NBME STEP 1 PHYSIOLOGY

RESPIRATORY:
25.
At a given PO2, more O2 can be unloaded from hemoglobin when which of the following is
decreased in erythrocytes?
A)
B)
C)
D)

2,3-Bisphosphoglycerate
pH
PCO2
Temperature

CARDIO
3.
A 63-year-old woman has chest pain while climbing the stairs of her office building. She sits
down and takes some medication, after which she is able to continue. Which of the following is the
mechanism of action of the drug?
A)

Decreased afterload

B)

Decreased preload

C)

Increased afterload and preload

D)

Increased preload

E)

Increased contractility

ENDOCRINE-GASTRO
4.
The absorption of calcium from the intestinal tract results principally from the direct action of
which of the following?
A)

Calcitonin

B)

Cyclic AMP

C)

1,25-Dihydroxycholecalciferol

D)

25-Hydroxycholecalciferol

E)

Parathyroid hormone

CARDIO:
42.
A 24-year-old man dies suddenly. At autopsy, there is evidence of cocaine abuse but no
evidence of gross or microscopic structural alterations of the heart. Which of the following is the
most likely cause of the cardiac malfunction in this man?
A)
B)
C)
D)
E)

Blockade of Ca2+ channels

Blockade of dopamine synthesis
Potentiation of norepinephrine and blocking of its presynaptic uptake
Potentiation of serotonin at postsynaptic sites in the atrioventricular node
Stroke due to malignant hypertension

RESPIRATORY

47.
During a marathon, a 28-year-old woman initially has pain and distress but suddenly feels
exhilaration about halfway through the race. The best explanation is most likely to be increased
release of..
A)
ACTH
B)
-endorphin
C)
epinephrine
D)
glucagon
E)
somatostatin
ENDOCRINE
1.
Which of the following tests best distinguishes central diabetes insipidus from nephrogenic
diabetes insipidus?
A)

Injection of ADH (vasopressin)

B)

Injection of hypertonic saline

C)

Injection of insulin

D)

Water deprivation

E)

Water loading

RESPIRATORY
9.
Fetal and maternal erythrocytes have the same concentration of 2,3-bisphosphoglycerate.
However, compared with maternal hemoglobin (HbA), fetal hemoglobin (HbF) has a higher oxygen
affinity, which facilitates transplacental diffusion of oxygen. The presence of which of the following
polypeptide chains in HbF accounts for this finding?
A)
B)
C)
D)

Chains alone
Chains alone
Chains
Both and chains

ENDOCRINE
15.
A 55-year-old man with multiple primary liver abscesses caused by Escherichia coli and
anaerobic bacteria has fever and shaking chills. Which of the following is the most likely cause of
these symptoms?
A)

Associated abscess in the hypothalamus

B)

Hypothalamic response to leukocytosis

C)

Leukocyte inflammation of the hypothalamus

D)

Release of fragments of damaged hepatocytes into the circulation

E)

Release of leukocyte cytokines into the circulation

ENDOCRINE- FLUIDS
18. A 20-year-old man ingests 1 L of water over 1 hour. Which of the following sets of changes is
most likely at the end of the hour?
Plasma

Urine

Urine

ADH

A)

(vasopressin)

osmolality

flow

B)

C)

D)

E)

F)

G)

H)

CARDIO
43.
During which phase of the ventricular action potential shown does norepinephrine influence
the influx of Ca2+?

A)
B)
C)
D)
E)
CARDIO
14. A 72-year-old woman comes to the physician because of an episode of acute substernal chest
pain that occurred while she was rushing to catch a bus. She has basilar crackles at both lung bases.
S1 is normal and S2 is decreased. A grade 3/6 systolic murmur is heard best at the upper right
sternal border and radiates to the neck. The following data obtained during cardiac catheterization
were taken before and during exercise:

Aortic pressure
(mm Hg)
Control
Exercise

Left ventricular volume

End-diastolic
End-systolic
Heart rate
(mL)
(mL)
(/min)

130/70
160/80

140
165

50
58

85
120

While exercising, the patient has shortness of breath but no chest pain. Which of the following is the
most likely cause of the shortness of breath?
A)

Decreased cardiac output during exercise

B)

Decreased pulmonary blood flow

C)

Increased aortic pressure

D)

Increased end-diastolic pressure of the left ventricle during exercise

E)

Tachycardia

RESPIRATORY
15.
The graph shows an isovolumetric pressure-flow curve obtained at 25% of total lung capacity.
An increase in which of the following is most likely to increase the plateau value of the expiratory
flow rate?

