$. *alclating t#i" 'ale #el)" to $etermine t#e ca"e o/ #&)oxemia.
A,a gra$ient B PAO- , Pa:-
P=:- i" t#e )artial )re""re o/ ox&gen in t#e al'eolar air. T#i" 'ale i" calclate$
"ing t#e al'eolar ga" e4ation<
P=O- B CAiO- x 1P , , 1Pa*O- 5 R2
Ai:- B Araction o/ in")ire$ air t#at i" ox&gen 1normal B :.-1 at "eal le'el2
R B T#e ratio o/ car!on $ioxi$e )ro$ction to ox&gen con"m)tion 1normal B :.@2
P( B (arometric )re""re 1normal B DE: mm Hg at "ea le'el2
P B Water 'a)or )re""re 1normal B =D mm Hg at "ea le'el2
T#i" e4ation can !e "im)li/ie$ !& in"erting t#e normal 'ale" at "ea le'el<
PAO- B 1?: , 1Pa*O- 1:.@2
In a #ealt#& in$i'i$al at "ea le'el0 t#e PAO- i" normall& a!ot 1:: mmHg.
Pa:- i" t#e )artial )re""re o/ ox&gen in t#e arterial !loo$. It i" a mea"re$ 'ale
$etermine$ 3it# an arterial !loo$ ga" anal&"i". In a #ealt#& in$i'i$al0 Pa:-F G-
mmHg. +ormall&0 t#e A,a gra$ient $oe" not excee$ 1:,1? mmHg.
U"ing t#e 'ale" )ro'i$e$ in t#e 4e"tion t#e PAO-/ort#i" )atient i" 1:E.-?mm Hg
an$ t#e PaO-i" gi'en a" D:mm Hg. T#"0 t#e A,a gra$ient i" 8E.-? mmHg. T#i"
'ale i" mc# #ig#er t#an normal.
1*#oice A2 Lng com)liance i" generall& increa"e$ in )atient" 3it# em)#&"ema.
1*#oice *2 Ti""e *O- )ro$ction i" increa"e$ 3#en t#e rate o/ celllar meta!oli"m
i" ele'ate$0 e.g. $ring exerci"e.
1*#oice D2 T#e $i//"ion ca)acit& o/ t#e lng" i" $ecrea"e$ in con$ition" 3#ere t#e
al'eolar 3all" are t#ic.ene$0 a" in )lmonar& /i!ro"i" an$ #&aline mem!rane
$i"ea"e.
1*#oice E2 Le/t,to,rig#t "#nting o/ !loo$ occr" 3it# a )atent $ct" arterio""0
atrial "e)tal $e/ect or 'entriclar "e)tal $e/ect.
1*#oice A2 T#e mixe$ 'eno" !loo$ ox&gen content i" increa"e$ in con$ition" 3#ere
a!normal #emoglo!in !in$" 3it# greater a'i$it& to ox&gen )re'enting nloa$ing o/
ox&gen in t#e ti""e" or in con$ition" 3#ere oxi$ati'e meta!oli"m i" in#i!ite$ "c#
a" in c&ani$e toxicit&.
E$cational O!;ecti'e<
Determining t#e $i//erence !et3een t#e al'eolar an$ arterial P:- 1A,a gra$ient2 can
#el) $etermine t#e ca"e o/ #&)oxemia. T#e arterial P:- i" mea"re$ 3it# an
arterial !loo$ ga" anal&"i"0 an$ t#e al'eolar P:- i" $etermine$ "ing t#e al'eolar ga"
e4ation.
8
Q NO 3: A 8=,&ear,ol$ male li'ing on t#e coa"t "//er" /rom mil$ $&")nea. Hi"
arterial !loo$ i" $ra3n an$ "#o3" a Pa:- o/ D: mmHg an$ a Pa*O- o/ 8?
mmHg. W#ic# o/ t#e /ollo3ing i" increa"e$ in t#i" )atient9
USMLE WORLD STEP 1
PHYSIOLOGY
W#ic# o/ t#e /ollo3ing !e"t ex)lain" t#e $i//erence in t#e "#a)e o/ t#e cr'e"9
A. *oncentration $i//erence acro"" t#e mem!rane
(. Di//"ion area
*. Mem!rane t#ic.ne""
D. Oil53ater )artition coe//icient
E. Protein carrier
Explanation:
T#e image a!o'e ill"trate" t#e $i//erence !et3een t#e rate o/ tran")ort o/ "olte
acro"" t#e cell mem!rane in "im)le $i//"ion 1line -2 an$ carrier,me$iate$ tran")ort
1line 12. T#e $i//erence in t#e "#a)e o/ t#e gra)#" i" ex)laine$ !& t#e )re"ence o/ a
carrier )rotein in t#e "cenario re)re"ente$ !& line 1.
T#ere are t3o t&)e" o/ $i//"ion<
1. Sim)le $i//"ion H molecle" mo'e t#rog# a mem!rane 3it#ot t#e #el) o/
carrier )rotein".
-. Aacilitate$ $i//"ion H re4ire" carrier )rotein".
*arrier )rotein" are t&)icall& tran"mem!rane )rotein" t#at )o""e"" !in$ing "ite" /or
t#e "!"trate t#e& tran")ort. T#e& !in$ extracelllar ion" an$ molecle" /orming a
carrier,"!"trate com)lex. (in$ing i" /ollo3e$ !& mo'ement o/ t#e com)lex acro""
t#e cell mem!rane to t#e intracelllar ")ace0 3#ere t#e "!"trate i" relea"e$ into t#e
c&to)la"m. (eca"e t#ere i" a /inite nm!er o/ carrier )rotein" in t#e cell mem!rane0
an$ t#e"e carrier )rotein" re4ire a $i"crete amont o/ time to )a"" a "ingle
molecle or ion t#rog# t#e mem!rane0 "atration i" an im)ortant )ro)ert& o/
carrier,me$iate$ $i//"ion 1/acilitate$ $i//"ion2. Once all o/ t#e carrier molecle" are
!on$ !& "!"trate. no /rt#er $i//"ion can occr ntil a carrier )rotein i" 'acate$.
T#i" maximm rate o/ tran")ort i" re/erre$ to a" t#e tran")ort maximm 1Tm2 an$ i"
"imilar in )rinci)le to t#e in "tan$ar$ en%&me .inetic".
1*#oice" AHD2 T#e ot#er /actor" mentione$ are not "igni/icantl& $i//erent !et3een
"im)le $i//"ion an$ /acilitate$ $i//"ion.
T#e $i//erence in t#e concentration o/ t#e "!"trate acro"" t#e mem!rane i" calle$
concentration gra$ient 1P2. T#e #ig#er t#e concentration gra$ient t#e #ig#er t#e rate
o/ tran")ort o/ t#e molecle or ion acro"" t#e mem!rane.
9
Q NO 4: T3o gra)#" ill"trating t#e tran")ort o/ lo3 moleclar 3eig#t "olte"
acro"" t#e )la"ma mem!rane are "#o3n on t#e "li$e !elo3.
USMLE WORLD STEP 1
PHYSIOLOGY
T#e larger t#e "r/ace area 1(A2 t#e greater t#e rate o/ $i//"ion. I/ t#e t#ic.ne"" o/
t#e mem!rane *T2 i" #ig#er 1eg0 lng /i!ro"i"2 t#en t#e rate o/ $i//"ion 3ol$ !e
"lo3er. Hig# moleclar 3eig#t 1MW2 com)on$" $i//"e "lo3l&.
A #ig# oil,3ater )artition coe//icient mean" t#at a "olte i" mc# more "ol!le in oil
t#an in 3ater. T#i" c#aracteri"tic i" 3i$el& "e$ to $e"cri!e t#e )#armaco.inetic
)ro)ertie" o/ general ane"t#etic".
E$cational O!;ecti'e<
*arrier,me$iate$ tran")ort incl$e" /acilitate$ $i//"ion an$ acti'e tran")ort.
Mo'ement o/ "!"trate acro"" t#e cell mem!rane !& t#e"e mec#ani"m" $e)en$" on
t#e )re"ence o/ carrier )rotein" in t#e mem!rane. Tran")ort mec#ani"m" tili%ing
)rotein" are a!le to !e "atrate$.
10
USMLE WORLD STEP 1
PHYSIOLOGY
A. T#re"#ol$
(. Tem)oral "mmation
*. S)acial "mmation
D. S)ace con"tant
E. *#lori$e c#annel $&"/nction
Explanation:
T#e ")ace con"tant i" a mea"re o/ #o3 /ar along an axon an electrical im)l"e 3ill
tra'el. A $ecrea"e in t#e ")ace con"tant re/lect" increa"e$ c#arge $i""i)ation along a
ner'e axon an$ 3ill re"lt in im)aire$ "timl" tran"mi""ion along an axon. T#e
)r)o"e o/ m&elin i" to increa"e t#e ")ace con"tant t#" $em&elination 3ill $ecrea"e
t#e ")ace con"tant an$ re"lt in ine//ecti'e "ignal tran"$ction. One can t#in. o/
m&elin a" in"lation aron$ a 3ire> t#e !etter in"late$ a 3ire0 t#e more e//ecti'e it"
tran"mi""ion o/ electrical c#arge".
Dem&elination $oe" not c#ange t#e ot#er )arameter" li"te$ in t#e 4e"tion.
T#re"#ol$ re/er" to t#e mem!rane )otential nee$e$ /or an action )otential to
$e'elo) 1*#oice A2. Tem)oral "mmation re/er" to "e4ential im)l"e" /rom t#e
"ame neron o'ertime 1*#oice (2 3#erea" ")atial "mmation re/er" to im)l"e"
/rom "e'eral $i//erent neron" 1*#oice *2.
1*#oice E2 *#lori$e c#annel $&"/nction i" t#e #allmar. o/ c&"tic /i!ro"i"0 not
mlti)le "clero"i".
E$cational O!;ecti'e<
T#e ")ace con"tant i" a mea"re o/ t#e a!ilit& o/ an im)l"e to tra'el $o3n an axon.
A lo3 ")ace con"tant $ecrea"e" t#e lengt# an im)l"e 3ill tra'el. Dem&elination
$ecrea"e" t#e ")ace con"tant an$ i" re")on"i!le /or "&m)tom" in mlti)le "clero"i".
11
Q NO 5: A -8,&ear,ol$ 3oman 3it# mlti)le "clero"i" ex)erience" $i)lo)ia $e to a
"mall area o/ axon $em&elination $etecta!le on a !rain MRI. A $ecrea"e in 3#ic# o/
t#e /ollo3ing i" mo"t li.el& re")on"i!le /or t#i" )atient7" "&m)tom"9
USMLE WORLD STEP 1
PHYSIOLOGY
A. *og# an$ "nee%ing
(. U))er air3a& tra))ing
*. Mcociliar& tran")ort
D. P#agoc&to"i"
E. Immnologic memor&
Explanation:
D"t )article" are con"tantl& !eing in#ale$ an$ cleare$ !& t#e re")irator& tract. T#e
clearance mec#ani"m" tili%e$ !& t#e lng 'ar& $e)en$ing on t#e "i%e o/ t#e
)article". Particle" 1:,1? )m in "i%e are tra))e$ in t#e ))er re")irator& tract.
Particle" -.?,1: )m in "i%e enter t#e trac#ea an$ !ronc#i an$ are cleare$ !&
mcociliar& tran")ort. T#e /ine"t )at $e" 1$iameter le"" t#an - Im2 reac# t#e
terminal !ronc#ioli an$ al'eoli an$ are )#agoc&ti%e$ !& macro)#age".
Al'eolar macro)#age" t#at ta.e ) $"t )article" !ecome acti'ate$ an$ relea"e a
nm!er o/ c&to.ine". Some o/ t#e"e c&to.ine" in$ce in;r& an$ in/lammation o/
al'eolar cell". Gro3t# /actor"0 incl$ing )latelet,$eri'e$ gro3t# /actor 1PDGA2 an$
in"lin,li.e gro3t# /actor 11SA20 are al"o relea"e$0 3#ic# "timlate /i!ro!la"t" to
)roli/erate an$ )ro$ce collagen. In/lammation 3it# "!"e4ent /i!ro"i" re"lt".
Pnemoconio"i" 1inter"titial lng /i!ro"i" "econ$ar& to in#alation o/ inorganic $"t2
ari"e" !& t#i" mec#ani"m.
1*#oice" A an$ (2 *og#ing0 "nee%ing0 an$ ))er air3a& tra))ing are mec#ani"m"
o/ clearing t#e large"t $"t )article".
1*#oice *2 Mcociliar& tran")ort i" t#e )rima mean" o/ eliminating me$im,"i%e$
)article".
1*#oice E2 D"t )article" $o not in$ce immnologic memor&.
E$cational O!;ecti'e<
D"t )article" "maller t#an -Im in "i%e reac# t#e al'eoli. T#e& are ta.en ) !&
macro)#age" an$ "timlate connecti'e ti""e gro3t#. T#e )nemoconio"e" are
$i"ea"e" t#at re"lt /rom t#e in#alation o/ /ine $"t )article".
12
Q NO 6: A =?,&ear,ol$ male #a" !een 3or.ing a" a coal miner /or t#e )a"t 1? &ear"
3#ere #e i" ex)o"e$ to in$"trial $"t. W#ic# o/ t#e /ollo3ing i" t#e )rima
)lmonar& $e/en"e mec#ani"m t#at clear" t#e re")irator" tract o/ $e)o"ite$ )article"
le"" t#an - Im in "i%e9
USMLE WORLD STEP 1
PHYSIOLOGY
E+aB JE:mK
E6B ,@:mK
E*lB ,D:mK
E*aB Jl-?mK
W#ic# o/ t#e /ollo3ing mo"t li.el& /orm" t#e re"ting mem!rane )otential o/ t#e cell9
A. Hig# )ota""im con$ctance an$ "ome "o$im con$ctance
(. Hig# c#lori$e con$ctance an$ "ome "o$im con$ctance
*. Hig# calcim con$ctance an$ "ome c#lori$e con$ctance
D. Hig# )ota""im con$ctance an$ "ome c#lori$e con$ctance
E. Hig# )ota""im con$ctance onl&
Explanation:
T#e re"ting )otential re/er" to t#e $i//erence in c#arge acro"" t#e cell mem!rane at
re"t 13#en t#ere i" no "ignaling acti'it&2. T#e mem!rane )re'ent" t#e /ree $i//"ion
o/ ion"0 an$ generall& t#ere i" an exce"" o/ )o"iti'e ion" ot"i$e t#e cell an$ an
exce"" o/ negati'e ion" in t#e c&to)la"m. T#i" "e)aration o/ )o"iti'e an$ negati'e
c#arge" acro"" t#e cell mem!rane gi'e" ri"e to an electrical )otential $i//erence t#at
range" /rom ,E: to ,@: mK> t#e t&)ical re"ting mem!rane )otential o/ a cell i" ,D:
mK.
T#e c&to)la"m o/ a t&)ical cell i" c#aracteri%e$ !& a lo3 concentration o/ +a an$ #ig#
concentration o/ 6. T#e extracelllar /li$ i" in'er"el& ric# in +a an$ lo3 in 6. T#i"
$i//erence in +a an$ 6 concentration i" maintaine$ !& t#e +a6,ATPa"e0 3#ic# )m)"
t#ree +a ion" ot o/ t#e cell /or e'er& - 6 ion" allo3e$ into t#e cell.
E'er& c#arge$ ion t#at t#e cell mem!rane i" )ermea!le attem)t" to )"# t#e re"ting
mem!rane )otential o/ t#e cell to3ar$ it" e4ili!rim )otential. T#e re"ting
mem!rane )otential can t#ere/ore !e 'ie3e$ a" a com!ination o/ t#e e4ili!rim
)otential" o/ t#e ion" t#at can )enetrate t#e cell mem!rane. Eac# )ermea!le ion
$oe" not contri!te e4all& to t#e mem!rane )otential< iti" o!'io" t#at t#e re"ting
mem!rane )otential $oe" not e4al t#e a'erage o/ t#e $i//erent e4ili!rim
)otential". T#e greater t#e )ermea!ilit& o/ a gi'en ion0 t#e greater it" contri!tion to
t#e re"ting mem!rane )otential 3ill !e. Ion" 3it# little )ermea!ilit& 3ill contri!te
'er& little to t#e re"ting mem!rane )otential. In t#e re"ting cell t#e )ermea!ilit& o/
t#e mem!rane /or 6 i" mc# #ig#er t#an t#at /or +a. Ot /lo3 o/ 6,ion" t#rog#
nongate$ c#annel" maintain" t#e negati'e c#arge in"i$e t#e mem!rane0 3#ic#
a))roac#e" t#e e4ili!rim )otential /or 6. T#ere are0 #o3e'er0 a "mall nm!er o/
c#annel" t#at allo3 t#e /lo3 o/ +a into t#e cell. T#i" "mall in/lx o/ +a ion" $ecrea"e"
t#e mem!rane )otential0 an$ /or t#i" rea"on t#e re"ting )otential o/ t#e mem!rane
i" al3a&" le"" negati'e t#an t#e e4ili!rim )otential /or 6 1*#oice A2.
1*#oice (2 I/ t#e c#lori$e e4ili!rim )otential i" ,D: mK an$ t#e re"ting mem!rane
)otential i" ,D: mK0 t#en c#lori$e 3ol$ nee$ to !e t#e onl& mem!rane )ermea!le
ion 3it# no contri!tion /rom ot#er ion". *#lori$e0 in realit&0 )la&" little role in t#e
$etermination o/ t#e mem!rane )otential.
1*#oice *2 Hig# calcim con$ctance 3ol$ ma.e t#e re"ting mem!rane )otential
)o"iti'e0 an$ t#e 4e"tion "tem "tate" t#at t#e mem!rane )otential i",LO mK.
1*#oice D2 Hig# )ota""im con$ctance $oe" occr at re"t an$ i" t#e large"t
contri!tor to t#e re"ting mem!rane )otential. *#lori$e )la&" little to no role in t#e
$etermination o/ t#e re"ting mem!rane )otential.
13
Q NO 7: T#e re"ting mem!rane )otential /or an i"olate$ m"cle cell i" ,D: mK.
E4ili!rim )otential" /or im)ortant ion" are gi'en !elo3<
USMLE WORLD STEP 1
PHYSIOLOGY
1*#oice E2 I/ a #ig# )ota""im con$ctance 3ere t#e onl& contri!tor to t#e re"ting
mem!rane )otential0 t#en t#e mem!rane )otential 3ol$ !e t#e "ame a" t#e
)ota""im e4ili!rim )otential.
E$cational O!;ecti'e<
T#e re"ting mem!rane )otential i" t#e $i//erence in t#e electrical c#arge" acro"" t#e
cell mem!rane n$er "tea$&, "tate con$ition". T#e ion" t#at are mo"t )ermea!le to
t#e cell mem!rane ma.e t#e large"t contri!tion to t#e re"ting mem!rane )otential.
In general0 a #ig# )ota""im e//lx an$ "ome "o$im in/lx are re")on"i!le /ort#e
'ale o/ t#e re"ting )otential0 3#ic# i" t&)icall& a!ot,LO mK.
14
USMLE WORLD STEP 1
PHYSIOLOGY
A. Mitral "teno"i"
(. Aortic "teno"i"
*. Dilate$ car$iom&o)at#&
D. Re"tricti'e car$iom&o)at#&
E. *ar$iac tam)ona$e
Explanation:
T#e )lmonar& ca)illar& 3e$ge )re""re 1P*WP2 i" t#e )re""re in a )lmonar&
arter& $i"tal to t#e )oint o/ it" occl"ion !& an in/late$ intra'a"clar !alloon. (eca"e
t#ere i" no "igni/icant !loo$ /lo3 to3ar$" t#e le/t atrim 1LA2 !e&on$ t#i" )oint o/
occl"ion0 t#e )re""re at t#e ti) o/ t#e M3e$ge$N )lmonar& arter& cat#eter
!ecome" nearl& e4al to t#e LA )re""re. Dring normal $ia"tole0 t#e LA )re""re i"
nearl& e4al to t#e le/t 'entriclar 1LK2 )re""re "ince t#e o)en mitral 'al'e o//er"
minimal re"i"tance to /lo3 !et3een t#e t3o c#am!er". In t#i" )atient0 car$iac
cat#eteri%ation re'eal" a LA en$,$ia"tolic )re""re 1LAEDP2 t#at i" "igni/icantl&
greater t#an t#e LKEDP. T#i" a!normal )re""re gra$ient im)lie" increa"e$
re"i"tance /lo3 !et3een t#e LA an$ LK0 i.e. mitral "teno"i".
1*#oice (2 I"olate$ aortic "teno"i" 3ol$ ca"e ele'ation o/ t#e le/t 'entriclar )ea.
"&"tolic )re""re. It col$ al"o ele'ate !ot# t#e P*KKP an$ t#e LKEDPI !t t#e"e t3o
'ale" 3ol$ remain a))roximatel& e4al.
1*#oice *2 Dilate$ car$iom&o)at#& 3ol$ re$ce t#e le/t 'entriclar )ea. "&"tolic
)re""re an$ ele'ate t#e P*WP an$ LKEDP. T#e P*WP an$ LKEDP 3ol$ remain
a))roximatel& e4al.
1*#oice D2 Re"tricti'e car$iom&o)at#& ca"e" $ia"tolic $&"/nction an$ "imilar
ele'ation" o/ t#e P*KKP an$ LKEDP. T#e P*WP an$ LKEDP 3ol$ remain
a))roximatel& e4al.
1*#oice E2 In t#e a!"ence o/ mitral "teno"i"0 tam)ona$e 3ol$ ele'ate t#e P*WP
an$ LKEDP to t#e "ame $egree0 .ee)ing t#em e4al.
E$cational O!;ecti'e<
T#e )lmonar& ca)illar& 3e$ge )re""re 1P*KOIP2 mea"re" t#e le/t atrial en$
$ia"tolic )re""re 1LAEDP2. Un$er normal con$ition"0 t#e LAEDP i" nearl& e4al to
t#e LK en$,$ia"tolic )re""re 1LKEDP2. Mitral "teno"i" ele'ate" t#e LAEDP an$ P*WP
relati'e to t#e LKEDP.
15
Q NO 8: A 8@,&ear,ol$ /emale i" !eing e'alate$ /or )rogre""i'e exertional
$&")nea. T#e /ollo3ing car$iac cat#eteri%ation $ata are o!taine$<
Le/t 'entriclar en$,$ia"tolic )re""re ,,, 1: mmHg 1normal 8,1- mmHg2
Le/t 'entriclar )ea. "&"tolic )re""re ,,, 11: mmHg 1normal 1::,1=: mmHg2
Plmonar& ca)illar& 3e$ge )re""re ,,, 8E mmHg 1normal P 1- mmHg2
W#ic# o/ t#e /ollo3ing i" t#e mo"t li.el& ca"e o/ t#i" )atient7" "&m)tom"9
USMLE WORLD STEP 1
PHYSIOLOGY