A)

Airway resistance

B)

Amount of surfactant in the alveolar space

C)

Ciliary beating frequency

D)

Expiratory effort

E)

Lung volume

F)

Parasympathetic activity of fibers innervating the airways

CARDIO
19.
Closure of the pulmonic valve occurs when the pressure in the pulmonary artery exceeds that
in the
A)

coronary sinus

B)

left atrium

C)

pulmonary veins

D)

right atrium

E)

right ventricle

ENDOCRINE
48.
During the second and third trimesters of pregnancy, women have increased levels of
circulating glucocorticoids but have few of the catabolic responses associated with excess
glucocorticoids. The most likely explanation of this finding is increased
A)
autoantibodies to steroids
B)

metabolic clearance of steroids

C)

steroid-binding proteins

D)

steroid receptors

E)

steroid uptake mechanisms

VASCULAR
5.
Relative to the normal values for parameters that govern capillary exchange, which
of the following is the most likely cause of the edema that results from use of a venous
occlusive tourniquet?
A)

Decreased interstitial fluid hydrostatic pressure

B)

Increased mean capillary hydrostatic pressure

C)

Increased plasma oncotic pressure

D)

Increased capillary filtration coefficient

E)

Increased capillary reflection coefficient for plasma proteins

CARDIOVASCULAR
6. A 50-year-old man has a 10-year history of poorly controlled hypertension. Vital signs are:
Pulse 96/min
Respirations 16/min
Blood pressure
Left arm
226/120 mm Hg
Right arm
218/118 mm Hg
With the patient in the left lateral decubitus position, a late diastolic sound is heard best with the bell
at the apex. Which of the following is the most likely explanation for this auscultatory finding?
A)
Aortic insufficiency
B)
Aortic stenosis
C)
Mitral insufficiency
D)
Mitral stenosis
E)
Opening snap
F)
Pulmonic insufficiency
G)
Pulmonic stenosis
H)
S3

I)
J)

S4
Tricuspid insufficiency

RENAL
14.
A previously healthy 56-year-old man has the sudden onset of severe headaches that become
worse in the afternoons. His blood pressure is 180/110 mm Hg. Renal arteriography shows 85%
occlusion of the right renal artery. The laboratory finding that best predicts whether an operation
that relieves the obstruction will reduce the blood pressure to normal is increased renin activity in
the
A)

left renal artery vs right renal artery

B)

left renal vein vs right renal vein

C)

right renal artery vs left renal artery

D)

right renal vein vs left renal vein

MUSCULOSKELETAL
14.
During contraction of striated muscle, the thick and thin filaments alter their relationship with
each other and the sarcomere shortens. Which of the following bands is most likely to maintain a
constant length during muscle contraction?
A)

B)

C)

D)

MEMBRANE TRANSPORT
25.
A series of experiments is performed to determine the mechanism by which a pharmacologic
agent traverses cell membranes and accumulates within target cells. The rate of transport depends
on the concentration of the drug only. When the extracellular concentration of the agent exceeds 10
mM, no further increase in the rate of uptake is observed. Structurally similar compounds pass
through the cell membrane, but at a lower rate. Ouabain, an inhibitor of Na+/ K+ ATPase, fails to
inhibit transport. Which of the following is the most likely mechanism by which this agent enters
cells?
A)

Antiport

B)

Facilitated diffusion

C)

Ion-gated coupling

D)

Simple diffusion

E)

Symport

RESPIRATORY
39.
A 32-year-old woman with pulmonary fibrosis is most likely to minimize the work of breathing
by using which of the following breathing patterns?
Respiratory Frequency
Tidal Volume
A)

B)

normal

C)
D)
E)
F)
G)
H)
I)

Normal
Normal
Normal

normal

normal

CARDIO
44.
An asymptomatic 42-year-old man with essential hypertension is started on an angiotensinconverting enzyme inhibitor. Which of the following shows the most likely effect of treatment on
circulating levels of aldosterone, renin, and bradykinin?
Aldosterone/Renin/Bradykinin
A)

B)

C)

D)

no change
E)

F)