A. Do!tamine in/"ion
(. +ormal "aline in/"ion
*. A!$ominal aorta clam)ing
D. Lo"" o/ contracting m&ocar$ial ma""
E. (loo$ 'olme lo""
Explanation:
Kentriclar )re""re,'olme loo)" $e)ict t#e relation"#i) !et3een )re""re an$
'olme in t#e le/t 'entricle $ring "&"tole an$ $ia"tole. T#e"e gra)#" re)re"ent le/t
'entriclar contraction0 e;ection0 relaxation an$ re/illing a" /ollo3"<
T#e $a"#e$ line a!o'e re/lect" increa"e$ 'entriclar )reloa$. T#e rig#t3ar$ "#i/t o/
t#e M'entriclar /illingN )ortion o/ t#e gra)# in$icate" t#at a larger t#an normal
'olme i" !eing )lace$ into t#e 'entricle $ring $ia"tole. T#i" can occr $ring an&
"tate o/ /li$ o'erloa$< renal /ailre conge"ti'e #eart /ailre0 or a/ter in/"ion o/
intra'eno" /li$".
16
Q NO 9: T#e "oli$ line !elo3 $e)ict" t#e )re""re,'olme loo) /or a =?,&ear,ol$
#o")itali%e$ )atient. T#e c#ange in$icate$ !& t#e $a"#e$ line ma& re/lect 3#ic#
o/ t#e /ollo3ing9
USMLE WORLD STEP 1
PHYSIOLOGY
Do!tamine in/"ion 3ol$ ca"e an increa"e in contractilit&. Hig#er )re""re"
3ol$ !e reac#e$ $ring t#e 'entriclar e;ection )#a"e o/ t#e )re""re,'olme loo)
an$ a greater 'olme o/ !loo$ 3ol$ !e e;ecte$ $ring contraction. T#e re"lt 3ol$
!e 3i$ening o/ t#e )re""re,'olme loo).
*lam)ing o/ t#e a!$ominal aorta 3ol$ $ra"ticall& increa"e a/terloa$0 ca"ing
narro3ing an$ )3ar$ "#i/t o/ t#e 'entriclar e;ection )#a"e o/ t#e )re""re,'olme
loo) 1t#e re"lt o/ #ig#er t#an normal )re""re" at t#e time o/ aortic 'al'e o)ening
an$ clo"re2. T#e gra)# 3ol$ !e narro3 !eca"e le"" !loo$ 3ol$ !e e;ecte$
$ring 'entriclar contraction com)are$ to t#e nclam)e$ )atient.
Lo"" o/ contracting m&ocar$ial ma"" 3ol$ re"lt in $ecrea"e$ contractilit&. T#i"
3ol$ a//ect !ot# t#e 'entriclar e;ection an$ i"o'olmetric relaxation )#a"e" o/ t#e
)re""re,'olme loo). T#e 'entriclar e;ection "egment 3ol$ li.el& not reac# a"
#ig# a )re""re a" a normal control an$ 3ol$ not la"t a" long a" a normal control.
T#e i"o'olmetric relaxation "egment 3ol$ t#ere/ore !e "#i/te$ to t#e rig#t
in$icating a "maller e;ection /raction 1a greater 'olme o/ !loo$ remaining in t#e
#eart a/ter contraction i" com)lete2.
1*#oice E2 (loo$ 'olme lo"" 3ol$ #a'e an e//ect o))o"ite t#at $e)icte$0 ca"ing
t#e 'entriclar /illing )#a"e to !e "#orter t#an in t#e normal control.
E$cational O!;ecti'e<
Pre""re,'olme loo)" re)re"ent t#e relation"#i) !et3een )re""re an$ 'olme in
t#e le/t 'entricle $ring "&"tole an$ $ia"tole. An increa"e in t#e circlating 'olme
3ol$ increa"e )reloa$ an$ ca"e a rig#t3ar$ 3i$ening o/ t#e )re""re,'olme loo).
17
USMLE WORLD STEP 1
PHYSIOLOGY

A. *#ronic arterio'eno" /i"tla
(. Acte ga"trointe"tinal !lee$
*. P#en&le)#rine in/"ion
D. M&ocar$ial in/arction
E. Ana)#&laxi"
Explanation:
T#e $a"#e$ line" $e)ict an increa"e$ car$iac ot)t 1increa"e in t#e #eig#t o/ t#e
car$iac /nction cr'e20 a $ecrea"e$ TPR 1increa"e$ "lo)e o/ !ot# t#e car$iac
/nction cr'e an$ t#e 'eno" retrn cr'e2 an$ an increa"e$ mean "&"temic
)re""re 1rig#t3ar$ "#i/t o/ t#e 'eno" retrn cr'e on t#e x,axi"2. A c#ronic
arterio'eno" /i"tla 3ol$ ca"e t#e"e c#ange". Actel&0 a /i"tla ca"e" a
$ecrea"e in TPR re"lting in an increa"e$ car$iac ot)t an$ an increa"e$ 'eno"
retrn. T#e 'eno" retrn cr'e $oe" not imme$iatel& "#i/t on t#e x,axi"0 !t o'er
time0 t#e "&m)at#etic ner'o" "&"tem an$ .i$ne&" 3ill !egin to com)en"ate /or a
c#ronic /i"tla !& increa"ing TPR0 car$iac contractilit&0 an$ t#e circlating !loo$
'olme. T#e"e c#ange" /rt#er increa"e t#e car$iac /nction cr'e an$ increa"e t#e
rig#t atrial )re""re0 ca"ing a rig#t3ar$ "#i/t o/ t#e 'eno" retrn cr'e on t#e x,
axi".
1*#oice (2 Acte GI !lee$" ca"e a "#ar) $ecrea"e in t#e circlating !loo$ 'olme
an$ "#i/t" t#e 'eno" retrn gra)# to t#e le/t.
1*#oice *2
18
Q NO 10: T#e car$iac an$ 'eno" retrn cr'e" o/ a #ealt#& )er"on are "#o3n
!elo3 in "oli$ line". W#ic# o/ t#e /ollo3ing i" t#e mo"t li.el& ca"e o/ t#e
c#ange $e)icte$ !& t#e $a"#e$ line"9
USMLE WORLD STEP 1
PHYSIOLOGY
A )#en&le)#rine in/"ion 3ol$ increa"e "&m)at#etic tone re"lting in
'a"ocon"triction an$ an increa"e in TPR0 a" "#o3n a!o'e. T#e increa"e$ TPR ca"e"
more !loo$ to remain on t#e arterial "i$e o/ t#e circlation t#" $ecrea"ing 'eno"
retrn. Since a/terloa$ i" #ig#0 car$iac ot)t $ecrea"e" a" 3ell.
1*#oice D2 M&ocar$ial in/arction ca"e" an i"olate$ $ecrea"e in car$iac ot)t 3it#
no c#ange in !loo$ 'olme" or 'eno" retrn.
1*#oice E2 Ana)#&laxi" ca"e" 3i$e")rea$ 'eno" an$ arteriolar $ilatation along
3it# increa"e$ ca)illar& )ermea!ilit& an$ t#ir$,")acing o/ /li$". T#i" re"lt" in a
"erio" $ro) in 'eno" retrn.
E$cational O!;ecti'e<
A c#ronic arterio'eno" "#nt 3ol$ increa"e car$iac ot)t !eca"e o/ increa"e$
"&m)at#etic "timlation to t#e #eart0 increa"e$ 'eno" retrn0 an$ $ecrea"e$ TPR.
It 3ol$ al"o ca"e t#e 'eno" retrn cr'e to "#i/t to t#e rig#t !eca"e t#e
circlating !loo$ 'olme i" increa"e$ !& renal retention o/ /li$" an$ t#e 'eno"
retrn i" increa"e$ !& "&m)at#etic tone.
19
USMLE WORLD STEP 1
PHYSIOLOGY
A. Ti$al 'olme
(. (reat# rate
*. Anctional re"i$al ca)acit&
D. Re"i$al 'olme
E. Dea$ ")ace
Explanation:
T#e minte 'entilation i" t#e 'olme o/ air t#at enter" or lea'e" t#e lng" an$
con$cting air3a&" in one minte. T#e minte 'entilation accont" /or all air0
incl$ing air t#at $oe" not )artici)ate in ga" exc#ange0 entering or lea'ing t#e
air3a&" )er minte. T#e minte 'entilation can !e calclate$ "ing t#e /ollo3ing
e4ation<
Minte 'entilation 1L5min2 % Ti$al Kolme 1L2 x !reat#"5minte
T#e 'olme o/ air t#at $oe" not )artici)ate in ga" exc#ange i" .no3n a" t#e
)#&"iologic $ea$ ")ace. T#e )#&"iologic $ea$ ")ace can !e calclate$ 3it# t#e
/ollo3ing /ormla<
KD B KT Q 11Pa *O- H PE*O-2 5 Pa*O-2
3#ere KD i" t#e $ea$ ")ace 'olme. KT i" t#e ti$al 'olme0 P8*:- i" t#e arterial
)artial )re""re o/ *:-0 an$ PE*O- i" t#e )artial )re""re o/ *O- in t#e ex)ire$ air.
T#e al'eolar 'entilation $i//er" /rom t#e minte 'entilation in t#at t#e al'eolar
'entilation re/er" onl& to t#e 'olme o/ air )artici)ating in ga" exc#ange )er minte.
T#"0 t#e al'eolar 'entilation $oe" not incl$e t#e $ea$ ")ace 'olme 3#ile t#e
minte 'entilation $oe". T#e al'eolar 'entilation can !e calclate$ 3it# t#e /ollo3ing
/ormla<
Al'eolar 'entilation 1L5min2 B 1Ti$al Kolme H Dea$ ")ace 'olme2 x
!reat#"5minte
1*#oice A2 T#e ti$al 'olme i" t#e 'olme o/ air t#at i" in#ale$ or ex#ale$ 3it# eac#
normal0 n/orce$ !reat# an$ i" a /actor in calclating !ot# t#e minte 'entilation
an$ t#e al'eolar 'entilation.
1*#oice (2 T#e !reat# rate i" t#e nm!er o/ !reat#" ta.en )er minte an$ i" a /actor
in calclating !ot# t#e minte 'entilation an$ t#e al'eolar 'entilation.
1*#oice *2 T#e /nctional re"i$al ca)acit& i" t#e 'olme o/ air remaining in t#e
lng" a/ter a normal ex#alation. It i" t#e "m o/ t#e re"i$al 'olme an$ t#e
ex)irator& re"er'e 'olme.
1*#oice D2T#e re"i$al 'olme i" t#e 'olme o/ air remaining in t#e lng" a/ter
/orce$ ex#alation. T#e re"i$al 'olme cannot !e mea"re$ !& ")irometr&.
E$cational O!;ecti'e<
T#e minte 'entilation i" e4al to t#e )ro$ct o/ t#e ti$al 'olme an$ t#e re")irator&
rate an$ incl$e" $ea$ ")ace 'entilation. T#e al'eolar 'entilation $oe" not ta.e into
accont t#e air in t#e )#&"iologic $ea$ ")ace. It i" t#e )ro$ct o/ t#e re")irator& rate
an$ t#e $i//erence !et3een t#e ti$al 'olme an$ t#e $ea$ ")ace 'olme.
20
Q NO 11: A re"earc#er mea"re" al'eolar 'entilation in a #ealt#& 'olnteer. W#ic#
o/ t#e /ollo3ing 'ale" accont" /or t#e $i//erence !et3een t#e minte 'entilation
an$ t#e al'eolar 'entilation9
USMLE WORLD STEP 1
PHYSIOLOGY
A. T#e ")#ere" 3ill !ecome e4al in "i%e
(. T#e "maller ")#ere 3ill increa"e in "i%e
*. T#e larger ")#ere 3ill $ecrea"e in "i%e
D. T#e "maller ")#ere 3ill colla)"e
E T#e larger ")#ere 3ill colla)"e
Explanation:
La)lace7" la3 tell" " t#at t#e )re""re in"i$e a !!!le i" $irectl& )ro)ortional to t#e
"r/ace ten"ion 1T2 an$ in'er"el& )ro)ortional to t#e ra$i" 1R2.
P R T5R
A""ming con"tantl&0 a !!!le 3it# a "maller ra$i" 3ill #a'e a #ig#er colla)"ing
)re""re. T#"0 3#en t#e clam) a!o'e i" o)ene$0 t#e "maller ")#ere 3ill ten$ to
colla)"e an$ t#e larger ")#ere 3ill in/late /rt#er. T#i" "itation mo$el" 3#at 3ol$
#a))en in t#e lng" i/ t3o al'eoli o/ $i//erent "i%e" 3it#ot "r/actant 3ere
connecte$ an$ t#en o)ene$ to t#e atmo")#ere. An im)ortant role o/ "r/actant i" to
$ecrea"e "r/ace ten"ion an$ t#" )re'ent al'eolar colla)"e.
E$cational O!;ecti'e<
Accor$ing to La)lace7" la30 a" t#e ra$i" o/ a ")#ere 3it# con"tant "r/ace ten"ion
$ecrea"e"0 t#e colla)"ing )re""re increa"e". Sr/actant conteract" al'eolar
colla)"e !& $ecrea"ing "r/ace ten"ion a" t#e al'eolar ra$i" $ecrea"e".
21
Q NO 12: T3o ")#ere" 3it# ela"tic )ro)ertie" "imilar to al'eoli are connecte$ a"
"#o3n !elo3. T#e "r/ace ten"ion 3it#in t#e t3o ")#ere" i" i$entical. +eit#er i"
line$ 3it# "r/actant. W#at "#ol$ !e ex)ecte$ 3#en t#e clam) i" o)ene$9
USMLE WORLD STEP 1
PHYSIOLOGY
A. Rig#t atrim
(. Rig#t 'entricle
*. Le/t 'entricle
D. Le/t atrim
E. Plmonar& arter&
Explanation:
T#i" 4e"tion te"t" or .no3le$ge o/ normal )re""re 'ariation" in t#e c#am!er" o/
t#e #eart an$ )lmonar& arter& $ring t#e car$iac c&cle. Re)re"entati'e 1a$lt2
'ale" are )ro'i$e$ !elo3.
Recall t#at in general0 le/t,"i$e$ )re""re are greater t#an rig#t,"i$e$ )re""re".
Wit#in t#e atria0 t#e normal )re""re maximm i" clo"e to 1:mm Hg. Wit#in t#e
rig#t 'entricle0 t#e maximm )re""re i" normall& a!ot -?mm Hg0 an$ 3it#in t#e
)lmonar& arter&0 t#e maximm )re""re i" normall& clo"e to -?mm Hg. T#e le/t
'entriclar an$ aortic maximm )re""re" are normall& clo"e to t#e "&"tolic !loo$
)re""re.
U"ing t#e a!o'e ta!le0 3e can "ee t#at t#e cat#eter 3a" )ro!a!l& initiall& )o"itione$
in t#e rig#t 'entricle 1RK2. T#e )atient7" RK )re""re" are in t#e normal range.
A$'ancement o/ t#e cat#eter /rom t#i" )oint 3ol$ )lace t#e cat#eter in t#e
)lmonar& arter& 1PA2. T#e "econ$ "et o/ )re""re rea$ing" are con"i"tent 3it#
normal PA )re""re".
E$cational O!;ecti'e<
+ormal 1a$lt2 )re""re" in t#e car$iac c#am!er" an$ )lmonar& arter& are a"
/ollo3"<
22
Q NO 13: A =E,&ear,ol$ )atient i" n$ergoing car$iac cat#eteri%ation0 Initiall&0 t#e
cat#eter recor$" )erio$ic )re""re c#ange" 3it# a maximm o/ -D mmHg an$
minimm o/ - mmHg. T#e cat#eter i" a$'ance$ /rt#er0 an$ t#en "#o3" )erio$ic
)re""re c#ange" 3it# a maximm o/ -E mmHg an$ a minimm o/ 1: mmHg. T#e
initial rea$ing" 3ere mo"t li.el& o!taine$ /rom 3#ic# o/ t#e /ollo3ing location"9
USMLE WORLD STEP 1
PHYSIOLOGY
A. Secretin
(. *#olec&"to.inin
*. Ga"trin
D. Ka"oacti'e inte"tinal )e)ti$e 1KIP2
E. Motilin
A. Somato"tatin
Explanation:
T#i" )atient )re"ent" 3it# cla""ic "ign" an$ "&m)tom" o/ !iliar& colic. Moreo'er0 "#e
#a" t#ree 3ell,.no3n ri". /actor" /or gall!la$$er $i"ea"e 1M/ort&N M/atN an$ M/emaleN2.
*#olec&"to.inin 1**62 i" t#e #ormone re")on"i!le /or gall!la$$er contraction. Iti"
)ro$ce$ !& l cell" o/ t#e $o$enm an$ ;e;nm 3#en /at,)rotein,ric# c#&me
enter" t#e $o$enm. It /nction" to increa"e )ancreatic en%&me "ecretion 1!&
acinar cell"2 an$ gall!la$$er contraction. an$ to $ecrea"e ga"tric em)ting. In
c#olec&"titi"0 /att& /oo$" increa"e **6 )ro$ction an$ )ain occr" 3#en an in/lame$
an$5or o!"trcte$ gall!la$$er contract".
1*#oice A2 Secretin )romote" !icar!onate "ecretion /rom )ancreatic $ctal
e)it#elim. It #a" no e//ect on )ancreatic en%&me "ecretion.
1*#oice *2 Ga"trin i" a #ormone ma$e in t#e "tomac# in re")on"e to "tomac#
$i"tention )e)ti$e"0 an$ 'agal "timlation. It "itate" ga"tric aci$ "ecretion an$
motilit&.
1*#oice D2 Ka"oacti'e inte"tinal )e)ti$e 1KIP2 i" )ro$ce$ in t#e )ancrea" an$
"timlate" inte"tinal 3ater "ecretion0 conteract" ga"trin in t#e "tomac#0 an$
)romote" !icar!onate "ecretion /or t#e )ancrea".
1*#oice E2 Motilin i" a #ormone ma$e in t#e "mall inte"tine t#at )romote" inte"tinal
motilit&.
1*#oice A2 Somato"tatin i" a #ormone ma$e in nmero" ti""e" 1#&)ot#alam"0
"tomac#0 inte"tine0 an$ )ancrea"2 in re")on"e to lo3 )H. It" )ro$ction i" in#i!ite$
!& 'agal "timlation. Somato"tatin in#i!it" t#e relea"e o/ gro3t# #ormone 1GH2 an$
t#&roi$ "timlating #ormone 1TSH20 an$ "))re""e" t#e relea"e o/ m&ria$ ot#er
molecle" 1e.g. ga"trin0 **60 KIP0 "ecretin0 in"lin0 glcagon2.
E$cational O!;ecti'e<
*#olec&"to.inin 1O*R2 i" t#e #ormone re")on"i!le /or gall!la$$er contraction. It i"
ma$e in t#e $o$enm an$ ;e;nm in re")on"e to /att& aci$" an$ amino aci$".
23
Q NO 14: A =8,&ear,ol$ o!e"e 3oman )re"ent" to t#e emergenc& room 3it# "e'ere
e)iga"tric )ain t#at "tarte$ a/ter a #ea'& meal. S#e #a" #a$ "e'eral mil$er e)i"o$e"
!e/ore relate$ to /att& /oo$ con"m)tion. P#&"ical examination re'eal" mar.e$
ten$erne"" in t#e rig#t "!co"tal area. W#ic# o/ t#e /ollo3ing #ormone" mo"t li.el&
)ro'o.e$ t#e crrent attac. in t#i" )atient9
USMLE WORLD STEP 1
PHYSIOLOGY
A. *O- content in t#e arterial !loo$
(. O- content in t#e arterial !loo$
*. *O- content in t#e mixe$ 'eno" !loo$
D. )H o/ t#e arterial !loo$
E. P#&"iologic $ea$ ")ace
Explanation:
Long $i"tance rnning an$ ot#er /orm" o/ aero!ic exerci"e ca"e increa"e$ oxi$ati'e
meta!oli"m o/ glco"e an$ /att& aci$" in ".eletal m"cle. T#e acti'e ".eletal m"cle"
increa"e t#eir rate o/ !ot# ox&gen con"m)tion an$ car!on $ioxi$e )ro$ction.
T#e"e increa"e" are !alance$ !& increa"e" o/ t#e car$iac ot)t5".eletal m"cle
)er/"ion an$ 'entilation0 re")ecti'el&. Homeo"tatic mec#ani"m" maintain arterial
:- an$ *O- content" an$ arterial )H near normal re"ting 'ale" !t t#ere are
"igni/icant c#ange" in t#e 'eno" !loo$ O- an$ *O- content" an$ )H. (eca"e
exerci"ing m"cle" extract a$$itional O- t#e 'eno" !loo$ :- content i" $ecrea"e$.
T#e 'eno" !loo$ *O- content i" increa"e$ $e to increa"e$ *O- )ro$ction. T#e
'eno" !loo$ )H i" $ecrea"e$.
1*#oice D2 T#e arterial )H i" "all& normal in mo$erate exerci"e !t ma& $ecrea"e
$ring "treno" exerci"e $e to lactic aci$o"i".
1*#oice E2 P#&"iologic $ea$ ")ace corre")on$" to region" o/ al'eolar 'entilation t#at
$o not engage in ga" exc#ange $e to relati'el& lo3 al'eolar )er/"ion an$5or
al'eolar #&)eraeration. T#e #&)er'entilation t#at accom)anie" exerci"e ma& "lig#tl&
increa"e t#e anatomic $ea$ ")ace !& "tretc#ing t#e con$cting air3a&" 3it# /ller
in")iration"0 !t $oe" not "igni/icantl& increa"e t#e )#&"iologic $ea$ ")ace. In
#ealt#& in$i'i$al"0 exerci"e ca"e" a ni/orm "imltaneo" increa"e in !ot#
'entilation an$ )er/"ion o/ in$i'i$al al'eoli.
E$cational O!;ecti'e<
Dring aero!ic exerci"e0 increa"e$ ".eletal m"cle *O- )ro$ction increa"e" t#e
P*O- o/ mixe$ 'eno" !loo$. Homeo"tatic mec#ani"m" maintain arterial !loo$ ga"
le'el" an$ arterial )H near t#e re"ting 'ale".
24
Q NO 15: A -8,&ear,ol$ male rn" /i'e mile". W#ic# o/ t#e /ollo3ing $o &o ex)ect
to increa"e at t#e )ea. o/ #i" exertion9
USMLE WORLD STEP 1
PHYSIOLOGY

A. H&)er)roteinemia
(. (la$$er nec. o!"trction
*. *on"triction o/ t#e e//erent arteriole
D. *on"triction o/ t#e a//erent arteriole
E. Dilation o/ t#e e//erent arteriole
Explanation:
*on"triction o/ t#e e//erent 1otgoing2 arteriole 3ill im)e$e !loo$ /lo3 t#rog# t#e
.i$ne&. T#i" 3ill $ecrea"e RPEI !t 3ill increa"e glomerlar ca)illar& #&$ro"tatic
)re""re a" t#e /li$ M!ac." )N in t#e glomerl"0 increa"ing #&$ro"tatic )re""re.
A" $e"cri!e$ !elo30 t#i" increa"e$ glomerlar #&$ro"tatic )re""re 3ill ca"e an
increa"e in t#e /iltration /raction.
T#e renal )la"ma /lo3 1RPE2 i" t#e 'olme o/ )la"ma t#at i" $eli'ere$ to t#e .i$ne&
)er nit time. T#e RPA i" )ro'i$e !& t#e renal !loo$ /lo30 3#ic# $eli'er" !ot#
er&t#roc&te" an$ )la"ma to t#e .i$ne&. T#e RPE i" t#eoreticall& calclate$ !&
"!tracting t#e amont o/ er&t#roc&te" 1#ematocrit2 /rom t#e total renal !loo$ /lo3.
*linicall&0 #o3e'er RPE i" generall& e"timate$ !& calclating t#e )ara,amino#i))ric
aci$ 1PAH2 clearance. EPE i" lin.e$ to t#e glomerlar /iltration rate 1GER2 an$ t#e
/iltration /raction 1AE2 !& t#e /ollo3ing e4ation<
AEB GAR5RPA
T#e /iltration /raction re/er" to t#e )ro)ortion o/ t#e RPE t#at i" /iltere$ /rom t#e
glomerlar ca)illarie" into (o3man7" ")ace an$ i" ex)re""e$ a" a )ercentage. U"ing
t#e e4ation a!o'e0 one can o!"er'e t#at increa"e" in GER or $ecrea"e" in RPA 3ill
increa"e t#e AE. T#e GER i" $e)en$ent on #&$ro"tatic an$ oncotic )re""re" in t#e
glomerlar ca)illarie" an$ (o3man7" ")ace an$ can !e calclate$ 3it# t#e /ollo3ing
e4ation<
GER B 6/ 11PG H P(2 H 1TTG H TT(22
W#ere 6/ re/er" to t#e coe//icient o/ /iltration0 PG re/er" to t#e #&$ro"tatic )re""re
in t#e glomerlar ca)illarie"0 P( re/er" to t#e #&$ro"tatic )re""re in (o3man7"
")ace0 TTG re/er" to t#e oncotic )re""re in t#e glomerlar ca)illarie" an$ TT( re/er"
to t#e oncotic )re""re in (o3man7" ")ace. Increa"e" in t#e glomerlar ca)illar&
#&$ro"tatic )re""re or t#e (o3man7" ")ace oncotic )re""re 3ill increa"e GAR0
25
Q NO 16: A re"earc#er i" "t$&ing t#e e//ect o/ 'ario" mani)lation" on .i$ne&
!loo$ /lo3 an$ glomerlar /iltration. W#ic# o/ t#e /ollo3ing i" mo"t li.el& to !ot#
$ecrea"e renal )la"ma /lo3 an$ increa"e t#e /iltration /raction9
USMLE WORLD STEP 1
PHYSIOLOGY
3#ile increa"e" in ca)illar& oncotic )re""re or (o3man7" ")ace #&$ro"tatic )re""re
3ill $ecrea"e GAR.
1*#oice A2 H&)er)roteinemia ca"e" increa"e$ glomerlar ca)illar& oncotic )re""re
t#ere!& $ecrea"ing GAR. T#i" 3ill #a'e no election t#e RPA !t 3ill ca"e a
$ecrea"e$ AA $e to t#e $ecrea"e$ GAR.
1*#oice (2 (la$$er nec. o!"trction ca"e" an increa"e in (o3man7" ")ace
#&$ro"tatic )re""re t#ere!& $ecrea"ing GAR. T#i" too 3ill #a'e no e//ect on t#e
RPA0 !t 3ill ca"e a $ecrea"e$ AA $e to t#e $ecrea"e$ GAR.
1*#oice D2 *on"triction o/ t#e a//erent 1incoming2 arteriole ca"e" a $ecrea"e in
glomerlar ca)illar& #&$ro"tatic )re""re lea$ing to a $ecrea"e$ GAR. RPE i" al"o
$ecrea"e$ !& t#i" )roce"". T#e AE remain" nc#ange$ $e to $ecrea"e" in !ot# GAR
an$ RPE.
1*#oice E2 Dilation o/ t#e e//erent arteriole ca"e" $ecrea"e$ glomerlar ca)illar&
#&$ro"tatic )re""re lea$ing to a $ecrea"e in GAR. T#e RPE i" increa"e$ !& t#i"
)roce""0 an$ t#e AA i" $ecrea"e$ $e to t#e $ecrea"e in GAR an$ increa"e in RPE.
E$cational O!;ecti'e<
Increa"e" in t#e ca)illar& #&$ro"tatic )re""re or t#e (o3man7" ")ace oncotic
)re""re 3ill increa"e GAR 3#ile increa"e" in ca)illar& oncotic )re""re or (o3man7"
")ace #&$ro"tatic )re""re 3ill $ecrea"e GAR. T#e /iltration /raction 1AA2 can !e
calclate$ !& $i'i$ing t#e GAR !& t#e renal )la"ma /lo3 1RPA2. Increa"e" in GAR or
$ecrea"e" in RPA 3ill increa"e t#e AA.
26
USMLE WORLD STEP 1
PHYSIOLOGY
A. Increa"e" glcagon "ecretion
(. Decrea"e" glcagon "ecretion
*. Aacilitate" t#e action o/ glcagon
D. Increa"e" renal glco"e )ro$ction
E. Increa"e" t#e renal t#re"#ol$ /or glco"e rea!"or)tion
Explanation:
T#i" )atient i" ex#i!iting cla""ic "ign" an$ "&m)tom" o/ $ia!etic .etoaci$o"i" 1DRA2.
T#e t#ree car$inal "ign" o/ $ia!ete" mellit" 1DM2 are )ol&ria0 )ol&$i)"ia an$
)ol&)#agia. Un$iagno"e$ DM can )rogre"" to D6A. D6A can !e t#e initial
)re"entation o/ DM0 e")eciall& in )atient" lac.ing reglar #ealt# /ollo3,).
DRA re"lt" /rom a $e/icienc& o/ in"lin an$ an exce"" o/ glcagon co)le$ 3it#
a$renergic acti'ation an$ increa"e$ le'el" o/ corti"ol an$ gro3t# #ormone. In"lin
an$ glcagon normall& act in o))o"ition to one anot#er0 3it# in"lin in#i!iting
glcagon relea"e. Patient" 3it# DM 1e")eciall& t&)e I DM2 #o3e'er0 are na!le to
"&nt#e"i%e "//icient in"lin to )re'ent #&)ergl&cemia an$ to in#i!it glcagon7"
e//ect".
(eca"e glco"e i" ina$e4atel& tran")orte$ into cell" in )atient" 3it# DM an$ DRA0
t#e !o$& )ercei'e" #&)ogl&cemia an$ a "tar'e$ "tate $e")ite #ig# "erm glco"e
le'el". A$renergic ner'o" "&"tem acti'ation an$ increa"e$ glcagon )ro$ction
re"lt. Glcagon "timlate" .etoaci$ "&nt#e"i" in a$i)o"e ti""e !eca"e $ring
"tar'ation .etoaci$" can !e "e$ !& cell" /or energ& in )lace o/ glco"e. Glcagon
al"o increa"e" gl&cogenol&"i"0 glconeogene"i"0 li)ol&"i"0 an$ rea )ro$ction.
Patient" 3it# DRA clinicall& ex#i!it na"ea an$ 'omiting0 "e'ere a!$ominal )ain0
tac#&car$ia0 tac#&)nea0 $r& mco" mem!rane" an$ let#arg&. T#ere i" cla""icall& a
/rit& o$or on t#eir !reat# $e to t#e )re"ence o/ .etone !o$ie".
1*#oice A2 Aactor" t#at increa"e glcagon "ecretion are #&)ogl&cemia0 increa"e$
"erm amino aci$ concentration0 a$renergic "timlation c#olec&"to.inin an$
acet&lc#oline.
1*#oice D2 In"lin )romote" glco"e "torage in t#e /orm o/ gl&cogen. Glcagon0 not
in"lin0 "timlate" glco"e )ro$ction 1glconeogene"i"2.
1*#oice E2 +ormall& all glco"e /iltere$ /rom t#e !loo$ in t#e glomerlar ca)illarie"
into (o3man7" ca)"le i" rea!"or!e$ in t#e )roximal con'olte$ t!le. In"lin $oe"
not a//ect t#i" )roce"".
E$cational O!;ecti'e<
In"lin o))o"e" glcagon action. Glcagon "timlate" gl&cogenol&"i"0
glconeogene"i"0 li)ol&"i" an$ .etone !o$& )ro$ction 3#ile in"lin increa"e"
glco"e0 amino aci$ an$ )ota""im )ta.e !& cell"0 in#i!it" .etoaci$ /ormation an$
in#i!it" li)ol&"i".
27
Q NO 17: A -8,&ear,ol$ male i" !rog#t to t#e emergenc& room 3it# 3ea.ne""
an$ con/"ion. He #a" ex)erience$ )ol&ria0 )ol&$i)"ia an$ increa"e$ a))etite
recentl&. Hi" !reat# #a" a /rit& o$or. T#i" )atient i" $e/icient in a "!"tance t#at
USMLE WORLD STEP 1
PHYSIOLOGY

A. A
(. (
*. *
D. D
E. E
Explanation:
T#e gra)# a!o'e $e)ict" t#e )otential 1'oltage 5 con$ctance2 c#ange" acro"" a cell
mem!rane> t#e"e c#ange" 1$e)olari%ation re)olari%ation0 #&)er)olari%ation an$
re"ting )otential2 are collecti'el& .no3n a" t#e action )otential. T#e action )otential
occr" $e to c#ange" in t#e mem!rane )ermea!ilit& to +a an$ 6 ion". T#e
mem!rane )otential o/ an excita!le cell 1ner'e0 m"cle2 n$ergoe" t#e /ollo3ing
"tage"<
1. Re"ting )otential 1*#oice A2< U"all& e4al to,LO mK. Iti" maintaine$ !& a #ig#
mem!rane )ermea!ilit& to Ran$ a lo3 )ermea!ilit& to +a. 6 e//lx occr" 'ia non,
gate$ 6 c#annel" 1lea. c#annel"2. Dring t#e re"ting )otential t#e inner "i$e o/ t#e
mem!rane i" negati'el& c#arge$ 3it# re")ect to t#e oter "r/ace o/ t#e mem!rane.
-. De)olari%ation< Occr" $e to o)ening o/ 'oltage,gate$ +a c#annel" 3it# ra)i$
in/lx o/ "o$im ion" into t#e cell. T#e large in/lx o/ +a ion" t#at occr" a/ter
o)ening o/ t#e 'oltage,gate$ "o$im c#annel" lea$" to an increa"e$ negati'e c#arge
ot"i$e t#e mem!rane .no3n a" $e)olari%ation 1*#oice (2. De)olari%ation ca"e"
t#e mem!rane )otential to !ecome )o"iti'e 1a))roximatel& J8?mK2. O'er"#oot
1*#oice *2 re/er" to t#e maximal 'ale o/ t#e action )otential 3#ere t#e mem!rane
)otential i" a )o"iti'e 'ale.
8. Re)olari%ation 1*#oice D2< Re"lt" /rom clo"re o/ +a c#annel" an$ "imltaneo"
o)ening o/ 6 c#annel". T#i" re"lt" in a "#ar) $ecrea"e in t#e con$ctance o/ "o$im
an$ a "igni/icant increa"e in )ota""im con$ctance to le'el" e'en #ig#er t#an t#o"e
"een in t#e re"ting mem!rane )otential. Pota""im e//lx i" re")on"i!le /or retrning
t#e mem!rane )otential !ac. to t#e re"ting )otential.
=. H&)er)olari%ing a/ter)otential 1*#oice E2< Occr" $e to t#e /act t#at /or a "#ort
moment /ollo3ing re)olari%ation !ot# t#e 'oltage,gate$ an$ t#e non,'oltage,gate$
)ota""im c#annel" are o)en. T#e mem!rane )otential !ecome" more negati'e t#an
t#e normal re"ting )otential an$ a))roac#e" t#e 6 e4ili!rim )otential o/,@? mK.
W#en t#e 'oltage,gate$ 6,c#annel" clo"e t#e mem!rane )otential retrn" to t#e
re"ting 'ale.
E$cational O!;ecti'e<
T#e action )otential re"lt" /rom c#ange" in t#e mem!rane con$ctance /or 6 an$
+a ion". De)olari%ation re"lt" /rom ma""i'e in/lx o/ +a t#rog# 'oltage,gate$
c#annel". Re)olari%ation occr" $e to clo"re o/ 'oltage,gate$ +a c#annel" an$
o)ening o/ 'oltage,gaite$ 6 c#annel". Pota""im ion con$ction i" #ig#e"t $ring t#e
re)olari%ation )#a"e o/ t#e action )otential.
28
Q NO 18: A recor$ing o/ t#e mem!rane )otential o/ a giant axon i" "#o3n on t#e
"li$e !elo3. W#ic# o/ t#e )oint" in$icate$ on t#e "li$e mo"t li.el& corre")on$" to
t#e #ig#e"t mem!rane con$ction /or )ota""im
Q NO 19: In or$er to maintain con"tant /li$ /lo3 t#rog# a t!e 3it# 'ar&ing
$iameter" 3#ic# o/ t#e /ollo3ing 3ol$ !e tre 13#ere Al an$ A- re)re"ent
cro"","ectional area"0 an$ K1 an$ K- re)re"ent t#e corre")on$ing /lo3
'elocitie"29
USMLE WORLD STEP 1
PHYSIOLOGY
A. K1BK-
(. K1BA1SK-
*. A-BA1SK15K-
D. K1BA1SA-5K-
E. K1SA-BK-SA1
Explanation:
T#e la3 o/ con"er'ation o/ ma"" a" a))lie$ to /li$ $&namic" tell" " t#at t#e total
/lo3 o/ ma"" into a containe$ "&"tem m"t !e e4al to t#e total ot/lo3 o/ ma""
/rom t#e "&"tem in t#e "tea$& "tate. A))l&ing t#i" la3 to t#e c&lin$er" a!o'e<
T in B gram" o/ /li$ material in )er nit time B 'olme in x $en"it& 1in25time
T ot B gram" o/ /li$ material ot )er nit time B 'olme ot x $en"it& 1ot2 time
Aor a relati'el& incom)re""i!le /li$ 1e.g. !loo$20 $en"it& ma& !e con"i$ere$
con"tant. T#ere/ore in an& "tea$& "tate0 'olme in 1Kol in2 B 'olme ot 1Kol ot2.
Kol in B A1SK1 B Kol ot B A-SK-
1*#oice *2 i" t#e onl& an"3er c#oice con"i"tent 3it# t#e a!o'e e4ation. T#i"
e4ation !a"icall& "tate" t#at in a "&"tem o/ connecte$ c&lin$er" o/ 'ar&ing ra$ii
1e.g. t#e car$io'a"clar "&"tem20 t#e "tea$& "tate 'elocit& o/ /li$ 1e.g. !loo$2 /lo3
at a gi'en )oint i" in'er"el& relate$ to t#e cro"" "ectional area at t#at )oint. In ot#er
3or$"0 t#e /lo3 'elocit& increa"e" at )oint" o/ narro3ing. T#i" )rinci)le i" a))lie$ in
clinical )ractice 3#en t#e cro"" "ectional aortic 'al'e area i" calclate$ /rom Do))ler
ec#ocar$iogra)#ic mea"rement" o/ t#e 'elocit& o/ t#e ;et o/ !loo$ /lo3 at t#e aortic
'al'e. Alt#og# in$i'i$al ca)illarie" #a'e a "mall cro"","ectional area t#e /lo3
'elocit& t#rog# t#e"e 'e""el" i" "lo3. T#i" i" !eca"e nmero" ca)illarie" arrange$
in )arallel recei'e /lo3 /rom a gi'en /ee$er 'e""el< t#" t#e /nctional cro"",
"ectional area o/ t#o"e ca)illarie" com!ine$ i" actall& mc# larger t#an t#at o/ t#e
/ee$er 'e""el /rom 3#ic# t#e& recei'e t#eir /lo3
E$cational O!;ecti'e<
T#e la3 o/ con"er'ation o/ ma"" a))lie$ to t#e "tea$& "tate /lo3 o/ an
incom)re""i!le /li$ t#rog# a "&"tem o/ c&lin$er" o/ 'ar&ing cro"" "ectional area"
tell" " t#at<
Total Alo3 B Alo3 Kelocit& x *ro"" Sectional Area B *on"tant
T#i" )rinci)le ma& !e a))lie$ to !loo$ /lo3 in t#e car$io'a"clar "&"tem.
29
USMLE WORLD STEP 1
PHYSIOLOGY

A.
*alcim !in$ing to tro)onin *
(. Tro)om&o"in $i")lacement /rom t#e groo'e on t#e actin molecle
*. M&o"in #ea$ $etac#ment /rom t#e actin /ilament
D. *ro"",!ri$ge /ormation
E. M&o"in lig#t c#ain )#o")#or&lation !& a ")eci/ic en%&me
Explanation:
Accor$ing to t#e mo$el )o"ite$ !& Ra&ment et al.0 t#e role o/ ATP in ".eletal an$
car$iac m"cle contraction ma& !e to relea"e t#e m&o"in #ea$ /rom it" actin !in$ing
"ite an$ t#en to energi%e a con/ormational c#ange t#at re"et" t#e m&o"in #ea$ to
McontractN again t#e next time it !in$" to actin.
1*#oice" A an$ (2 *alcim !in$ing to tro)onin * "#i/t" tro)om&o"in a3a& /rom t#e
m&o"in !in$ing "ite on actin. T#e"e "te)" $o not $e)en$ $irectl& on ATP.
1*#oice D2 I/ ATP i" not a'aila!le0 t#e cro"",!ri$ge !et3een m&o"in an$ actin 3ill
)er"i"t 1rigor morti"2.
1*#oice E2 M&o"in lig#t c#ain .ina"e )#o")#or&late" t#e m&o"in lig#t c#ain0
acti'ating m&o"in to !in$ actin /ilament" in "moot# m"cle cell". T#ere i" no m&o"in
#ea$ )#o")#or&lation !& a ")eci/ic .ina"e in ".eletal m"cle contraction.
E$cational O!;ecti'e<
Dring t#e ".eletal m"cle contraction c&cle0 ATP !in$ing to m&o"in ca"e" relea"e
o/ t#e m&o"in #ea$ /rom it" !in$ing "ite on t#e actin /ilament.
30
Q NO 20: A" )art o/ an ex)eriment0 ra$iola!ele$ ATP i" in;ecte$ into ".eletal
m"cle. Dring m"cle contraction0 t#e la!ele$ ATP i" o!"er'e$ to attac# to
t#e "arcomere. T#i" attac#ment ca"e" imme$iate<
USMLE WORLD STEP 1
PHYSIOLOGY

A. Di//"ion limitation
(. Per/"ion limitation
*. Wa"te$ 'entilation 1$ea$ ")ace2
D. Keno" a$mixtre
E. S#i/t in t#e #emoglo!in $i""ociation cr'e
Explanation:
T#i" gra)# ill"trate" t#e ):- o/ !loo$ a" it mo'e" /rom t#e 'eno" "&"tem t#rog#
t#e lng" an$ into t#e "&"temic circlation. A" !loo$ enter" t#e rig#t #eart /rom t#e
'eno" "&"tem0 it #a" a lo3 ):- !eca"e mc# o/ it" ox&gen #a" !een remo'e$ /or
"e in t#e ti""e". (loo$ i" "!"e4entl& )m)e$ /rom t#e rig#t 'entricle into t#e
)lmonar& arterie" /or ox&genation in t#e lng". T#i" i" re)re"ente$ !& t#e cr'e7"
/ir"t )3ar$ $e/lection. +ormall&0 a" !loo$ mo'e" t#rog# t#e lng"0 it !ecome"
)rogre""i'el& ox&genate$ ntil it e4ili!rate" 3it# t#e al'eolar ):- 1):-20 3#ic# i"
generall& a!ot 1:= mmHg in t#e )lmonar& ca)illar& !e$". A/ter !ecoming /ll&
ox&genate$ in t#e )lmonar& ca)illarie"0 !loo$ retrn" to t#e le/t #eart 'ia t#e
)lmonar& 'ein". (loo$ in t#e le/t atrim #o3e'er0 #a" a lo3er ):- 11:: mmHg2
t#an !loo$ in t#e )lmonar& ca)illarie". T#i" $ecrea"e i" $e to t#e a$mixtre o/
$eox&genate$ !ronc#ial !loo$ 3it# !loo$ in t#e )lmonar& 'ein" an$ i" re)re"ente$
on t#e a!o'e gra)# !& t#e $o3n3ar$ $e/lection i$enti/ie$ !& t#e arro3.
T#e le/t an$ rig#t !ronc#ial arterie" ari"e /rom t#e $e"cen$ing t#oracic aorta. T#e"e
'e""el" carr& ox&genate$ !loo$ to t#e !ronc#i an$ !ronc#iole" an$ toget#er 3it# t#e
)lmonar& 'ein" /orm t#e $al !loo$ "))l& to t#e lng". W#ile !ronc#ial 'ein" $o
exi"t0 t#e ma;ori o/ !loo$ /rom t#e !ronc#ial arterie" i" retrne$ to t#e le/t #eart in
31
Q NO 21: T#e !loo$ ox&gen ten"ion cr'e /or an a))arentl& #ealt#& in$i'i$al i"
"#o3n !elo3. W#ic# o/ t#e /ollo3ing mo"t li.el& ex)lain" t#e ten"ion c#ange
in$icate$ !& t#e arro39
USMLE WORLD STEP 1
PHYSIOLOGY
$eox&genate$ /orm 'ia t#e )lmonar& 'ein". T#e !ronc#ial 'ein" retrn !loo$ to t#e
rig#t #eart 'ia t#e a%&go"0 acce""or& #emia%&go" or interco"tal" 'ein".
1*#oice A2 Di//"ion limitation i" a ca"e o/ #&)oxia t#at t&)icall& re"lt" /rom
)lmonar& /i!ro"i"0 a$lt re")irator& $i"tre"" "&n$rome0 em)#&"ema or #&aline
mem!rane $i"ea"e o/ t#e in/ant. In $i//"ion,limite$ ga" exc#ange0 t#e !loo$ ):-
$oe" not e4ili!rate 3it# t#e al'eolar ):- !& t#e en$ o/ t#e al'eolar ca)illar&. In
gra)# /orm0 t#ere 3ol$ !e no al'eolar !loo$ ):- )latea.
1*#oice *2 Wa"te$ 'entilation 1$ea$ ")ace2 re/er" to a 'olme o/ in")ire$ air t#at i"
not a'aila!le /or ga" exc#ange. T#e )#&"iologic 1anatomic2 $ea$ ")ace re/er" to t#e
'olme o/ air t#at remain" in t#e con$cting )art" o/ t#e air3a&"0 "c# a" t#e
!ronc#i an$ !ronc#iole". Al'eolar $ea$ ")ace re/er" to t#e 'olme o/ al'eolar air
t#at cannot tran"/er ox&gen to t#e !loo$ $e to ina$e4ate !loo$ /lo3.
1*#oice E2T#e #emoglo!in $i""ociation cr'e "#i/t" to t#e rig#t 3#en t#e ti""e
en'ironment /a'or" ox&gen nloa$ing. Increa"e" in )*O-0 tem)eratre an$5or -8,
$i)#o")#ogl&cerate concentration all ca"e "#i/ting o/ t#e H! $i""ociation cr'e to
t#e rig#t. T#e o))o"ite con$ition" "#i/t t#e cr'e to t#e le/t an$ /a'or ox&gen loa$ing
in t#e lng".
E$cational O!;ecti'e<
T#e ):- in t#e le/t atrim i" lo3er t#an t#at in t#e )lmonar& 'ein" !eca"e
$eox&genate$ !loo$ /rom t#e !ronc#ial arterie" mixe" 3it# ox&genate$ !loo$ in t#e
)lmonar& 'ein".
32
USMLE WORLD STEP 1
PHYSIOLOGY
A. Pro"taglan$in"
(. En$ot#elin
*. Angioten"in II
D. Al$o"terone
E. +atriretic )e)ti$e"
A. (ra$&.inin
Explanation:
Aro"emi$e i" a loo) $iretic t#at 3or." !& in#i!iting +a,6,-*1 "&m)orter" in t#e
a"cen$ing lim! o/ t#e loo) o/ Henle. It !in$" to "&m)orter" an$ e//ecti'el& !loc." +a
an$ *l tran")ort re"lting in increa"e$ +a0 *l an$ /li$ excretion. A$$itionall&0 loo)
$iretic" al"o "timlate )ro"taglan$in relea"e. Pro"taglan$in" #a'e 'a"o$ilator&
e//ect". T#" !& "timlating renal )ro"taglan$in relea"e0 loo) $iretic" al"o increa"e
renal !loo$ /lo3 lea$ing to increa"e$ GAR an$ en#ance$ $rg $eli'er&. (ot# /actor"
ltimatel& en#ance $iretic re")on"e.
+on,"teroi$al anti,in/lammator& $rg" li.e i!)ro/en0 na)roxen0 an$ in$omet#acin
in#i!it )ro"taglan$in "&nt#e"i". T#" concrrent "e o/ +SAID" 3it# loo) $iretic"
can re"lt in a $ecrea"e$ $iretic re")on"e.
1*#oice (2 En$ot#elin i" a )e)ti$e /on$ in "moot# m"cle" t#at ca"e" "moot#
m"cle contraction. It i" a 'er& )otent 'a"ocon"trictor. En$ot#elin $oe" not )la& a
role in t#e e//ect" o/ loo) $iretic".
1*#oice *2 Angioten"in II i" a )e)ti$e re")on"i!le /or 'a"ocon"triction an$
al$o"terone relea"e. Alt#og# loo) $iretic" $o "timlate renin relea"e lea$ing to
angioten"in II /ormation0 angioten"in II $oe" not )la& a role in t#e $iretic re")on"e
o/ loo) $iretic".
1*#oice D2 Al$o"terone i" a #ormone "ecrete$ !& t#e a$renal cortex. Al$o"terone
)romote" +a rea!"or)tion in t#e $i"tal t!le an$ t#e collecting $ct. Loo) $iretic"
$o not a//ect al$o"terone. Rat#er0 al$o"terone antagoni"t $iretic" li.e
")ironolactone 3or. !& in#i!iting al$o"terone.
1*#oice E2 +atriretic )e)ti$e" li.e A+P an$ (+P are natral )rotein" t#at #el)
reglate +a an$ /li$ !alance in t#e !o$&. T#e& ca"e 'a"o$ilation0 natrire"i"0 an$
$ire"i" in re")on"e to 'olme ex)an"ion. +e"iriti$e i" a (+P analog t#at i" "e$ in
t#e "etting o/ acte $ecom)en"ate$ #eart /ailre /or it" 'a"o$ilator& an$ $iretic
e//ect". +atriretic )e)ti$e" $o not )la& a role in t#e e//ect o/ loo) $iretic".
1*#oice A2 (ra$&.inin i" a )e)ti$e t#at "timlate" )ain0 'a"o$ilation0 an$ increa"e$
'a"clar )ermea!ilit&. It i" an im)ortant me$iator in t#e !o$&7" in/lammator&
re")on"e. (ra$&.inin $oe" not )la& a role in t#e e//ect" o/ loo) $iretic".
E$cational O!;ecti'e<
Aro"emi$e i" a loo) $iretic t#at 3or." !& in#i!iting +a,6,-*1 "&m)orter" in t#e
loo) o/ Henle e//ecti'el& ca"ing increa"e$ +a0 *l0 an$ /li$ excretion. A$$itionall&0
loo) $iretic" al"o "timlate )ro"taglan$in relea"e. (& "timlating renal
)ro"taglan$in relea"e0 loo) $iretic" al"o increa"e renal !loo$ /lo3 lea$ing to
increa"e$ GAR an$ en#ance$ $rg $eli'er&. T#" concrrent "e o/ +SAID? 3it#
loo) $iretic" can re"lt in a $ecrea"e$ $iretic re")on"e.
33
Q NO 22: A =8,&ear,ol$ male i" $iagno"e$ 3it# #e)atic cirr#o"i" $e to )rolonge$
#ea'& alco#ol con"m)tion. He $e'elo)" ma""i'e a"cite" an$ lo3er extremit&
e$ema t#at re")on$" 3ell to /ro"emi$e t#era)&. Ho3e'er0 a 3ee. later t#e
)atient recei'e" #ig#,$o"e i!)ro/en /or ;oint )ain" an$ "oon $e'elo)" 3or"ening
a!$ominal $i"tention. (lnting o/ t#e $iretic re")on"e in t#i" )atient i" $e to
interr)tion o/ 3#ic# o/ t#e /ollo3ing "!"tance"9
USMLE WORLD STEP 1
PHYSIOLOGY
A. Maximal excretion rate i" reac#e$
(. Maximal rea!"or)tion rate i" reac#e$
*. *arrier tran")ort i" "atrate$
D. Ailtration /raction i" $ecrea"e$
E. Renal )la"ma /lo3 i" $ecrea"e$
Explanation:
Para,amino#i))ric aci$ 1PAH2 i" an organic aci$ t#at i" a'i$l& /iltere$ /rom t#e
!loo$ in t#e glomerl" an$ "ecrete$ !& t#e cell" lining t#e )roximal t!le o/ t#e
ne)#ron. (eca"e PAH i" !ot# /iltere$ an$ "ecrete$ !& t#e glomerl" an$ renal
t!le"0 t#e calclate$ clearance o/ t#i" aci$ can !e "e$ to e"timate t#e renal
)la"ma /lo3 1RPA2.
T#e /iltration o/ PAH i" not a )roce"" t#at can !e "atrate$. At an& gi'en !loo$
concentration0 a con"tant )ro)ortion o/ PAH 3ill !e /iltere$ /rom t#e glomerlar
ca)illarie" into t#e t!lar /li$ in (o3man7" ")ace. A" t#e !loo$ PAH concentration
increa"e" t#e t!lar /li$ PAH concentration in (o3man7" ")ace 3ill al"o increa"e
on a linear !a"i".
In a$$ition to !eing /reel& /iltere$0 PAH i" al"o ta.en ) !& t#e )roximal t!lar
e)it#elial cell" /rom t#e )erit!lar ca)illarie" an$ "ecrete$ into t#e t!lar /li$.
T#i" "ecretion i" a carrier en%&me,me$iate$ )roce"" an$ t#ere/ore i" a!le to !e
"atrate$. A" t#e !loo$ concentration o/ PAH increa"e"0 t#e "ecretion o/ PAH !&
)roximal t!lar e)it#elial cell" increa"e"H!t onl& ) to a maximm 'ale o/
a))roximatel& @: mg5mm. T#i" maximm "ecretion rate corre")on$" 3it# t#e
tran")ort maximm 1TMAQ2 o/ t#e "ecretion en%&me" an$ at t#i" le'el "ecretion
)latea" an$ an& increa"e" in t#e rine PAH concentration are $e to increa"e$
/iltration.
1*#oice A2 Excretion o/ a "!"tance i" $e/ine$ a" t#e /iltration )l" t#e "ecretion
min" t#e rea!"or)tion. Once carrier,me$iate$ "ecretion an$ rea!"or)tion
mec#ani"m" are "atrate$ t#e"e )roce""e" are at t#eir maximal rate. Ailtration0
#o3e'er i" not en%&me or )rotein me$iate$ "o it $oe" not "#o3 a maximal 'ale.
(eca"e /iltration can not !e "atrate$ neit#er can excretion.
1*#oice (2 T#e maximal rea!"or)tion rate $oe" not a))l& to PAH0 3#ic# i" a "ecrete$
"!"tance. Glco"e i" an exam)le o/ a "!"tance t#at i" aggre""i'el& rea!"or!e$ in
t#e )roximal t!le. Un$er normal con$ition" no glco"e i" lo"t in t#e rine0 $e")ite
t#e /act t#at glco"e i" /iltere$ into (o3man7" ")ace. In ncontrolle$ $ia!ete"
#o3e'er glco"e i" "een in t#e rine !eca"e t#e rea!"or)tion carrier )rotein"
!ecome "atrate$ at 'er& #ig# glco"e concentration".
34
Q NO 23: It i" e"timate$ t#at /or )ara,amino#i))ric aci$ 1PAH2 t#e extraction ratio
1arterial )la"ma PAH min" 'eno" )la"ma PAH $i'i$e$ !& arterial )la"ma PAH2 i"
near G:U at arterial )la"ma concentration" lo3er t#an -: mg5$L. Once t#e )la"ma
concentration o/ PAH i" increa"e$ a!o'e t#i" le'el t#e extraction ratio $ecrea"e"
)rogre""i'el&. W#ic# o/ t#e /ollo3ing !e"t ex)lain" t#e o!"er'e$ $ecrea"e in t#e PAH
extraction ratio9
USMLE WORLD STEP 1
PHYSIOLOGY
1*#oice D2 T#e /iltration /raction i" $ecrea"e$ !& $ecrea"e" in GAR or increa"e" in
PA.
1*#oice E2T#e renal )la"ma /lo3 1RPA2 i" $ecrea"e$ !& /actor" t#at con"trict !loo$
'e""el" in t#e .i$ne& "c# a" e)ine)#rine nore)ine)#rine an$ angioten"in II.
E$cational O!;ecti'e<
Para,amino#i))ric aci$ 1RAH2 i" /reel& /iltere$ /rom t#e !loo$ in t#e glomerlar
ca)illarie" to t#e t!lar /li$ in (o3man7" ")ace. Iti" al"o "ecrete$ /rom t#e !loo$
into t#e t!lar /li$ !& t#e cell" o/ t#e )roximal t!le !& a carrier Protein,
me$iate$ )roce"". T#e "ecretion o/ PAH can !e "atrate$ at #ig# !loo$
concentration".
35
USMLE WORLD STEP 1
PHYSIOLOGY
Mo'ement o/ 3#ic# o/ t#e /ollo3ing ion" or com!ination" o/ ion" create" t#e
$e/lection in$icate$ !& t#e arro39
A. So$im
(. Pota""im
*. *alcim
D. *#lori$e
E. So$im an$ )ota""im
A. So$im an$ calcim
Explanation:
T#e gra)#" a!o'e ill"trate t#e action )otential" o/ t3o $i//erent cell t&)e". T#e
arro3 )oint" to an area o/ t#e )acema.er cell action )otential.
36
Q NO 24: S)ecial electro$e" are "e$ to recor$ t#e mem!rane )otential c#ange" o/
$i//erent car$iac m"cle cell" 1"ee !elo32.
USMLE WORLD STEP 1
PHYSIOLOGY
Pacema.er cell" are ni4e in t#at t#e& ex#i!it atomaticit& 1an in#erent a!ilit& to
$e)olari%e 3it#ot an& external incen"e2. Atomaticit& i" ma$e )o""i!le !& a "lo3
in3ar$ "o$im ion crrent t#at occr" $ring )#a"e = o/ t#e )acema.er action
)otential0 "ometime" re/erre$ to a" t#e M/nn& crrent 1L2 . A" t#e /nn& crrent
!ring" t#e mem!rane )otential clo"erto,=:mK0 )#a"e : $e)olari%ation occr".
De)olari%ation i" ca"e$ !& a calcim ion in/lx in )acema.er cell". T#e arro3 a!o'e
in$icate" )#a"e : o/ t#e )acema.er action )otential. Pacema.er cell $e)olari%ation i"
/ollo3e$ !& )#a"e 8 o/ t#e action )otential0 3#ic# re"lt" /rom an ot3ar$ )ota""im
crrent. Pacema.er cell action )otential" $o not #a'e )#a"e" 1 or -.
In t#e 'entriclar m&oc&te0 )#a"e = corre")on$" to t#e re"ting mem!rane )otential
an$ i" t&)icall& "ta!le at a))roximatel&,G: mK 1near t#e e4ili!rim )otential o/
)ota""im2. P#a"e : o/ t#e 'entriclar action )otential i" me$iate$ !& a ra)i$ "o$im
ion in/lx0 in contra"t to t#e *a,me$iate$ $e)olari%ation o/ )acema.er cell". P#a"e 1
i" an earl& "#ort re)olari%ation t#at occr" imme$iatel& a/ter t#e ra)i$
$e)olari%ation0 me$iate$ !& an increa"e$ ot/lo3 o/ )ota""im ion" an$ a $ecrea"e$
"o$im ion con$ctance. P#a"e - i" t#e )latea )#a"e o/ t#e action )otential0 3#ere
in3ar$ calcim crrent conteract" t#e ot3ar$ mo'ement o/ )ota""im ion" t#at
"tarte$ in )#a"e 1. P#a"e 8 i" t#e re)olari%ation )#a"e1 3#ere )ota""im ion" r"#
ot o/ t#e cell an$ calcim con$ctance i" $ecrea"e$.
E$cational O!;ecti'e<
In )acema.er cell"0 )#a"e : $e)olari%ation i" me$iate$ !& an in3ar$ /lx o/ calcim
ion". T#i" $i//er" /rom )#a"e : o/ 'entriclar cell"0 3#ic# re"lt" /rom an in3ar$
"o$im ion crrent.
37
USMLE WORLD STEP 1
PHYSIOLOGY

A. ASH
(. LH
*. in#i!in (
D. Te"to"terone
E. DHEA
Explanation:
Pl"atile "ecretion o/
gona$otro)#in relea"ing
#ormone /rom t#e
#&)ot#alam" "timlate" t#e
relea"e o/ /olliclar "timlating #ormone 1ESH2 an$ lteini%ing #ormone 1LH2 /rom
t#e gona$otro)# cell" in t#e anterior )ititar&. LH "timlate" t#e relea"e o/
te"to"terone /rom t#e Le&$ig cell" o/ t#e te"ticle" an$ ASH "timlate" t#e relea"e o/
in#i!in ( /rom t#e Sertoli cell" o/ t#e "emini/ero" t!le" o/ t#e te"ticle".
Te"to"terone an$ in#i!in ( create negati'e /ee$!ac. on LH an$ ESH0 re")ecti'el&.
ESH al"o "timlate" t#e Sertoli cell" to )ro$ce "omet#ing calle$ Man$rogen !in$ing
)roteinN locall&0 3it#in t#e "emini/ero" t!le". T#i" an$rogen,!in$ing )rotein i"
re")on"i!le /or t#e #ig# local te"to"terone concentration. Hig# local le'el" o/
te"to"terone an$ ESH are nece""ar& /or ")ermatogene"i". De/ecti'e ESH rece)tor"
3ill ca"e lo"" o/ ")ermatogene"i"0 a" 3ell a" lo3 in#i!in ( le'el"0 !eca"e ESH i"
re")on"i!le /or !ot# ")ermatogene"i" an$ in#i!in ( )ro$ction.
1*#oice A2 ESH 3ill !e #ig# in )atient" 3it# ESH rece)tor $e/ect" !eca"e t#ere 3ill
not !e an& negati'e /ee$!ac. /rom in#i!in (0 a" in#i!in ( cannot !e )ro$ce$
3it#ot )ro)er /nctioning o/ ESH an$ t#e ESH rece)tor" 1"ee a!o'e $iagram2.
1*#oice" ( an$ D2 LH an$ te"to"terone le'el" are li.el& to !e normal in t#i" )atient
!eca"e ESH $oe" not )la& a role in eit#er LH or te"to"terone /ee$!ac. 1"ee a!o'e
$iagram2. I/ t#e ASH rece)tor $e/ect i" trl& i"olate$ t#i" )atient 3ill #a'e normal
te"to"terone an$ LH le'el".
1*#oice E2 T#e circlating le'el" o/ ot#er an$rogen" "c# a" DHEA0 DHEAS an$
an$ro"tene$ione are al"o not a//ecte$ !& ESH.
E$cational O!;ecti'e<
LH "timlate" t#e relea"e o/ te"to"terone /rom t#e Le&$ig cell" o/ t#e te"te"< ESH
"timlate" t#e relea"e o/ in#i!in ( /rom t#e Sertoli cell" in t#e "emini/ero" t!le".
Te"to"terone an$ in#i!in ( )ro'i$e negati'e /ee$!ac. o/ LH an$ ESH0 re")ecti'el&.
38
Q NO 25: A -?,&ear,ol$ male i" e'alate$ /or in/ertilit&. La! "t$ie" re'eal a lo3
")erm cont. A more t#orog# e'alation elci$ate" a rare genetic a!normall&
t#at lea$" to t#e inacti'ation o/ ESH rece)tor". W#ic# o/ t#e /ollo3ing "!"tance"
i" mo"t li.el& $ecrea"e$ in t#i" )atient9
USMLE WORLD STEP 1
PHYSIOLOGY
A. Ex)irator& /lo3 rate"
(. Ela"tic recoil o/ t#e lng"
*. Wor. o/ !reat#ing
D. Plmonar& arterial re"i"tance
E. K5T ratio
Explanation:
T#e main )lmonar& e//ect o/ increa"e$ 'ag" ner'e e//erent acti'it& i" !ronc#ial
"moot# m"cle con"triction. T#i" e//ect i" me$iate$ !& acet&lc#oline /rom
)o"tganglionic )ara"&m)at#etic neron" acting on m"carinic rece)tor".
Acet&lc#oline al"o act" on t#e M8 rece)tor" o/ mco" glan$" in t#e !ronc#ial
"!mco"a0 ca"ing increa"e$ "ecretion". (ronc#ocon"triction an$ increa"e$ mc"
"ecretion 3ol$ increa"e air/lo3 re"i"tance an$ t#ere/ore increa"e t#e 3or. o/
!reat#ing.
1*#oice (2 Increa"ing 'ag" ner'e acti'it& 3ol$ not "igni/icantl& a//ect lng ela"tic
recoil.
1*#oice D2T#e atonomic ner'o" "&"tem exerci"e" onl& 3ea. control o'er t#e
)lmonar& circlation. Increa"e$ )ara"&m)at#etic acti'it& ma& !e 3ea.l&
'a"o$ilator&. 1(ot# R, an$ V,a$renergic rece)tor" are )re"ent on t#e )lmonar&
'a"clatre. Increa"e$ "&m)at#etic tone can ca"e "ome 'a"ocon"triction o/ t#e
larger )lmonar& arterie".2
1*#oice E2 Increa"e$ air3a& re"i"tance mig#t $ecrea"e total lng 'entilation 1K2 $e
to increa"e$ 3or. o/ !reat#ing. H&)oxic )lmonar& 'a"o con"triction mig#t t#en
$ecrea"e total lng )er/"ion 1:2. T#ere 3ol$ not !e a net increa"e in t#e total K5:
ratio.
E$cational O!;ecti'e<
Stimlation o/ t#e 'ag" ner'e !ranc#e" "))l&ing t#e lng 3ol$ ca"e
!ronc#ocon"triction an$ increa"e$ !ronc#ial mc" "ecretion. T#e"e e//ect" 3ol$
increa"e air3a& re"i"tance an$ t#e 3or. o/ !reat#ing.
39
Q NO 26: (ronc#i are ric#l& inner'ate$ !& t#e atonomic ner'o" "&"tem. W#ic# o/
t#e /ollo3ing )arameter" 3ol$ increa"e mo"t a" a re"lt o/ 'agal "timlation9
USMLE WORLD STEP 1
PHYSIOLOGY

A. J1:mmHg
(. J?mmHg
*. :
D. ,?mmHg
E. ,1:mmHg
Explanation:
T#e gra)# in t#e 4e"tion "tem i" a )re""re,'olme cr'e t#at $emon"trate" t#e
com)liance o/ t#e lng an$ t#e c#e"t 3all 1i$enti/ie$ !& la!el"2 an$ t#e net com!ine$
com)liance o/ t#e"e "trctre" $ring in")iration 1t#e cr'e mar.e$ !& )oint A2. De
to t#e ela"ticit& o/ t#e lng"0 t#e al'eolar tran"mral )re""re i" al3a&" )o"iti'e0
re"lting in a )er)etal colla)"ing /orce on t#e lng"> t#i" i" 3#& t#e cr'e mar.e$
MlngN i" al3a&" a )o"iti'e 'ale. In'er"el& t#e c#e"t 3all ten$" to tran"mit an
ex)an$ing /orce at a !a"eline0 re"lting in a )o"iti'e tran"mral )re""re acro"" t#e
c#e"t 3all at all time"0 exce)t $ring maximal in")iration0 a" ill"trate$ on t#e a!o'e
gra)#. T#e"e t3o /orce"0 t#e )o"iti'e al'eolar tran"mral )re""re an$ t#e negati'e
c#e"t 3all tran"mral )re""re o))o"e one anot#er e4all& at t#e /nctional re"i$al
ca)acit& 1AR*2 re"lting in an air3a& )re""re o/ %ero. T#" at t#e ER*I t#e air3a&
)re""re i" %ero an$ t#ere i" no ten$enc& /or air to /lo3 eit#er into or ot o/ t#e
lng" at t#i" )oint.
40
Q NO 27: T#e lng an$ c#e"t 3all com)liance cr'e" /or a #ealt#& in$i'i$al are
"#o3n on t#e "li$e !elo3. W#ic# o/ t#e /ollo3ing i" t#e !e"t e"timate o/ t#e
intra)leral )re""re at )oint A9
USMLE WORLD STEP 1
PHYSIOLOGY
T#e 4e"tion "tem0 #o3e'er0 $oe" not a". a!ot t#e air3a& )re""re> it a"." 3#at
t#e intra)leral )re""re i" mo"t li.el& to !e at t#e AR*. At t#e AR*0 t#e intra)leral
)re""re i" negati'e 3it# a 'ale o/ a))roximatel&,? mmHg. T#e )re"ence o/ t#i"
negati'e )re""re can !e ill"trate$ clinicall& $ring a tramatic in;r& t#at exten$"
into t#e intra)leral ")ace0 "c# a" a "ta! 3on$ or !& t#e acci$ental in"ertion o/ a
nee$le0 a" ma& occr $ring "!cla'ian central cat#eter )lacement. W#en )nctre
o/ t#e )lera allo3" commnication 3it# atmo")#eric )re""re0 t#e negati'e
intra)leral )re""re e4ili!rate" 3it# atmo")#eric )re""re /a'oring air entr& into
t#e intra)leral ")ace> i.e. a )nemot#orax 3ill $e'elo) a" t#e lng ")ring" in3ar$
1colla)"e"2 an$ t#e c#e"t 3all ")ring" ot3ar$.
E$cational O!;ecti'e<
T#e center o/ t#e air3a& )re""re,'olme cr'e i" t#e /nctional re"i$al ca)acit&
1AR*2 o/ t#e lng"0 an$ it i$enti/ie" t#e re"ting "tate 3#ere t#e air3a& )re""re
e4al" %ero. At t#e ER*I t#e intra)leral )re""re i" "lig#tl& negati'e 3it# a 'ale o/
H? mmHg.
41
USMLE WORLD STEP 1
PHYSIOLOGY
A. Ka"o)re""in i" relea"e$ $e to !loo$ 'olme c#ange"
(. Ka"o)re""in i" relea"e$ $e to !loo$ o"molarit& c#ange"
*. Ka"o)re""in i" relea"e$ $e to !loo$ 'olme an$ o"molarit& c#ange"
D. Ka"o)re""in i" relea"e$ $e to #&)oreninemia
E. Ka"o)re""in "ecretion i" in#i!ite$ $e to !loo$ 'olme c#ange"
A. Ka"o)re""in "ecretion i" in#i!ite$ $e to !loo$ o"molarit& c#ange"
Explanation:
Mo$erate or "e'ere #ea$ in;rie" o/ten re"lt in increa"e$ intracranial )re""re
"econ$ar& to cere!ral "3elling. Mlti)le treatment" exi"t to re$ce t#e total !rain
'olme incl$ing $iretic a$mini"tration )er/"ion agmentation0 meta!olic
"))re""ion0 an$ $ecom)re""i'e "rgical )roce$re".
Diretic" are extremel& e//ecti'e at $ecrea"ing !rain 'olme 1an$0 t#ere/ore at
lo3ering intracranial )re""re2> one o/ t#e mo"t commonl& "e$ /or t#i" )r)o"e i"
mannitol0 an o"motic $iretic 3it# ra)i$ on"et. A "gar alco#ol t#at )ll" t#e exce""
3ater /rom t#e !rain into t#e intra'a"clar com)artment0 mannitol can 4ic.l&
in$ce a #&)er o"molal "tate. It" $iretic e//ect i" "o )o3er/l t#at electrol&te" an$
"erm o"molalit& m"t !e clo"el& monitore$ $ring "age to en"re t#at t#e )atient
remain" e'olemic. In re")on"e to t#e mannitol,in$ce$ ri"e in !loo$ o"molalit& an$
$ecrea"e in !loo$ 'olme t#e )o"terior )itita relea"e" 'a"o)re""in 1anti$iretic
#ormone CADHW2to limit t#e amont o/ 3ater excrete$ !& t#e .i$ne&".
More ")eci/icall&0 3#en o"molalit& increa"e"0 t#e #&)ot#alamic o"morece)tor cell"
"#rin. an$ "en$ "ignal" to t#e ")rao)tic an$ )ara'entriclar nclei. T#e"e nclei in
trn "en$ im)l"e" to t#e )o"terior )ititar& t#at )rom)t t#e relea"e o/ ADH.
Secon$l& a re$ction in t#e circlating !loo$ 'olme 1e")eciall& in exce"" o/ 1:U2
ca"e" an inten"e increa"e in )la"ma ADH. Sc# $ro)" in !loo$ 'olme are $etecte$
!& arterial !arorece)tor" 1eg0 caroti$ "in"2 an$ t#rog# $ecrea"e$ "tretc# o/ t#e
le/t atrim an$ t#e )lmonar& 'ein".
1*#oice" A an$ (2 *#ange" in !loo$ 'olme or !loo$ o"molalit& alone $o not entirel&
ex)lain t#e "timl" /or 'a"o)re""in relea"e.
1*#oice D2 Dimini"#e$ renal !loo$ /lo3 "timlate" t#e relea"e o/ renin0 3#ic# in trn
increa"e" angioten"in II )ro$ction. Angioten"in II act" on t#e !rain to "timlate
ADH relea"e. T#ere/ore #&)erreninemia 1not #&)oreninemia2 can contri!te to an
increa"e in 'a"o)re""in le'el".
1*#oice" E an$ A2 Ka"o)re""in i" "timlate$ ,, not in#i!ite$ ,, !& c#ange" in !loo$
'olme or !loo$ o"molalit&.
E$cational O!;ecti'e<
T#e a$mini"tration o/ mannitol in$ce" #&)ero"molarit& an$ re$ce$ !loo$ 'olme
!ot# o/ 3#ic# are "trong "timli /or 'a"o)re""in relea"e.
42
Q NO 28: A 8=,&ear,ol$ con"trction 3or.er lo"e" con"cio"ne"" a/ter #ea$
trama. Aollo3ing an initial e'alation t#at incl$e$ a #ea$ *T "can0 intra'eno"
mannitol i" a$mini"tere$. W#ic# o/ t#e /ollo3ing i" mo"t li.el& to #a))en "#ortl&
a/ter t#e in/"ion "tart"9
USMLE WORLD STEP 1
PHYSIOLOGY

A. Arterial re"i"tance
(. Mean arterial )re""re
*. Dia"tolic arterial )re""re
D. Dri'ing )re""re /or !loo$ /lo3
E. (loo$ /lo3 )er minte
A. Arterial ox&gen content
Explanation:
Un$er normal con$ition" in a #ealt#& a$lt li'ing at "ea le'el0 t#e )lmonar&
circlation i" a lo3,)re""re #ig#,/lo3 "&"tem. In or$er to )ro'i$e contino" !loo$
/lo3 to t#e !o$& t#e !loo$ /lo3 )er minte 1mL5min2 in t#e )lmonar& circlation
m"t !e i$entical to t#e !loo$ /lo3 in t#e "&"temic circlation. T#i" i" tre /or
con$ition" o/ !ot# exerci"e an$ re"t. I/ t#e /lo3 o/ !loo$ t#rog# t#e )lmonar&
circlation 3ere "lo3er t#an t#e /lo3 o/ !loo$ in t#e "&"temic circlation t#e le/t
'entricle 3ol$ "oon em)t& com)letel&. Alternati'el&0 i/ t#e /lo3 o/ !loo$ 3ere /a"ter
in t#e )lmonar& circlation t#an in t#e "&"temic circlation t#e le/t 'entricle 3ol$
"oon !e o'erloa$e$. (eca"e t#e circlator& "&"tem i" a contino" circit t#e
'olme ot)t o/ t#e le/t 'entricle m"t e4al t#e ot)t o/ t#e rig#t 'entricle at all
time". T#e lo3 alter loa$ )re""re" o/ t#e )lmonar& circlation allo3 t#e t#in rig#t
'entricle to .ee) )ace 3it# t#e more "!"tantial le/t 'entricle.
1*#oice A2 T#e arterial re"i"tance in t#e "&"temic circlation i" con"i$era!l& #ig#er
t#an t#at in t#e )lmonar& circlation in all "cenario". T#e re"i"tance o/ t#e
)lmonar& 'a"clatre ma&!e increa"e$ in in$i'i$al" li'ing at #ig# altit$e"0 in
)atient" 3it# i$io)at#ic )lmonar& #&)erten"ion0 etc.
1*#oice" (0 * an$ D2 T#e mean arterial )re""re $ia"tolic arterial )re""re an$
$ri'ing )re""re /or !loo$ /lo3 1"&"tolic arterial )re""re2 are con"i$era!l& $i//erent
in t#e )lmonar& an$ "&"temic circlation" !ot# at re"t an$ $ring exerci"e. T#e
normal "&"temic !loo$ )re""re i" 1-:1@: mmHg 3#ile t#e normal mean )lmonar&
arterial )re""re i" 1= mmHg. T#e )lmonar& arterial !loo$ )re""re increa"e" !&
onl& a /e3 mm Hg $ring maximal exerci"e $e")ite t#e /act t#at t#e rate o/ !loo$
/lo3 increa"e" ?,to D,/ol$.
1*#oice A2T#e arterial ox&gen content" o/ t#e )lmonar& an$ "&"temic circlation"
are $ramaticall& $i//erent $e to t#e /act t#at t#e !loo$ in t#e )lmonar& arterial
circlation i" $eox&genate$ an$ t#e !loo$ in t#e "&"temic arterial circlation i"
ox&genate$.
E$cational O!;ecti'e<
T#e )lmonar& circlation i" )art o/ a contino" circit 3it# t#e "&"temic
circlation. T#e rate o/ !loo$ /lo3 t#rog# t#e )lmonar& circlation m"t e4al t#e
rate o/ !loo$ /lo3 in t#e "&"temic circlation at all time". T#e arterial )re""re" an$
ox&gen content" o/ t#e )lmonar& an$ "&"temic arterial "&"tem" are con"i$era!l&
$i//erent !ot# at re"t an$ $ring exerci"e.
43
Q NO 29: A -8,&ear,ol$ militar& recrit !egin" ")ecial training t#at in'ol'e" #ig#,i
inten"it& )#&"ical exerci"e. At t#e )ea. o/ t#e exerci"e0 3#ic# o/ t#e /ollo3ing
)arameter" i" t#e "ame in t#e "&"temic an$ )lmonar& circlation"9
USMLE WORLD STEP 1
PHYSIOLOGY
A.
H&)oglo""al
(. Acce""or&
*. Trigeminal
D. Glo""o)#ar&ngeal
E. Kagal
Explanation:
Arterial !arorece)tor" )ro'i$e con"tant monitoring o/ t#e "&"temic !loo$ )re""re.
(arorece)tor" "en"e arterial 3all "tretc#0 an in$icator o/ t#e "&"temic )re""re in t#e
arterial circlation. W#en "timlate$ !& "tretc# t#e ner'e" inner'ating !arorece)tor"
)ro$ce an increa"e$ nm!er o/ "ignal". T#e re"lt i" a !loo$ )re""re $ecrea"e
t#rog# )eri)#eral 'a"o$ilatation an$ $ecrea"e$ car$iac ot)t 1$ecrea"e$
contractilit&5"tro.e 'olme an$ $ecrea"e$ #eart rate2. *on'er"el& #&)oten"ion lea$"
to $ecrea"e$ !arorece)tor "ignaling0 3#ic# relea"e" in#i!ition o/ t#e 'a"ocon"trictor
center an$ increa"e" t#e !loo$ )re""re.
44
Q NO 30: A E?,&ear,ol$ male lo"e" con"cio"ne"" 3#ile !ttoning a tig#t "#irt
collar. He re)ort" t#at t#i" #a" #a))ene$ "e'eral time" in t#e )a"t. Hi" !loo$
)re""re 3a" D:5=: mmHg an$ #i" #eart rate 3a" =?5mm $ring one o/ t#e
e)i"o$e". Stimlation o/ 3#ic# o/ t#e /ollo3ing ner'e" i" mo"t li.el&
re")on"i!le9
USMLE WORLD STEP 1
PHYSIOLOGY
T#e caroti$ "in" an$ aortic arc# !arorece)tor" are e")eciall& im)ortant in !loo$
)re""re control. T#e caroti$ "in" i" a $ilatation o/ t#e internal caroti$ arter&
locate$ ;"t a!o'e t#e !i/rcation o/ t#e common caroti$ arter&. A//erent /i!er" /rom
caroti$ "in" "tretc# rece)tor" /orm a "mall caroti$ "in" ner'e0 Hering7" ner'e0
3#ic# i" a !ranc# o/ t#e glo""o)#ar&ngeal ner'e 1*+ IQ2 1*#oice D2. Ai!er" /rom t#e
aortic arc# !arorece)tor" rn 3it#in t#e 'ag" ner'e 1*+Q2 1*#oice E2. A//erent
/i!er" /rom !ot# "et" o/ !arorece)tor" terminate in t#e "olitar& ncle" o/ t#e
me$lla.
External )re""re on t#e caroti$ "in"e"0 a" $e"cri!e$ in t#e 4e"tion "tem0 ca"e"
t#e !arorece)tor" to react a" i/ t#ere 3a" a "&"temic !loo$ )re""re increa"e. T#e&
increa"e t#eir in#i!itor& $i"c#arge" in re")on"e0 ca"ing !ra$&car$ia0 #&)oten"ion0
an$ "ometime" "&nco)e. Sc# caroti$ "in" "&nco)e ten$" to occr in )atient" 3it#
'er& "en"iti'e caroti$ "in"e".
1*#oice" A0 ( an$ *2 T#e #&)oglo""al 1*+ QII20 acce""or& 1*+ Ql2 an$ trigeminal
1*+K2 ner'e" $o not tran"mit "ignal" /rom t#e caroti$ "in" !arorece)tor". T#e
#&)oglo""al ner'e )rimaril& control" t#e m"cle" o/ t#e tonge0 t#e acce""or& ner'e
control" t#e "ternoclei$oma"toi$ an$ t#e tra)e%i" m"cle" an$ t#e trigeminal ner'e
)rimaril& me$iate" /acial "en"ation.
E$cational O!;ecti'e<
T#e caroti$ "in" i" a $ilatation o/ t#e internal caroti$ arter& t#at lie" at t#e
!i/rcation o/ t#e caroti$ arter&. (loo$ )re""re increa"e" or external )re""re on
t#e caroti$ "in"e" "timlate !arorece)tor" in t#e caroti$ "in" 3all" lea$ing to
'a"o$ilatation0 a $ecrea"e in #eart rate an$ contractilit&0 an$ a $ecrea"e in !loo$
)re""re.
45
USMLE WORLD STEP 1
PHYSIOLOGY

A.
(a"al "ecretion
(. *e)#alic )#a"e
*. Ga"trin relea"e
D. Inte"tinal in/lence"
E. Rece)ti'e relaxation
A. Po"t)ran$ial al.aline ti$e
Explanation:
*la""icall&0 t#e "timlation o/ aci$ "ecretion 3it#in t#e "tomac# i" "e)arate$ into
t#ree )#a"e"< ce)#alic0 ga"tric0 an$ inte"tinal. T#e ce)#alic )#a"e i" me$iate$
)rimaril& !& c#olinergic an$ 'agal mec#ani"m"0 an$ i" triggere$ !& t#e t#og#t0
"ig#t0 "mell0 an$ ta"te o/ /oo$. T#e ga"tric )#a"e i" me$iate$ !& t#e )re"ence o/
ga"trin 13#ic# "timlate" #i"tamine "ecretion an$ t#ere/ore in$irectl&0 aci$
"ecretion20 an$ i" triggere$ !& t#e c#emical "timl" o/ /oo$ an$ $i"ten"ion o/ t#e
"tomac#. T#e inte"tinal )#a"e i" initiate$ 3#en )rotein,containing /oo$ enter" t#e
$o$enm !t t#i" )#a"e )la&" onl& a minor role in "timlating ga"tric aci$
"ecretion.
In /act0 inte"tinal in/lence" are e//ecti'e in $o3n,reglating ga"tric aci$ "ecretion
a/ter a meal. T#e ilem an$ colon relea"e )e)ti$e W0 3#ic# !in$" to rece)tor" on t#e
en$ocrine0 #i"tamine,containing cell" $e"cri!e$ a" enteroc#roma//in,li.e 1E*L"2.
Sc# !in$ing conteract" t#e ce)#alic an$ ga"tric )#a"e" o/ aci$ "ecretion !&
in#i!iting ga"trin,"timlate$ #i"tamine relea"e /rom E*L". Ot#er /actor" t#at in#i!it
aci$ "ecretion incl$e "omato"tatin an$ )ro"taglan$in".
1*#oice A2 (a"al ga"tric "ecretion #a" !een $e/ine$ a" t#e ga"tric ;ice" "ecrete$ in
t#e a!"ence o/ intentional or a'oi$a!le "timli 1e""entiall&0 t#e M!a"elineN ga"tric
aci$ "ecretion2. (a"al ga"tric "ecretion i" not an im)ortant /actor in t#e $o3n,
reglation o/ )o"t)ran$ial ga"tric "ecretion.
1*#oice" ( an$ *2 T#e ce)#alic an$ ga"tric )#a"e" !ot# "timlate ga"tric aci$
"ecretion not $o3n,reglate it.
1*#oice E2 Rece)ti'e relaxation i" a re/lex t#at allo3" t#e ga"tric /n$" to $ilate in
antici)ation o/ /oo$ )a""ing t#rog# t#e )#ar&nx an$ e"o)#ag". It i" not an
im)ortant /actor in t#e $o3n,reglation o/ )o"t)ran$ial ga"tric "ecretion.
1*#oice A2 Po"t)ran$ial al.aline ti$e i" $e/ine$ a" an increa"e in )la"ma H*:8 an$
$ecrea"e in )la"ma *A "econ$ar& to t#e "rge o/ aci$ 3it#in t#e ga"tric lmen. It i"
not an im)ortant /actor in t#e $o3n,reglation o/ )o"t)ran$ial ga"tric "ecretion.
E$cational O!;ecti'e<
T#e ce)#alic an$ ga"tric )#a"e" "timlate ga"tric aci$ "ecretion 3#ile inte"tinal
in/lence" ten$ to re$ce ga"tric aci$ "ecretion.
46
Q NO 31: Ex)erimental ga"tric /nction monitoring in #ealt#& "!;ect" !e/ore0
$ring an$ a/ter a meal "#o3" an initial ri"e0 )ea.0 an$ t#en $ecline in ga"tric
aci$ )ro$ction. W#ic# o/ t#e /ollo3ing" #el)" mo"t to $o3n,reglate ga"tric
"ecretion a/ter a meal9
USMLE WORLD STEP 1
PHYSIOLOGY
A.
Sco)olamine
(. Met#ac#oline
*. P#enox&!en%amine
D. I"o)roterenol
E. I)ratro)im !romi$e
Explanation:
T#e )atient $e"cri!e$ in t#e 4e"tion "tem i" ex)eriencing re")irator& $i//icltie"
t#at ma& !e attri!ta!le to a"t#ma. A"t#ma i" an o!"trcti'e air 3a& $i"ea"e t#at
occr" $e to #&)er"en"iti'it& o/ t#e con$cting air3a&" to 'ario" "timli0 incl$ing
)#&"ical0 c#emical0 an$ allergenic irritant".
T#e $iagno"i" o/ a"t#ma i" t&)icall& ma$e !& ")irometr&. Hi"tor& can ai$ in rai"ing
t#e "")icion o/ a"t#ma i/ a )atient #a" a )er"onal or /amil& #i"tor& o/ ot#er $i"ea"e"
in t#e Mallergic tria$ i.e.N allergic r#initi" or ato)ic $ermatiti". Patient" 3it# a"t#ma
3ill $emon"trate a $ecrea"e$ AEK an$ )ea. ex)irator& /lo3 rate on ")irometr&.
T#e"e c#ange" are t&)icall& re'er"i!le 3it# t#e "e o/ a !ronc#o$ilator0 t&)icall& an
in#ale$ !etaa$renergic agoni"t0 li.e al!terol. W#en a )atient )re"ent" 3it# a
#i"tor& con"i"tent 3it# a"t#ma0 !t #a" normal ")irometr& 'ale"0 agent" "c# a"
met#ac#oline0 #i"tamine0 exerci"e0 or col$ air in#alation can !e "e$ to )ro'o.e
a"t#ma "&m)tom". Met#ac#oline i" a m"carinic c#olinergic again"t t#at ca"e"
!ronc#ocon"triction an$ increa"e$ air3a& "ecretion"> a $ecrea"e in EAK !& more
t#an -:U a/ter a met#ac#oline c#allenge in$icate" t#e $iagno"i" o/ !ronc#ial
a"t#ma.
1*#oice A2 Sco)olamine i" an antagoni"t o/ m"carinic c#olinergic rece)tor". It i"
mo"t commonl& "e$ to $ilate t#e ))il /or o)#t#almologic exam"0 !t can act a" an
antiemetic an$ a "e$ati'e.
1*#oice *2 P#enox&!en%amine i" an al)#a,1,a$renergic antagoni"t "e$ in t#e
treatment o/ #&)erten"ion an$ !enign )ro"tatic #&)er)la"ia.
1*#oice D2 I"o)roterenol i" a non")eci/ic !eta,a$renergic agoni"t. T#i" me$ication
#a" a !ronc#o$ilator& e//ect in a"t#matic )atient".
1*#oice E2 I)ratro)im !romi$e0 li.e "co)olamine0 i" an antagoni"t o/ m"carinic
c#olinergic rece)tor". It i" t&)icall& "e$ in an in#ale$ /orm to treat
!ronc#ocon"triction in )atient" 3it# o!"trcti'e lng $i"ea"e"0 "c# a" a"t#ma.
E$cational O!;ecti'e<
T#e met#ac#oline c#allenge te"t can !e "e$ to in$ce !ronc#ocon"triction in
)atient" 3it# a"t#ma0 t#ere!& allo3ing $emon"tration o/ t#e $i"ea"e on ")irometr&.
Met#ac#oline i" a m"carinic c#olinergic agoni"t t#at act" !& in$cing !ronc#ial
"moot# m"cle contraction an$ increa"e$ !ronc#ial mco" )ro$ction.
47
Q NO 32: A -8,&ear,ol$ male com)lain" o/ occa"ional nig#ttime $&")nea an$
3#ee%ing. He #a" no #i"tor& o/ allergie"0 !t #i" ol$er !rot#er "//er" /rom
ato)ic $ermatiti". S)irometr& /in$ing" are normal in t#i" )atient. W#ic# o/ t#e
/ollo3ing i" t#e !e"t $rg to "e a" a )ro'ocation te"t in t#i" )atient9
USMLE WORLD STEP 1
PHYSIOLOGY

W#ic# o/ t#e /ollo3ing i" t#e mo"t li.el& ca"e o/ t#e c#ange $e)icte$ !& t#e $a"#e$
line"9
A. Exce""i'e #&$ration
(. Acte #emorr#age
*. *#ronic anemia
D. M&ocar$ial in/arction
E. Ana)#&laxi"
Explanation:
T#e gra)# a!o'e com!ine" car$iac an$ 'a"clar /nction cr'e". T#e car$iac
/nction cr'e0 la!ele$ a" car$iac ot)t 1*O2 ill"trate" t#e Aran.,Starling e//ect.
T#e Aran.,Starling e//ect "tate" t#at a" car$iac m"cle i" increa"ingl& "tretc#e$0 t#e
car$iac ot)t increa"e" 1) to a limit2. T#i" i" e""entiall& a lengt#,ten"ion
relation"#i). T#i" relation"#i) reac#e" it" limit at t#e /lat )ortion o/ t#e cr'e.
T#e 'a"clar /nction cr'e0 la!ele$ 'eno" retrn0 gi'e" t#e mean "&"temic
)re""re 3#ere it inter"ect" 3it# t#e x axi" an$ t#e total )eri)#eral re"i"tance 1TPR2
3it# it" "lo)e. Increa"e" in !loo$ 'olme "#i/t t#i" gra)# to t#e rig#t an$ increa"e"
in t#e TPR $ecrea"e t#e "lo)e o/ t#e cr'e 1in )art $e to t#e increa"e$ a/terloa$ in
t#e "&"temic circlation2.
T#e $a"#e$ line" $e)ict $ecrea"e$ car$iac ot)t an$ nc#ange$ 'eno" retrn
1nc#ange$ !loo$ 'olme an$ TPR2. An i"olate$ $ecrea"e in car$iac ot)t in$icate"
$ecrea"e$ contractilit& t#at i" not t#e re"lt o/ $ecrea"e$ )reloa$ 1!eca"e t#e
'eno" retrn line i" nc#ange$2. T#i" in$icate" eit#er t#e action o/ a negati'e
inotro)ic $rg or in;r& to t#e m&ocar$im in#i!iting contraction0 "c# a" a
m&ocar$ial in/arction.
48
Q NO 33: T#e car$iac ot)t an$ 'eno" retrn cr'e" o/ a #ealt#& )er"on are
"#o3n !elo3 3it# "oli$ line".
USMLE WORLD STEP 1
PHYSIOLOGY
1*#oice A2 Exce""i'e #&$ration or a !loo$ tran"/"ion 3ol$ increa"e t#e !loo$
'olme> "#i/t t#e 'eno" retrn gra)# to t#e rig#t an$ c#ange t#e car$iac ot)t
/rom )oint A to )oint (. (eca"e t#ere i" more 'olme in t#e rig#t atrim0 t#e rig#t
atrial )re""re i" al"o ele'ate$.
1*#oice (2 Acte #emorr#age 3ol$ ca"e a "#ar) $ecrea"e in t#e circlating !loo$
'olme an$ 3ol$ "#i/t t#e 'eno" retrn cr'e to t#e le/t.
1*#oice *2 *#ronic anemia ca"e" an increa"e in car$iac ot)t in an e//ort to meet
t#e meta!olic $eman$" o/ t#e ti""e". T#i" ca"e" an increa"e in t#e "lo)e o/ t#e
car$iac ot)t gra)#.
1*#oice E2 Ana)#&laxi" ca"e" 3i$e")rea$ 'eno" an$ arteriolar $ilatation along
3it# increa"e$ ca)illar& )ermea!ilit& an$ t#ir$,")acing o/ /li$". T#i" re"lt" in a
"erio" $ro) in 'eno" retrn.
E$cational O!;ecti'e<
M&ocar$ial in/arction ca"e" a "#ar) $ecrea"e in car$iac ot)t $e to lo"" o/
/nction o/ a %one o/ m&ocar$im. On a car$iac /nction cr'e0 m&ocar$ial in/arction
3ol$ $ecrea"e !ot# t#e "lo)e an$ t#e maximal #eig#t o/ t#e line.
49
USMLE WORLD STEP 1
PHYSIOLOGY
Q NO 34: A "mall 'olnteer "t$& i" con$cte$ to a""e"" air/lo3 re"i"tance along
t#e !ronc#ial tree. W#ic# o/ t#e /ollo3ing cr'e" !e"t corre")on$" to t#e air3a&
re"i"tance )attern in normal lng"9
Explanation:
(eginning at t#e trac#ea t#ere are -8 generation" o/ !ronc#i. Me$im an$ "mall,
"i%e$ !ronc#i greater t#an -mm in $iameter 1t#e /ir"t 1: generation" o/ !ronc#i2
)ro'i$e t#e greate"t "mmate$ /rictional re"i"tance to air/lo3 in normal air3a&".
Air3a& generation" -,? 1incl$ing t#e "egmental !ronc#i2 normall& #a'e a #ig#er
regional re"i"tance t#an t#e ))er re")irator& tract 1na"al )a""age"0 mot# )#anx0
lar&nx0 an$ trac#ea2 acconting /or t#e cr'e7" earl& )ara!olic "#a)e. In contra"t
air3a&" "maller t#an - mm in $iameter normall& contri!te le"" t#an -:U o/ t#e
50
USMLE WORLD STEP 1
PHYSIOLOGY
total air3a& /rictional re"i"tance. T#i" i" !eca"e t#e "malle"t !ronc#i an$
!ronc#iole" #a'e a larger total cro"" "ectional area a" t#e& contine to $i'i$e into
/rt#er generation".
1*#oice (2 T#i" )attern col$ a))l& to a )atient 3it# "e'ere $i"tal "mall air3a&
o!"trcti'e $i"ea"e.
1*#oice *2 T#e )attern "#o3n #ere i" e""entiall& an in'er"e o/ t#e normal )attern.
T#i" 3ol$ !e a goo$ re)re"entation o/ air3a& con$ctance 'er"" air3a& cali!er.
1*#oice E2T#i" )attern col$ a))l& to a )atient 3it# "igni/icant $i"tal "mall air3a&
o!"trcti'e $i"ea"e.
E$cational O!;ecti'e<
T#e ma;orit& o/ total /rictional air3a& re"i"tance i" locali%e$ to t#e me$im an$
"mall,"i%e$ !ronc#i greater t#an -mm in $iameter in normal in$i'i$al". Regional
air3a& re"i"tance i" maximal in t#e "econ$ to /i/t# generation air3a&"0 incl$ing t#e
"egmental !ronc#i. Air3a& re"i"tance i" minimal in !ronc#iole".
51
USMLE WORLD STEP 1
PHYSIOLOGY
Urine Serm
Inlin -::.: mg5$l -.: mg5$l
Glco"e : @:.: mg5$l
Pota""im ?:.: mE45L ?.: mE45L
Uric aci$ 1?.: mg5$l 8.: mg5$l
PAH 1:: mg5ml :.- mg5ml
A""ming a #ematocrit o/ ?:U an$ a rine /lo3 o/ ml5mm0 3#ic# o/ t#e /ollo3ing i"
t#e !e"t e"timate o/ t#i" )atient7" renal !loo$ /lo39
A. 1:: ml5min
(. -:: ml5min
*. ?:: ml5min
D. 1::: ml5min
E. -::: ml5min
Explanation:
T#e renal !loo$ /lo3 1R(A2 i" t#e 'olme o/ !loo$ t#at /lo3" t#rog# t#e .i$ne& )er
nit time. T#e R(A i" $e)en$ent )on t#e )re""re $i//erence !et3een t#e renal
arter& an$ renal 'ein a" 3ell a" t#e re"i"tance in t#e renal 'a"clatre. T#e R(A i"
tig#tl& reglate$ !& mec#ani"m" 3it#in t#e .i$ne& t#at mo$late renal 'a"clar
re"i"tance to .ee) t#e R(A con"tant o'er a 3i$e range o/ "&"temic !loo$ )re""re".
T#e R(A can !e calclate$ /rom )re""re an$ re"i"tance 'ale" a" /ollo3"<
R(A B 1renal arter& )re""re H renal 'ein )re""re2 5 renal 'a"clar re"i"tance
In )ractice0 $etermining t#e 'ale" /or t#e a!o'e e4ation 3ol$ !e in'a"i'e an$
$i//iclt. A "im)ler mean" o/ calclating t#e R(A "e" t#e renal )la"ma /lo3 1RPA2
an$ #ematocrit 'ale". W#erea" t#e R(A i" t#e com)lete !loo$ 'olme t#at /lo3"
t#rog# t#e .i$ne& )er nit time0 t#e RPA i" t#e )la"ma 'olme 1)la"ma B !loo$H
er&t#roc&te"2 t#at /lo3" t#rog# t#e .i$ne& )er nit time. T#e RPA can !e calclate$
"ing t#e clearance o/ )ara,amino#i))ric aci$ 1PAH2 a" /ollo3"<
RPA B PAH clearance B 1rine CPAHW x rine /lo3 rate2 5 )la"ma CPAHW
T#e #ematocrit i" t#e /raction o/ t#e !loo$ 'olme occ)ie$ !& er&t#roc&te". T#"
t#e /raction o/ t#e !loo$ 'olme occ)ie$ !& )la"ma i" e4i'alent to 1 1,#ematocrit2.
T#e R(A can t#ere/ore !e $etermine$ !& $i'i$ing t#e RPA !& t#e /raction o/ t#e !loo$
'olme occ)ie$ !& )la"ma a" /ollo3"<
R(A B 1PAH clearance2 5 11 H #ematocrit2
Aor t#e )r)o"e" o/ t#e 4e"tion a!o'e<
R(A B C11:: x 1.:25:.-15 11H:.?2 B ?::5:.? B 1::: ml5mm
E$cational O!;ecti'e<
T#e renal !loo$ /lo3 1R(A2 re/er" to t#e 'olme o/ !loo$ t#at /lo3" t#rog# t#e
.i$ne& )er nit time an$ can !e calclate$ !& $i'i$ing t#e renal )la"ma /lo3 !& 11 H
#ematocrit2.
52
Q NO 35: T#e /ollo3ing mea"rement" 3ere ta.en /rom a #ealt#& 88,&ear,ol$
'olnteer.
USMLE WORLD STEP 1
PHYSIOLOGY
A. Acar!o"e
(. Gl&!ri$e
*. Met/ormin
D. Ro"iglita%one
E. Enala)ril
A. Lo3,calorie $iet
Explanation:
T#i" )atient li.el& #a" t&)e - $ia!ete" 3it# "ome re"i$al )ancreatic C8,cell /nction.
He $oe" not #a'e gl&co"ria or .eto"i" !eca"e #i" i"let cell" are "ecreting "ome
in"lin. In"lin i" $eri'e$ /rom "ingle,c#ain )roin"lin in )ancreatic 18,cell". Wit#in
t#e en$o)la"mic reticlm o/ t#e"e cell" en$o)e)ti$a"e" clea'e )roin"lin to /orm
in"lin an$ * )e)ti$e. * )e)ti$e an$ matre in"lin are "!"e4entl& )ac.age$ into
"ecretor& granle" in t#e Golgi a))arat". * )e)ti$e an$ in"lin are "ecrete$ in
e4imolar concentration"0 !t nli.e in"lin0 * )e)ti$e i" not "igni/icantl& extracte$
on /ir"t )a"" t#rog# t#e li'er. T#"0 it" circlating le'el" in )la"ma can !e "e$ a" a
mar.er o/ t#e total rate o/ 18,cell en$ogeno" in"lin "ecretion n$er "tea$&,"tate
con$ition".
E""entiall& t#i" 4e"tion a"." " 3#ic# o/ t#e agent" li"te$ increa"e" t#e rate o/
in"lin "ecretion !& re"i$al )ancreatic i"let ;8,cell" in )atient" 3it# t&)e - $ia!ete".
53
Q NO 36: A =?,&ear,ol$ male i" $iagno"e$ 3it# $ia!ete" mellit" $ring a rotine
c#ec.,). Hi" rine i" negati'e /or glco"e an$ .etone"0 #o3e'er. Treatment 3it#
3#ic# o/ t#e /ollo3ing agent" 3ol$ increa"e t#e *,)e)ti$e le'el in t#i" )atient7"
!loo$9
USMLE WORLD STEP 1
PHYSIOLOGY
Gl&!ri$e i" an oral #&)ogl&cemic agent 1a "l/on&lrea2 t#at "timlate" in"lin
relea"e in t&)e - $ia!etic".
1*#oice A2 Acar!o"e in#i!it" a,glco"i$a"e in t#e inte"tinal !r"# !or$er0 3#ic#
im)air" t#e #&$rol&"i" o/ "gar" an$ )o"t)ran$ial a!"or)tion o/ inge"te$ )ol&meric
glco"e. (& re$cing )o"t)ran$ial #&)ergl&cemia0 acar!o"e $ecrea"e" en$ogeno"
in"lin "ecretion an$ * )e)ti$e le'el" in t&)e - $ia!etic" 3it# re"i$al )ancreatic C8,
cell /nction.
1*#oice" * an$ D2 Met/ormin 1a !igani$e2 an$ ro"iglita%one 1a t#ia%oli$ine$ione2
increa"e t#e "en"iti'it& o/ target ti""e" to in"lin. T#e& #a'e little e//ect on in"lin
"ecretion.
1*#oice E2T#e A*E,in#i!itor enala)ril i" a reno )rotecti'e agent t#at $ecrea"e"
$ia!etic )roteinria. It $oe" not #a'e "igni/icant e//ect" on !loo$ glco"e le'el" or
en$ogeno" in"lin "ecretion.
1*#oice A2 Aa"ting an$ $ecrea"e$ caloric inta.e 3ol$ $ecrea"e t#e rate o/
en$ogeno" in"lin "ecretion an$ corre")on$ing * )e)ti$e le'el".
E$cational O!;ecti'e<
* )e)ti$e can !e "e$ a" a mar.er o/ t#e total rate o/ en$ogeno" 8,cell in"lin
"ecretion n$er "tea$&,"tate con$ition". Sl/on&lrea" increa"e t#e rate o/ in"lin
"ecretion an$ * )e)ti$e le'el" in )atient" 3it# t&)e - $ia!ete".
54
USMLE WORLD STEP 1
PHYSIOLOGY
A. A
(. (
*. *
D. D
E. E
55
Q NO 37: T#e 'olme an$ )re""re tracing" /or t#e le/t 'entricle o/ a 8=,&ear,ol$
male are "#o3n !elo3. W#ic# o/ t#e /ollo3ing )oint" corre")on$" to aortic 'al'e
o)ening9
USMLE WORLD STEP 1
PHYSIOLOGY
Explanation:
T#e gra)# a!o'e $e)ict" t#e le/t 'entriclar )re""re an$ 'olme $ring t#e car$iac
c&cle. Toget#er t#e"e gra)#" can !e "e$ to )lot t#e 'ario" )#a"e" o/ t#e car$iac
c&cle. Air"t0 on t#e le/t0 i" atrial "&"tole. In t#i" )#a"e0 !loo$ i" /orce/ll& ex)elle$
/rom t#e atria into t#e 'entricle" ca"ing t#e "lig#t increa"e in 'entriclar )re""re
an$ 'olme "een on t#e /ar le/t o/ t#e gra)#. +ext t#e mitral 'al'e clo"e" ca"ing a
"lig#t $e)re""ion o/ t#e 'entriclar )re""re cr'e 1mar.e$ a" )oint A a!o'e2. T#e
'entricle t#en !egin" to contract. T#e "egment !et3een )oint" A an$ ( corre")on$"
to i"o'olmetric contraction. Dring t#i" time t#e 'entriclar )re""re increa"e" !t
t#e 'entriclar 'olme remain" t#e "ame !eca"e t#e aortic an$ mitral 'al'e" are
clo"e$. W#en t#e 'entriclar )re""re excee$" t#e $ia"tolic "&"temic !loo$ )re""re
t#e aortic 'al'e o)en" 1)oint (2. +o3 t#e 'entriclar 'olme !egin" to $ecrea"e
"#ar)l& a" !loo$ i" ex)elle$. T#e le/t 'entriclar )re""re contine" to increa"e
!et3een )oint" ( an$ * ntil t#e "&"tolic maximm !loo$ )re""re i" reac#e$. W#en
t#e"e t3o 'ale" are e4al0 t#e aortic 'al'e clo"e" 1)oint *2. I"o'olmetric
relaxation occr" !et3een )oint" * an$ D. T#e 'entricle relaxe" an$ !ot# t#e aortic
an$ mitral 'al'e" are clo"e$. At )oint D0 t#e mitral 'al'e o)en"0 initiating t#e )#a"e
o/ $ia"tolic /illing.
E$cational O!;ecti'e<
Kentriclar )re""re an$ 'olme cr'e" allo3 one to i$enti/& t#e )#a"e" o/ t#e
car$iac c&cle an$ to $etermine t#e exact time o/ o)ening an$ clo"re o/ t#e car$iac
'al'e".
56
USMLE WORLD STEP 1
PHYSIOLOGY
(o3man7" Proximal Loo) o/ Di"tal *ollecting
ca)"le con'olte$ Henle con'olte$ $ct
t!le" t!le"
A. 1::U 8:U -8U 1?U 1?:U
(. 1::U 8:U -8U 1?:U 1?:U
*. 1::U 1?:U 1?:U 1?:U 1?:U
D. 1::U 1::U 1::U 1?:U 1?:U
E. 1::U 1::U 1::U 1-:U 1?:U
Explanation:
Eac# "egment o/ t#e ne)#ron )la&" a role in )ota""im #omeo"ta"i". T#e $egree o/
)ota""im /iltration in t#e glomerl" $e)en$" )on t#e glomerlar /iltration rate
1GER2 an$ i" relati'el& con"tant. In a #ealt#& )er"on t#e )ota""im concentration
3it#in t#e glomerlar ca)illarie" 3ill al3a&" !e e4al to t#e )ota""im concentration
in t#e t!lar /li$ in (o3man7" ")ace. Patient" 3it# renal /ailre an$ a )oor GER
ma& $e'elo) ele'ate$ )la"ma )ota""im $e to /ailre to /ilter )ota""im /rom t#e
)la"ma to t#e rine.
A))roximatel& -58 o/ t#e /iltere$ )ota""im loa$ i" rea!"or!e$ in t#e )roximal
con'olte$ t!le". Art#er rea!"or)tion o/ )ota""im 1a!ot -:U o/ t#e /iltere$
)ota""im loa$2 occr" in t#e loo) o/ Henle !& t#e action o/ t#e +a565-*
cotran")orter. T#e"e )roce""e" rea!"or! )ota""im at a /ixe$ rate0 an$ $o not )la& a
"igni/icant role in t#e reglation o/ )ota""im excretion in t#e rine. E'en in
#&)er.alemic "tate"0 )atient" 3ill rea!"or! t#e ma;orit& o/ t#e /iltere$ )ota""im in
t#e )roximal t!le an$ loo) o/ Henle.
T#e cortical collecting $ct i" t#e )rimar& "ite o/ )ota""im reglation. In t#e
#&)o.alemic "tate0 collecting $ct al)#a, intercalate$ cell" rea!"or! extra )ota""im
'ia HS56S,AT Pa""e". *on'er"el&0 /actor" t#at increa"e )ota""im "ecretion into t#e
t!lar /li$ incl$e<
1. Hig# $ietar& )ota""im con"m)tion
-. Al$o"terone< Stimlate" t#e +aS56S,)m) 3#ic# lea$" to "o$im retention 1an$
)a""i'e 3ater retention2 at t#e ex)en"e o/ 6 lo"t into t#e t!lar /li$
S. Al.alo"i"< In al.alo"i" )ota""im i" lo"t in t#e rine in or$er to )re"er'e )roton"
16 an$ H /reel& exc#ange acro"" t#e t!lar cell mem!rane2
=. T#ia%i$e $iretic"0 loo) $iretic"0 an$ an& ot#er ca"e o/ increa"e$ /lo3 rate
t#rog# t#e $i"tal t!le< T#ere i" increa"e$ )ota""im lo"" in t#e "etting o/ #ig#
/lo3 t#rog# t#e collecting $ct" !eca"e t#e /li$ #ere i" $ilte0 #ence a "#i/t o/
)ota""im into t#e t!lar /li$ /rom t#e t!lar cell"
E$cational O!;ecti'e<
T#e collecting $ct i" t#e )rimar& "ite o/ reglation o/ )ota""im concentration" in
t#e t!lar /li$ an$ rine.
57
Q NO 38: A #ealt#& 8-,&ear,ol$ male 3#o #a" !een con"ming a #ig# )ota""im
$iet /or t#e )a"t t3o 3ee." i" /on$ to #a'e a rine )ota""im concentration t#at
i" #ig#er t#an #i" )la"ma )ota""im concentration. W#ic# o/ t#e /ollo3ing !e"t
$e"cri!e" t#e )ercentage o/ t#e Ailtere$ )ota""im loa$ remaining in t#e t!lar
/li$ a" it /lo3" along t#e ne)#ron in t#i" )atient9
USMLE WORLD STEP 1
PHYSIOLOGY
W#ic# o/ t#e /ollo3ing location" i" t#e mo"t li.el& "ite o/ t#i" )atient7" $i"ea"e9
A. +a"o)#ar&nx
(. (rain"tem
*. Pericar$ial ")ace
D. Peri)#eral ner'e"
E. +erom"clar ;nction
Explanation:
T#i" )#&"io gra)# "#o3" $ecrea"ing am)lit$e" o/ c&clic intra)leral )re""re
c#ange" a" $ee) !reat#ing contine". Dia)#ragmatic contraction i" re")on"i!le /or
mo"t o/ t#e intra)leral )re""re /all $ring in")iration. T#e )attern ill"trate$ a!o'e
t#" "gge"t" t#at t#i" )atient7" $ia)#ragmatic contraction" are !ecoming
)rogre""i'el& 3ea.er 3it# re)etition "ince t#ere i" no a))arent $ecrement in total
)#renic ner'e "timlation o/ t#e $ia)#ragm $ring in")iration. T#e 3ea.ening o/
in")irator& $ia)#ragmatic contraction" "een #ere i" mo"t li.el& $e to "ome
)at#olog& o/ t#e nerom"clar ;nction0 o/ t#e ".eletal m"cle it"el/0 or o/ t#e lng
ti""e an$5or c#e"t 3all. T#i" col$ !e con"i"tent 3it# m&a"t#enia gra'i" or
re"tricti'e lng or c#e"t 3all $i"ea"e 13ol$ ca"e a normal $ia)#ragm to /atige
ra)i$l&2. Al"o )o""i!le0 t#og# le"" li.el&0 i" "e'ere in")irator& air/lo3 o!"trction
ca"ing ra)i$ $ia)#ragmatic /atige.
1*#oice A2 +a"o)#ar&ngeal le"ion" 3ol$ !e nli.el& to ca"e "e'ere enog#
in")irator& air/lo3 o!"trction to ca"e ra)i$ $ia)#ragmatic /atige.
1*#oice D2 Peri)#eral nero)at#& a//ecting t#e )#renic ner'e 3ol$ ca"e ni/orml&
3ea. in")iration" $ring maximal 'olntar& 'entilation.
E$cational O!;ecti'e<
Progre""i'el& 3ea.ening $ia)#ragmatic contraction" $ring maximal 'olntar&
'entilation 3it# con"tant )#renic ner'e "timlation $ring in")iration in$icate
nerom"clar ;nction )at#olog& 1e.g. $ecremental "&na)tic tran"mi""ion2 an$5or
a!normall& ra)i$ $ia)#ragmatic m"cle /atige.
58
Q NO 39: A )atient i" !eing e'alate$ /or #&)o'entilation. He i" a".e$ to ta.e
"e'eral $ee) !reat#" in ra)i$ "cce""ion0 an$ t#e /ollo3ing )#&"iologic
in/ormation i" o!taine$<
USMLE WORLD STEP 1
PHYSIOLOGY

Explanation:
Ailtration o/ /li$ t#rog# t#e glomerli $e)en$" on t#e renal )la"ma /lo3 1RPE2 an$
t#e glomerlar /iltration rate 1GER2. T#e GER i" t#e 'olme o/ /li$ /iltere$ /rom t#e
renal glomerlar ca)illarie" into (o3man7" ca)"le )er nit time. T#e RPE i" t#e
'olme o/ )la"ma $eli'ere$ to t#e .i$ne& )er nit time. T#e /iltration /raction i" a
ratio o/ glomerlar /iltration rate to renal )la"ma /lo3 1EEBGER5RPE2. +ormall& t#e
RPE i" a))roximatel& E::,D:: ml5mm0 an$ t#e GER i" a))roximatel& 1-? mI5mm
t#og# t#e"e nm!er" 'ar& !& gen$er an$ /rom )er"on to )er"on. T#e /iltration
/raction "ing t#e"e nm!er" i" :.1?, :.-:0 3#ic# mean" t#at a!ot 15? o/ t#e
)la"ma t#at )a""e" t#rog# t#e glomerlar ca)illarie" i" /iltere$ into (o3man7"
ca)"le.
Renal )la"ma /lo3 $e)en$" on t#e circlating !loo$ 'olme an$ t#e re"i"tance o/ t#e
a//erent an$ e//erent arteriole". In a 3i$e range o/ !loo$ )re""re" 11::,-:: mm
Hg2 renal )la"ma /lo3 i" maintaine$ at a con"tant le'el !& local c#ange" in 'a"clar
re"i"tance. W#en t#e !loo$ )re""re $ro)" !elo3 a certain )oint atoreglator&
mec#ani"m" !ecome na!le to maintain RPE.
T#e )atient $e"cri!e$ in t#i" clinical 'ignette i" "e'erel& #&)o'olemic. Pro/"e
$iarr#ea an$ 'omiting le$ to a ra)i$ $ecline in t#e circlating !loo$ 'olme0 3it# a
"!"e4ent $ecrea"e in renal )la"ma /lo3. H&)o'olemia "timlate" "ecretion o/
renin0 3#ic# i" /ollo3e$ !& "&nt#e"i" o/ angioten"in II. Angioten"in II con"trict" t#e
e//erent glomerlar arteriole0 3#ic# increa"e" #&$ro"tatic )re""re in t#e glomerlar
ca)illarie" an$ maintain" t#e glomerlar /iltration rate. De to t#i" com)en"ator&
mec#ani"m t#e $ecrea"e in GAR in #&)o'olemia i" le"" )rononce$ t#an t#e
$ecrea"e in RPA re"lting in an increa"e$ /iltration /raction !eca"e AABGARl5RPAll.
1c#oice A2.
E$cational O!;ecti'e<
De#&$ration lea$" to a $ecrea"e in renal )la"ma /lo3 an$ a $ecrea"e in t#e
glomerlar /iltration rate. *om)en"ator& acti'ation o/ t#e renin,angioten"in
mec#ani"m in re")on"e to #&)oten"ion lea$" to con"triction o/ t#e e//erent
1otgoing2 arteriole to maintain GER. T#e /iltration /raction 3#ic# i" e4al to t#e GER
$i'i$e$ !& t#e RPEI increa"e" in #&)o'olemia a" t#e RPE $ro)" )ro)ortionatel& more
t#an $oe" t#e GER $e to t#e a/orementione$ com)en"ator& mec#ani"m.
59
Q NO 40: A D-,&ear,ol$ male i" !rog#t to t#e ER 3it# $iarr#ea an$ 'omiting. T#e
"&m)tom" "tarte$ -= #or" ago an$ #e #a" !een na!le to ta.e mc# /li$ $ring
t#i" )erio$ o/ time. Hi" mco" mem!rane" are $r& an$ #i" !loo$ )re""re i" G:5E:
mmHg. W#ic# o/ t#e /ollo3ing c#ange" in renal )la"ma /lo3 1RPE2 glomerlar
/iltration rate 1GER2 an$ /iltration /raction 1AE2 $o &o ex)ect mo"t in t#i" )atient9
USMLE WORLD STEP 1
PHYSIOLOGY

A. Hig# altit$e
(. Exerci"e
*. Plmonar& em!oli"m
D. *aroti$ "in" ma""age
E. Panic attac.
Explanation:
Increa"e$ #eart rate an$ car$iac ot)t 3it# )re"er'ation o/ arterial )artial
)re""re" o/ :- an$ *O- are mo"t con"i"tent 3it# t#e integrate$ car$iore")irator&
re")on"e to exerci"e. Heart rate an$ car$iac ot)t increa"e to meet increa"e$
ti""e ox&gen $eman$"0 an$ t#e re")irator& rate increa"e" to eliminate exce"" *O-
)ro$ce$. T#e content o/ :- an$ *O- in arterial !loo$ remain" relati'el& clo"e to
re"ting 'ale" at mo"t le'el" o/ exerci"e. *#ange" in t#e )artial )re""re" o/ :- an$
*O- $ring exerci"e occr )re$ominantl& in t#e 'eno" !loo$.
1*#oice A2 At #ig# altit$e 1con$ition o/ am!ient #&)oxia20 #eart rate an$ car$iac
ot)t can increa"e in or$er to im)ro'e ox&gen $eli'er& to ti""e". Ho3e'er0 t#e
Pa:- an$ Pa*O- 3ol$ !e lo3er t#an normal $e to t#e #&)oxemia an$ re"lting
#&)er'entilation an$ re")irator& al.alo"i".
1*#oice *2 Plmonar& em!oli"m 1PE2 ca"e" lo3 !loo$ /lo3 to t#e le/t "i$e o/ t#e
#eart. *ar$iac ot)t i" t#" $ecrea"e$ an$ com)en"ator& tac#&car$ia ta.e" )lace.
PE o/ten ca"e" #&)oxemia 1lo3 Pa:-2 $e to acte K5T im!alance" in t#e a//ecte$
lng. H&)oxemia an$ "timlation o/ lng 'agal irritant rece)tor" in i"c#emic lng
)arenc#&ma al"o ten$ to )ro$ce #&)er'entilation an$ a re")irator& al.alo"i" 3it# a
lo3ere$ Pa*O-.
1*#oice D2 *aroti$ "in" ma""age ca"e" a re/lex 'agal $i"c#arge to t#e "inoatrial
no$e0 atrial m&oc&te"0 an$ atrio'entriclar no$e. T#e #eart rate an$ car$iac ot)t
are tran"ientl& re$ce$. *aroti$ "in" ma""age 3ol$ not "igni/icantl& a//ect t#e
Pa:- or Pa*O-.
1*#oice E2 A )anic attac. col$ rai"e #eart rate an$ car$iac ot)t 'ia "&m)at#etic
"timlation o/ t#e #eart. Ho3e'er0 t#ere i" "all& a""ociate$ #&)er'entilation an$
re")irator& al.alo"i"0 an$ t#" a /all in t#e Pa*O-.
E$cational O!;ecti'e<
T#e integrate$ car$iore")irator& re")on"e to exerci"e incl$e" increa"e$ #eart rate0
increa"e$ car$iac ot)t0 an$ increa"e$ re")irator& rate in or$er to !alance t#e
increa"e$ total ti""e :- con"m)tion an$ *O- )ro$ction. T#e"e increa"e" are
coor$inate$ "o t#at arterial !loo$ ga"e" remain relati'el& con"tant0 3#ile 'eno" P:-
i" $ecrea"e$ an$ 'eno" P*O- i" increa"e$.
60
Q NO 41: Increa"e" in #eart rate an$ car$iac ot)t are o!"er'e$ in a 8-,&ear,ol$
3oman. Simltaneo" arterial !loo$ ga" "t$ie" "#o3 a normal Pa:- an$ Pa*O-.
T#e"e c#ange" are mo"t li.el& )art o/ an integrate$ re")on"e to 3#ic# o/ t#e
/ollo3ing9
USMLE WORLD STEP 1
PHYSIOLOGY
A. Genetic /actor"
(. *alcim inta.e
*. P#&"ical acti'it& le'el
D. Kitamin "))lementation
E. Meno)a"e on"et
Explanation:
(one ma"" i" a ma;or $eterminant o/ t#e ri". /or o"teo)orotic /ractre". (one ma""
increa"e" $ring c#il$#oo$ an$ a$ole"cence0 )ea.ing !et3een -: an$ 8: &ear" o/
age. E)i$emiological an$ t3in "t$ie" #a'e "#o3n t#at genetic /actor" are
re")on"i!le /or 1?U o/ t#e 'ariation in )ea. !one ma"" among in$i'i$al". T#e
gene" t#at contri!te to t#i" 'ariation are largel& n.no3n0 alt#og# )ol&mor)#i"m
i" li.el&. Stati"ticall&0 *aca"ian" #a'e lo3er !one $en"itie" t#an )eo)le o/ A/rican
$ecent. T#e $i//erence" in !one $en"it& among t#e t3o 3omen gra)#e$ a!o'e are
mo"t li.el& $e to genetic /actor".
1*#oice (2 Genetic /actor" are t#e mo"t im)ortant $eterminator in )ea. !one ma"".
En'ironmental /actor" $o )la& a role0 al!eit a le""er one. In$i'i$al" 3it# lo3er
calcim an$ 'itamin D inta.e #a'e a lo3er )ea. !one ma"" !eca"e0 $ring
c#il$#oo$ an$ earl& a$lt#oo$0 t#e& $o not e"ta!li"# an a$e4ate !one $en"it& )ea..
T#e ine'ita!le lo"" o/ !one mineral $en"it&0 t#en0 )t" t#e"e )atient" at an increa"e$
ri". /or o"teo)oro"i" later in li/e !eca"e !one i" lo"t /rom a lo3er,t#an,a'erage
)ea.. 1*#oice *2 P#&"ical acti'it& al"o increa"e" !one ma"". P#&"ical acti'it& i"
!elie'e$ to contri!te to !one mineral $en"it& $ring t#e teen an$ &ong a$lt
&ear"0 an$ "ome "cienti"t" !elie'e t#at exerci"e al"o $imini"#e" t#e rate o/ !one
ma"" lo"" ex)erience$ later in li/e. P#&"ical acti'it& i" not a" "igni/icant a contri!tor
to t#e !one $en"it& o/ an in$i'i$al a" genetic".
1*#oice D2 A #ig#,"o$im $iet increa"e" calcim lo"" in t#e rine0 3#ic# can al"o
contri!te to lo3 !one mineral $en"it&. Altering en'ironmental /actor"0 "c# a"
o)timi%ing calcim an$ 'itamin D inta.e0 $ail& 3eig#t,!earing )#&"ical acti'it&0 an$
re"triction o/ "o$im in t#e $iet can agment )ea. !one ma""0 !t en'ironment i"
not a" "igni/icant a" genetic" in t#e $i//erence" in !one $en"it& 1gra)#e$ a!o'e2.
1*#oice E2 A" "een in !ot# cr'e"0 !one ma"" )rogre""i'el& $ecline" "#ortl& a/ter
reac#ing it" )ea. in t#e -:" or 8:". Mo"t "!;ect" 3ill lo"e a )re$icta!le amont o/
!one mineral $en"it& )er &ear. (one lo"" accelerate" at meno)a"e !eca"e
e"trogen le'el" $ecline "igni/icantl&. (one lo"" can !e minimi%e$ !& li/e"t&le
c#ange"0 "c# a" increa"ing )#&"ical acti'it& an$ o)timi%ing calcim an$ 'itamin D
inta.e. T#e"e mo$i/ication" o/ten "lo3 !one lo"" an$ t#" re$ce /ractre ri"..
Genetic" are more "igni/icant contri!tor" to !one mineral $en"it& t#an
en'ironment0 #o3e'er.
E$cational O!;ecti'e< T#e $i//erence" in t#e !one $en"it& cr'e" can !e !e"t
ex)laine$ !& genetic $i//erence". Ot#er /actor"0 li.e calcim inta.e an$ $ail& )#&"ical
acti'it&0 )la& a "maller role. T#e"e li/e,"t&le mo$i/ication" "#ol$ not !e ignore$0
#o3e'er0 a" 3omen at ri". /or o"teo)oro"i" can c#ange t#eir en'ironment"0 !t
cannot c#ange t#eir genetic ma.e).
61
Q NO 42: (one ma"" i" an im)ortant $eterminant o/ /ractre ri".. On t#e gra)#
!elo30 !one ma"" 'er"" li/etime i" "#o3n /or t3o #ealt#&0 /ractre,tree 3omen.
W#ic# o/ t#e /ollo3ing /actor" !e"t ex)lain" t#e $i//erence" !et3een t#e t3o cr'e"9
USMLE WORLD STEP 1
PHYSIOLOGY
A. Kal"al'a mane'er
(. Ex)iration
*. Stan$ing
D. Aro"emi$e in;ection
E. Am&l nitrite in#alation
Explanation:
T#i" )atient )re"ent" 3it# "ign" an$ "&m)tom" o/ #eart /ailre. Heart /ailre can
re"lt /rom a 'ariet& o/ )at#ogenic )roce""e". Re)eate$ !ot" o/ m&ocar$ial
i"c#emia are t#e mo"t common ca"e.
In #eart /ailre re"lting /rom "&"tolic $&"/nction t#e e;ection /raction i" $ecrea"e$
an$ t#e #eart i" le/t 3it# a con"i$era!le en$,"&"tolic 'olme 3it#in t#e 'entricle". An
?80 or 'entriclar gallo) #eart "on$ i" commonl& #ear$ in )atient" 3it# le/t
'entriclar /ailre 1t#i" can !e a normal 'ariant in #ealt#& c#il$ren an$ a$ole"cent"2.
T#e 88 #eart "on$ i" a lo3 /re4enc& "on$ t#at occr" imme$iatel& /ollo3ing 8-
$ring t#e )#a"e o/ ra)i$ )a""i'e 'entriclar /illing. It re"lt" /rom !loo$ r"#ing into
a )artiall& /ille$ 'entricle or into a 'er& "ti// 'entricle in )atient" 3it# re"tricti'e
car$iom&o)at#&. T#e 88 i" !e"t a))reciate$ 3it# t#e !ell o/ t#e "tet#o"co)e )re""e$
lig#tl& again"t t#e ".in in t#e region o/ t#e 'entriclar a)ex. 1T#e !ell i" 3ell,"ite$
to $etect lo3 /re4enc& "on$" 3#ile t#e $ia)#ragm i" !e"t /or #earing #ig#,)itc#e$
"on$" li.e S1 an$ S-.2 Ha'ing t#e )atient lie in t#e le/t lateral $ec!it" )o"ition
ma.e" it ea"ier to #ear ?8. Ha'ing t#e )atient ex#ale com)letel& 3#ile in t#i"
)o"ition can ma.e t#e "on$ e'en more a$i!le !& $ecrea"ing t#e 'olme o/ t#e
lng" an$ !ringing t#e #eart clo"er to t#e c#e"t 3all.
1*#oice" A an$ *2 T#e Kal"al'a mane'er 1!earing $o3n again"t a clo"e$ glotti"2
an$ t#e "tan$ing )o"ition can !e "e$ to $i//erentiate !et3een t#e 'ario" ca"e" o/
a "&"tolic mrmr in t#e le/t #eart. (ot# mane'er" $ecrea"e 'eno" retrn to t#e
#eart t#ere!& re$cing le/t 'entriclar 'olme an$ !loo$ )re""re. T#e mrmr"
a""ociate$ 3it# mitral 'al'e )rola)"e an$ #&)ertro)#ic car$iom&o)at#& !ecome
more a$i!le an$ t#o"e a""ociate$ 3it# aortic "teno"i" !ecome le"" a$i!le.
S4atting an$ Kal"al'a relea"e 1mane'er" t#at increa"e 'eno" retrn2 #a'e t#e
o))o"ite e//ect.
1*#oice D2 Aro"emi$e in;ection ca"e" !ri". $ire"i". T#e 'olme re$ction 3ol$
li.el& le""en t#e inten"it& o/ t#e 88 "on$.
1*#oice E2 Am&l nitrite in#alation ca"e" 'a"o$ilatation an$ $ecrea"e$ !loo$
)re""re. It 3ol$ #a'e t#e "ame e//ect a" t#e Kal"al'a mane'er on t#e mrmr"
o/ mitral )rola)"e #&)ertro)#ic car$iom&o)at#& an$ aortic "teno"i".
E$cational O!;ecti'e<
A 88 "on$ i" a lo3 /re4enc& #eart "on$ t#at can !e )#&"iologic in c#il$ren !t i"
t&)icall& )at#ologic in a$lt" 3#ere it generall& re"lt" /rom le/t 'entriclar /ailre or
re"tricti'e car$iom&o)at#&. T#e 88 "on$ can !e accentate$ !& #a'ing t#e )atient
lie in t#e le/t lateral $ec!it" )o"ition an$ ex#ale /ll&.
62
Q NO 43: A ?8,&ear,ol$ male )re"ent" to &or o//ice 3it# $i//iclt& !reat#ing an$
increa"ing /atige. He #a" !een "lee)ing in a recliner c#air to relie'e #i" "#ortne""
o/ !reat#. Hi" )a"t me$ical #i"tor& i" "igni/icant /or a m&ocar$ial in/arction t3o
mont#" ago. On car$iac a"cltation0 a $ia"tolic "on$ i" #ear$ 3#en t#e )atient
lie" in t#e le/t lateral $ec!it" )o"ition. W#ic# o/ t#e /ollo3ing i" mo"t li.el& to
accentate t#i" )#&"ical examination /in$ing9
USMLE WORLD STEP 1
PHYSIOLOGY

A.
Homon&mo" #emiano)"ia
(. (ina"al #emiano)"ia
*. (item)oral #emiano)"ia
D. Arcate "cotoma"
E. *entral "cotoma"
Explanation:
T#e macla i" a &ello3i"# ")ot a))roximatel& 1.? mm in $iameter locate$ near t#e
center o/ t#e retina. It i" c#aracteri%e$ #i"tologicall& !& t#e )re"ence o/ $en"el&
)ac.e$ cone"0 /e3 o'erl&ing cell" an$ no !loo$ 'e""el". Eac# maclar cone "&na)"e"
to a "ingle !i)olar cell0 3#ic#0 in trn0 "&na)"e" to a "ingle ganglion cell. De to t#i"
arrangement t#e 'i"al acit& in t#e macla0 an$ )articlarl& t#e /o'ea0 i" greater
t#an in an& ot#er area o/ t#e retina. T#e neral /i!er" t#at "er'e t#e macla tran"mit
to an area o/ t#e occi)ital 'i"al cortex t#at i" "e)arate /rom t#e area o/
re)re"entation o/ t#e )eri)#eral /iel$" 1t#i" area i" al"o relati'el& large in "i%e2. De
to t#i" )ecliar cortical re)re"entation0 maclar ")aring i" common in le"ion" o/ t#e
occi)ital cortex.
Maclar le"ion" im)air central 'i"ion an$ re"lt in central "cotomata 1*#oice E2. T#e
term "cotoma re/er" to an& 'i"al $e/ect "rron$e$ !& a relati'el& nim)aire$ /iel$
o/ 'i"ion. Scotoma" occr $e to )at#ologic )roce""e" t#at in'ol'e )art" o/ t#e retina
or o)tic ner'e. Exam)le" o/ "c# )roce""e" incl$e $em&elinating $i"ea"e" "c# a"
mlti)le "clero"i"0 $ia!etic retino)at#& an$ retiniti" )igmento"a. Pat#ologic
)roce""e" t#at in'ol'e t#e entire o)tic ner'e lea$ to monoclar !lin$ne"".
T#e )atient $e"cri!e$ in t#i" clinical 'ignette i" li.el& to #a'e maclar $egeneration
1MD2. T#i" $i"or$er i" /re4entl& age,relate$0 an$ i" t#e mo"t common ca"e o/
!lin$ne"" in )eo)le o'er ?: &ear" ol$ in t#e US. Maclar $egeneration i"
c#aracteri%e$ !& )rogre""i'e lo"" o/ central 'i"ion $e to $e)o"ition o/ /alt& ti""e
1$r"en2 !e#in$ t#e retina 1$r& MD2 an$ neo'a"clari%ation o/ t#e retina 13et MD2.
1*#oice A2 Homon&mo" #emiano)"ia i" a lo"" o/ 'i"ion in t#e "ame "i$e o/ t#e
'i"al /iel$ in !ot# e&e". It occr" $e to tran"ection o/ t#e contralateral o)tic tract0
t#e /i!er" o/ t#e 'i"al )at#3a& lin.ing t#e o)tic c#ia"m to t#e lateral geniclate
!o$&.
1*#oice (2 (ina"al #emiano)"ia i" a lo"" o/ 'i"ion in t#e na"al /iel$" o/ !ot# e&e". It
i" ca"e$ !& )re""re to t#e lateral area" o/ t#e o)tic c#ia"m. T#i" ma& re"lt /rom
calci/ie$ caroti$ arterie".
1*#oice *2 (item)oral #emiano)"ia i" a lo"" o/ 'i"ion in t#e tem)oral /iel$" o/ !ot#
e&e". It i" ca"e$ !& com)re""ion o/ t#e me$ial )art o/ t#e o)tic c#ia"m 3#ere t#e
na"al /i!er" $ec""ate0 mo"t commonl& !& a )ititar& a$enoma.
1*#oice D2 Arcate "cotoma" occr $e to $amage to a )articlar region o/ t#e o)tic
ner'e #ea$. T#e re"lting 'i"al /iel$ $e/ect /ollo3" t#e arcate "#a)e o/ t#e ner'e
/i!er )attern.
E$cational O!;ecti'e<
A "cotoma i" a 'i"al /iel$ $e/ect t#at occr" $e to a )at#ologic )roce"" t#at
in'ol'e" )art" o/ t#e retina or t#e o)tic ner'e re"lting in a $i"crete area o/ altere$
'i"ion "rron$e$ !& %one" o/ normal 'i"ion. Le"ion" o/ t#e macla ca"e central
"cotoma".
63
Q NO 44: A E?,&ear,ol$ male com)lain" o/ !ilateral 'i"al $i//iclt& t#at #a"
)rogre""e$ o'er t#e la"t &ear. An$"co)& re'eal" "mall &ello3 retinal
le"ion" cl"tere$ in t#e macla. W#ic# o/ t#e /ollo3ing 3ol$ &o ex)ect
mo"t on 'i"al /iel$ examination9
USMLE WORLD STEP 1
PHYSIOLOGY
A. +o contraction in re")on"e to intracelllar *a-
(. Uncoor$inate$ contraction o/ m&o/i!ril"
*. Poor /orce generation on re)eate$ "timlation
D. Im)aire$ relaxation a/ter a "ingle contraction
E. Im)aire$ energ& )ro$ction $ring contraction
Explanation:
T,t!le" are in'agination" o/ t#e m"cle cell mem!rane 1"arcolemma2. T,t!le"
are t#ere/ore exten"ion" o/ t#e extracelllar ")ace. T#e& rn )er)en$iclar to t#e
long axi" o/ t#e m"cle /i!er an$ lie in clo"e )roximit& to exten"ion" o/ t#e
"arco)la"mic reticlm 1terminal ci"tern"2. In ".eletal m"cle0 one T,t!le contact"
t3o terminal ci"tern" /orming a tria$ at t#e ;nction o/ t#e A,!an$ an$ t#e I,!an$.
T#e /nction o/ T,t!le" i" to tran"mit a $e)olari%ation /rom t#e "arcolemma to
"arco)la"mic reticlm in a ra)i$ an$ ni/orm manner. (eca"e t#e& are exten"ion"
o/ t#e cell mem!rane t#e& con"i"t o/ a )#o")#oli)i$ !ila&er 3it# a large nm!er o/
'oltage,gate$ calcim c#annel" 1$i#&$ro)&ri$ine rece)tor"2 locate$ in clo"e
)roximit& to r&ano$ine rece)tor" on t#e terminal ci"tern" o/ t#e "arco)la"mic
reticlm. R&ano$ine rece)tor" are calcim relea"e c#annel" t#at are o)ene$ n$er
t#e in/lence o/ acti'ate$ $i#&$ro)&ri$ine rece)tor" on t#e T,t!le". T#i" lea$" to
relea"e o/ calcim /rom t#e "arco)la"mic reticlm an$ in$ction o/ m"cle
contraction.
T#e ni/orm $i"tri!tion o/ T,t!le" in ".eletal m"cle /i!er" en"re" t#at a
$e)olari%ing "ignal reac#e" eac# /i!er at t#e "ame time. T#i" coor$ination i"
nece""ar& /or m"cle contraction. A lac. o/ T,t!le" in "ome m&o/i!ril" 3ol$ lea$
to ncoor$inate$ contraction o/ in$i'i$al /i!er" 1*#oice (2.
1*#oice A2 *alcim relea"e$ /rom t#e "arco)la"mic reticlm !in$" tro)onin *
ca"ing a mo'ement o/ tro)om&o"in to re'eal t#e m&o"in,!in$ing "ite" on actin. An
a!normalit& o/ tro)onin * or m&o"in 3ol$ lea$ to a!"ence o/ contraction in
re")on"e to relea"e o/ calcim.
1*#oice *2 Poor contractile /orce on re)eate$ m"cle "timlation i" a c#aracteri"tic
/in$ing in m&a"t#enia gra'i". It occr" $e to t#e )re"ence o/ atoanti!o$ie" to
acet&lc#oline rece)tor" in t#e nerom"clar ;nction.
1*#oice D2 Im)aire$ relaxation a/ter a "ingle contraction occr" in m&otonic
$&"tro)#&. T#i" ato"omal,$ominant $i"ea"e occr" $e to an a!normalit& o/
m&otonic )rotein .ina"e re"lting /rom trincleoti$e re)eat ex)an"ion.
1*#oice E2 McAr$le $i"ea"e 1gl&cogen "torage $i"ea"e t&)e K2 i" an exam)le o/ a
$i"ea"e 3it# im)aire$ energ& )ro$ction $ring m"cle contraction. It mani/e"t"
3it# m"cle 3ea.ne"" an$ cram)ing $ring exerci"e re"lting /rom /ailre o/ m"cle
gl&cogen !rea.$o3n $e to a $e/ect in m&o)#o")#or&la"e.
E$cational O!;ecti'e<
T,t!le" are in'agination" o/ t#e "arcolemma t#at exten$ into eac# m"cle /i!er.
T#e& tran"mit $e)olari%ation "ignal" to t#e "arco)la"mic reticlm an$ trigger t#e
relea"e o/ calcim. T#e ni/orm $i"tri!tion o/ T,t!le" en"re" coor$inate$
contraction o/ all m&o/i!ril".
64
Q NO 45: S.eletal m"cle !io)"& i" )er/orme$ on a 1D,&ear,ol$ male 3it# )roximal
m"cle 3ea.ne"". +o a!normalitie" are /on$ on lig#t micro"co)&. Electron
micro"co)& o/ t#e ")ecimen re'eal" no T,t!le" in "ome m"cle /i!er". W#ic# o/
t#e /ollo3ing i" t#e mo"t li.el& con"e4ence o/ t#e o!"er'e$ /in$ing in t#e a//ecte$
m"cle cell"9
USMLE WORLD STEP 1
PHYSIOLOGY
A. Decrea"e$ arterial )artial ox&gen ten"ion
(. Decrea"e$ arterial ox&gen content
*. Decrea"e$ arterial )artial *O- ten"ion
D. Decrea"e$ arterial )H
E. Increa"e$ arterial lactate content
Explanation:
T#e )atient in t#i" 'ignette i" #a'ing a )anic attac.. Panic attac." are t&)icall&
accom)anie$ !& #&)er'entilation an$ $ecrea"e$ )*O- 1#&)oca)nia2. H&)oca)nia can
ca"e $ecrea"e$ cere!ral )er/"ion an$ t#" nerological "&m)tom".
W#en t#e arterial !loo$ )re""re i" maintaine$ in t#e range o/ E:,1=: mm Hg0 t#e
arterial !loo$ ga"e" exert t#e mo"t )o3er/l in/lence on t#e !rain circlation.
*ar!on $ioxi$e a )otent cere!ral 'a"o$ilator exert" t#e mo"t "ign 1H cant e//ect".
An increa"e in t#e )*O- /rom -? to 1:: mm Hg ca"e" a linear increa"e in cere!ral
!loo$ /lo3 an$ a $ecrea"e in t#e )*O- ca"e" a linear $ecrea"e in cere!ral
)er/"ion. 1(eca"e #&)oca)nia can $ecrea"e cere!ral !loo$ /lo3 )atient" 3it#
cere!ral e$ema are o/ten #&)er'entilate$ in or$er to $ecrea"e intracranial )re""re.2
T#e ):- #a" mc# le"" o/ an in/lence on cere!ral !loo$ /lo3. Aor ):- in t#e range
o/ ?:,1:: mm Hg. cere!ral )er/"ion remain" con"tant. Se'ere #&)oxia 1):- P?:
mm Hg2 lea$" to a ra)i$ increa"e in cere!ral !loo$ /lo3 an$ intracranial )re""re.
Ot#er 'a"oacti'e "!"tance" in t#e "&"temic circlation $o not a//ect cere!ral !loo$
/lo3 !eca"e t#e& $o not cro"" t#e !loo$,!rain !arrier.
1*#oice" A an$ (2 H&)er'entilation $oe" not $ecrea"e t#e ):- or t#e arterial ox&gen
content. I/ an&t#ing t#e"e )arameter" 3ol$ increa"e.
1*#oice D2 H&)er'entilation )ro$ce" re")irator& al.alo"i"0 mar.e$ !& an increa"e$
arterial )H an$ a $ecrea"e$ )::-.
1*#oice E2 Increa"e$ arterial lactate content i" a "ign o/ ti""e #&)oxia 1e.g. /rom
i"c#emia0 c&ani$e )oi"oning0 car!on monoxi$e )oi"oning0 "ei%re"0 or "e)"i"2 an$ i"
not a""ociate$ 3it# )anic attac.". Lactic aci$o"i" i" al"o a""ociate$ 3it# met/ormin
"e.
E$cational O!;ecti'e<
Panic attac." are a""ociate$ 3it# #&)er'entilation an$ $ecrea"e$ )::-. H&)oca)nia
ca"e" cere!ral 'a"ocon"triction an$ $ecrea"e$ cere!ral !loo$ /lo3.
65
Q NO 46: A 8-,&ear,ol$ /emale 3it# cla"tro)#o!ia 1/ear o/ clo"e$ ")ace"2 i" "tc.
in a mal/nctioning ele'ator. S#e ex)erience" "e'ere anxiet& a" 3ell a" $i%%ine""0
3ea.ne"" an$ !lrre$ 'i"ion. W#ic# o/ t#e /ollo3ing i" t#e mo"t li.el& ca"e o/ t#i"
)atient7" "&m)tom"9
USMLE WORLD STEP 1
PHYSIOLOGY
A. S&"tolic !loo$ )re""re
(. Renal !loo$ /lo3
*. *ar$iac "tro.e 'olme
D. S&"temic 'a"clar re"i"tance
E. Rig#t atrial )re""re
Explanation:
Stimlation o/ t#e "&m)at#etic ner'o" "&"tem i" e""ential $ring exerci"e /or a
nm!er o/ rea"on". Air"t0 t#e increa"e$ meta!olic $eman$" o/ t#e exerci"ing ti""e
re4ire car$iac ot)t 1*O B SK x HR2 to increa"e /rom a re"ting rate o/ ? L5min to
a))roximatel& -: L5min $ring maximal exertion. Secon$0 in or$er to "))l& enog#
)reloa$ to t#e #eart to meet t#i" increa"e$ "tro.e 'olme0 "&m)at#etic "timlation
ca"e" contraction o/ t#e 'eno" "&"tem0 increa"ing 'eno" retrn to t#e #eart.
T#ir$0 "&m)at#etic $i"c#arge ca"e" contraction o/ t#e arteriole" in all ti""e" exce)t
t#e acti'el& 3or.ing m"cle"0 e//ecti'el& "#nting !loo$ to3ar$ t#e exerci"ing
m"cle. De")ite t#e"e t#ree "&m)at#etic ner'o" "&"tem e//ect"0 t#e mean arterial
)re""re t&)icall& increa"e" onl& -:,=: mmHg $ring /ll !o$& exerci"e.
T#e mean arterial )re""re remain" /airl& "ta!le $ring exerci"e $e to an a$a)ti'e
$ecrea"e in t#e "&"temic 'a"clar re"i"tance 1SKR2. Exerci"ing m"cle relea"e" local
'a"o$ilator& /actor" incl$ing a$eno"ine0 )ota""im ion"0 ATPI *O- an$ lactate.
T#ere i" al"o a "mall 'a"o$ilator& e//ect o/ "&m)at#etic !eta rece)tor".
1*#oice A2 S&"tolic !loo$ )re""re i" increa"e$ "lig#tl& $ring exerci"e $e to
"&m)at#etic ner'o" "&"tem e//ect".
1*#oice (2 Renal !loo$ /lo3 normall& accont" /or -?U o/ t#e total car$iac ot)t.
Dring exerci"e0 t#e .i$ne&" recei'e a greater total !loo$ /lo3 $e to t#e "igni/icant
increa"e in car$iac ot)t0 !t a "lig#tl& "maller )ro)ortion o/ t#e *O !eca"e
"&m)at#etic "timlation ca"e" 'a"ocon"triction o/ t#e renal arteriole". *#ange" in
t#e renal !loo$ /lo3 $o not contri!te to !loo$ )re""re maintenance $ring
exerci"e.
1*#oice *2 T#e car$iac "tro.e 'olme i" increa"e$ $ring exerci"e. Increa"e$ 'eno"
retrn mean" en#ance$ $ia"tolic /illing an$ more /orce/l "&"tolic contraction"
t#rog# t#e Aran.,Starling mec#ani"m. A$$itionall&0 nero#ormonal in/lence"
$irectl& en#ance contractilit&.
1*#oice E2 T#e rig#t atrial )re""re increa"e" $ring )rolonge$ exerci"e $e to
increa"e$ retrn o/ !loo$ to t#e #eart an$ $ecrea"e$ )ooling o/ !loo$ in t#e 'eno"
"&"tem.
E$cational O!;ecti'e<
Exerci"ing m"cle" can recei'e ) to @?U o/ t#e total car$iac ot)t $ring )erio$"
o/ "treno" acti'it& t#an." to local relea"e o/ 'a"o$ilator& /actor". Alt#og#
"&m)at#etic $i"c#arge $ring exerci"e ca"e" an increa"e in car$iac ot)t an$
increa"e$ contraction o/ !loo$ 'e""el"0 t#ere i" onl& a mo$e"t !loo$ )re""re
increa"e !eca"e t#e 'a"o$ilatation 3it#in m"cle "o "igni/icantl& $ecrea"e" t#e total
"&"temic 'a"clar re"i"tance.
66
Q NO 47: A -8,&ear,ol$ man #a" a mean arterial )re""re o/ G? mm Hg at re"t.
A/ter "3imming /or 8: minte" #i" mean arterial )re""re #a" ri"en onl& "lig#tl&
to 11?mm Hg. A $ecrea"e in 3#ic# o/ t#e /ollo3ing $ring exerci"e mo"t li.el&
accont" /or t#e o!"er'e$ /in$ing9
USMLE WORLD STEP 1
PHYSIOLOGY
T#e /lo3 cr'e mo"t li.el& re/lect" t#e /lo3 )attern in 3#ic# o/ t#e /ollo3ing ti""e"9
A. S!cortical nclei
(. (rain cortex
*. S!en$ocar$ial m&ocar$im
D. Renal me$lla
E. Renal cortex
A. A$renal me$lla
Explanation:
T#e /lo3 cr'e "#o3" a c&clic re$ction in !loo$ /lo3 $ring t#e OT inter'al0 3#ic#
corre")on$" to 'entriclar "&"tole. T#e coronar& circlation i" ni4e in t#at onl&
1:U o/ total )er/"ion t#rog# t#e m&ocar$ial ca)illarie" o/ t#e le/t 'entricle occr"
$ring "&"tole. T#e great ma;orit& o/ !loo$ /lo3 t#rog# t#e 'a"clar !e$" "))lie$
!& t#e coronar& arterie" to t#e le/t 'entricle 1LK2 occr" $ring $ia"tole0 3#en t#e
!loo$ 'e""el" are not com)re""e$ !& m&ocar$ial contraction. T#e "&"tolic re$ction
in coronar& !loo$ /lo3 i" greate"t in t#e LK "!en$ocar$ial m&ocar$im0 ma.ing it
t#e region mo"t )rone to i"c#emia an$ m&ocar$ial in/arction.
E$cational O!;ecti'e<
Onl& 1:U o/ total )er/"ion t#rog# t#e m&ocar$ial ca)illarie" o/ t#e LK occr"
$ring "&"tole0 3#ile t#e ma;orit& o/ le/t 'entriclar !loo$ /lo3 occr" $ring
$ia"tole. T#e "&"tolic re$ction in coronar& !loo$ /lo3 i" greate"t in t#e
"!en$ocar$ial m&ocar$im o/ t#e LK.
67
Q NO 48: A gro) o/ in'e"tigator" "t$ie" )attern" o/ !loo$ /lo3 in 'ario" ti""e".
One o/ t#e )attern" t#e& o!tain i" "#o3n on t#e "li$e !elo3.
USMLE WORLD STEP 1
PHYSIOLOGY
A. A
(. (
*. *
D. D
E. E
Explanation:
T#e ti$al 'olme 1KT2 i" t#e 'olme o/ air mo'e$ into an$ ot o/ t#e lng" $ring
normal !reat#ing. KT i" re)re"ente$ !& t#e ")ace !et3een )oint" * an$ Don t#e
gra)# a!o'e. Dring maximal in")iration0 a )er"on can $ra3 more air into t#e lng"
t#an occr" $ring normal ti$al 'olme !reat#ing. T#i" a$$itional in")ire$ air i"
re/erre$ to a" t#e in")irator& re"er'e 'olme 1IRK20 re)re"ente$ !& t#e ")ace
!et3een )oint" D an$ Eon t#e gra)# a!o'e. T#e a$$itional 'olme ex#ale$ $ring
maximal ex)iration i" .no3n a" t#e ex)irator& re"er'e 'olme 1ERK20 re)re"ente$
!& t#e ")ace !et3een )oint" ( an$ * on t#e gra)#. T#e remaining 'olme !et3een
)oint" A an$ ( i" t#e re"i$al 'olme0 a con"tant 'olme o/ ga" t#at remain" in t#e
lng" a/ter maximal ex#alation. T#e"e 'olme" can !e com!ine$ into lng ca)acitie"
a" /ollo3"<
Total lng ca)acit& 1TL*2 B IRK J KT J ERK J RK
Kital ca)acit& 1K*2 B IRK J KT J ERK
In")irator& ca)acit& 1I*2 B IRK J KT
Anctional re"i$al ca)acit& B ERK J E+
H&)oxia gra'it& an$ t#e le'el o/ lng ex)an"ion can a//ect t#e )lmonar& !loo$ /lo3.
T#e )lmonar& 'a"clar re"i"tance i" lo3e"t at t#e /nctional re"i$al ca)acit& 1AR*2
re)re"ente$ !& )oint * on t#e gra)# !eca"e at t#i" le'el o/ in/lation t#e lng i"
maximall& com)liant0 t#e intrat#oracic )re""re i" atmo")#eric0 an$ t#e al'eoli $o
68
Q NO 49: A 8=,&ear,ol$ male n$ergoe" ")irometr& a" a )art o/ a )re,em)lo&ment
e'alation. At 3#ic# )oint on t#e gra)# !elo3 i" t#e total )lmonar& 'a"clar
re"i"tance lo3e"t9
USMLE WORLD STEP 1
PHYSIOLOGY
not exert meaning/l )re""re on t#e )lmonar& 'a"clatre. A" air i" $ra3n into
t#e lng" $ring in#alation0 t#e lng 'olme increa"e" /rom t#e AR*. T#e al'eoli
ex)an$ a" t#e& /ill 3it# in")ire$ air an$ t#e inter"titial ela"tic ti""e o/ t#e lng" i"
)t n$er ten"ion. T#e"e c#ange" exert colla)"ing )re""re an$ ten"ion on t#e
)lmonar& 'a"clatre lea$ing to an increa"e in )lmonar& 'a"clar re"i"tance.
W#en air i" /orce/ll& ex#ale$ )o"iti'e )re""re i" )lace$ on t#e lng" !& t#e
"rron$ing m"clatre re"lting in com)re""ion o/ !ot# air3a&" an$ !loo$ 'e""el".
T#i" al"o #a" t#e e//ect o/ increa"ing )lmonar& 'a"clar re"i"tance.
E$cational O!;ecti'e<
Plmonar& 'a"clar re"i"tance 1PKR2 i" lo3e"t at t#e /nctional re"i$al ca)acit&.
In#alation increa"e" PKR $e to t#e )re""re )lace$ on )lmonar& 'e""el" !& t#e
ex)an$ing al'eoli. Aorce$ ex#alation increa"e" PKR $e to t#e colla)"ing )o"iti'e
)re""re )lace$ on t#e lng )arenc#&ma.
69
USMLE WORLD STEP 1
PHYSIOLOGY

Arterial !loo$ ox&gen content -: ml O-51:: ml !loo$
Plmonar& arter& $ia"tolic )re""re 1- mmHg
Le/t 'entriclar $ia"tolic )re""re 1: mmHg
Mean rig#t atrial )re""re = mmHg
Keno" !loo$ ox&gen content 1? ml O-51:: ml !loo$
W#at a$$itional in/ormation i" nece""ar& to calclate car$iac ot)t in t#i" )atient9
A. (loo$ ox&gen carr&ing ca)acit&
(. (loo$ #emoglo!in concentration
*. Ox&gen con"m)tion
D. Re")irator& 4otient
E. Arterio'eno" $i//erence in t#e ox&gen content
Explanation:
T#e car$iac ot)t0 ex)re""e$ in liter" )er minte0 i" commonl& calclate$ "ing t#e
/ollo3ing /ormla<
*ar$iac ot)t B Stro.e 'olme x Heart rate
*ar$iac ot)t can al"o !e $etermine$ "ing t#e Pic. )rinci)le0 3#ic# calclate"
car$iac ot)t !& $etermining #o3 mc# !loo$ m"t /lo3 t#rog# t#e )lmonar& or
"&"temic circlation to accont /or t#e $i//erence in ox&gen content !et3een t#e
arterial an$ 'eno" circlation".
*O B O- con"m)tion 5 arterio'eno" O- $i//erence
In'a"i'e met#o$" are re4ire$ to gat#er $ata /or t#e Aic. calclation o/ car$iac
ot)t. One m"t mea"re t#e 'eno" O- content 1t&)icall& o!taine$ /rom t#e
)lmonar& ane320 t#e arterial O- content0 an$ t#e le'el o/ ti""e O- con"m)tion.
Here0 3e .no3 t#e arterial an$ 'eno" O- content> all t#at i" nee$e$ i" t#e ox&gen
con"m)tion.
1*#oice (2 T#e !loo$ #emoglo!in 1H!2 concentration can !e "e$ in t#e /ollo3ing
/ormla to e"timate t#e car$iac ot)t !t t#i" /ormla al"o re4ire" t#at t#e
)atient7" !o$& "r/ace area 1(SA2 !e .no3n<
*O B 118? x (SA2 5 C118 x H!2 x 1SaO-,S'O-2W
1*#oice D2 T#e re")irator& 4otient i" t#e ratio o/ *O-to :- acro"" t#e al'eolar
mem!rane. It i" "e$ to e"timate t#e meta!olic rate. T#e normal 'ale i" t&)icall&
:.@.
1*#oice E2 T#e arterio'eno" $i//erence in ox&gen )artial )re""re" can !e
calclate$ "ing t#e in/ormation )ro'i$e$ in t#e 4e"tion "tem.
E$cational O!;ecti'e<
T#e Aic. )rinci)le can !e "e$ to calclate t#e car$iac ot)t. It "tate" t#at t#e
car$iac ot)t i" e4al to t#e ox&gen con"m)tion !& t#e ti""e" $i'i$e$ !& t#e
arterio'eno" ox&gen $i//erence.
70
Q NO 50: In'a"i'e monitoring tool" "e$ on a ?=,&ear,ol$ "t$& )artici)ant re'eal
t#e /ollo3ing<

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