MECHANISMS OF ACTION.
Figure 185 shows the pathways for angiotensin II formation, which occurs systemically as well as
locally in cardiac and vascular tissue. Note that generation of angiotensin II is accomplished by two
pathways, one that uses converting enzyme found in high abundance in endothelium and one that
uses the protease chymase, which is found in interstitial cells. Transmyocardial studies in the intact
human heart have indicated that greater than 80 percent of the generation of angiotensin II is via
the ACE pathway,[336] but studies in isolated human heart preparations[337] and in model
systems[338] have emphasized the contribution of the chymase pathway. If the chymase pathway is
important in producing ventricular remodeling in the failing heart, angiotensin receptorblocking
agents (ARBs) would be more effective than ACE inhibitors in decreasing angiotensin II signaling. If,
on the other hand, ACE inhibitors are just as effective clinically as ARBs, by inference, the ACE
pathway is the dominant mechanism for generating angiotensin II in the failing heart. Finally, if ACE
inhibitors are superior to ARBs, additional properties of
Figure 18-5 Pathways of angiotensin II formation. ACE=angiotensin-converting enzyme; Ang1=angiotensin I; AT1 R=angiotensin II type 1 receptor; NE=norepinephrine.
582
TABLE 18-7 -- BIOLOGICAL RESPONSES MEDIATED BY ANGIOTENSIN II RECEPTORS IN THE HUMAN
CARDIOVASCULAR SYSTEM BIOLOGICAL RESPONSE
RECEPTOR MEDIATION
Cardiac myocyte growth
AT1
Positive inotropic response (minimal)
AT1
Myocyte apoptosis
AT1 , AT2
Aldosterone release AT1
Norepinephrine release
AT1
Cardiac myocyte toxicity
Beta-adrenergic via norepinephrine release
Fibroblast proliferation
AT1
Smooth muscle proliferation
AT1
Vasoconstriction
AT1
ACE inhibitors, such as increasing bradykinin,[339] are presumably responsible. Based on the results
of the Evaluation of Losartan in the Elderly Study II (ELITE-II, see below), at present it would seem
that the ACE pathway is the predominant means of generating angiotensin II in the human heart and
that enhancement of bradykinin levels may well be important.

Studies in the failing human heart indicate that ACE gene[340] [341] and protein[341] expression
and enzyme activity [336] [341] are increased, but chymase gene expression is not.[340]
Systemically increased renin is taken up by failing human ventricles in larger amounts than by
nonfailing ventricles,[342] and failing human hearts also exhibit lower angiotensinogen protein levels
compatible with substrate depletion.[342] Finally, angiotensin II type 1 (AT1 ) receptors are
selectively downregulated in the failing human heart at the protein[343] and mRNA[344] levels,
probably as a result of increased exposure to angiotensin II. These data indicate that the local
myocardial renin-augiotensin system (RAS) is induced in the failing human heart, which adds to the
increased systemic activation. No such induction seems to occur with the chymase system.
As shown in Table 187 , increased levels of angiotensin II have several adverse effects on the
cardiovascular system, including cardiac myocyte hypertrophy, myocyte apoptosis, presynaptic
facilitation of norepinephrine release, and mitogenic effects on fibroblasts. Most, if not all of these
effects are mediated via the AT1 subtype. In addition, most of these biological effects of angiotensin
II contribute to the development of hypertrophy and remodeling.
CLINICAL OBSERVATIONS.
Two types of studies demonstrate the consistent efficacy of ACE inhibitors in HF: post-myocardial
infarction studies and clinical trials in chronic HF. As shown in Table 188 , more of the former
studies than the latter have been conducted. All placebo-controlled chronic HF trials, with the
exception of the asymptomatic Studies of Left Ventricular Dysfunction (SOLVD) Prevention Study,
[345] demonstrated a reduction in mortality. As can be observed in Table 188 , the Class IV
Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS I) had a much larger effect
size than did the SOLVD Treatment Trial (Fig. 186) , which in turn had a larger effect size than the
SOLVD Prevention Trial did. Although only these three placebo-controlled mortality trials have been
conducted in patients with chronic HF, it seems obvious that ACE inhibitors reduce mortality in direct
relation to the degree of severity of chronic HF. Although not placebo controlled, the V-HeFT-II Trial
provided evidence that ACE inhibitors improve the natural history of HF through mechanisms other
than vasodilation, inasmuch as subjects treated with enalapril had significantly lower mortality than
did subjects treated with the nonneurohormonal inhibitor-vasodilator combination of hydralazine plus
isosorbide dinitrate.[103]
Although only one ACE inhibitor, enalapril, has been used in placebo-controlled mortality trials in
chronic HF, as can be observed in Table 188 , multiple ACE inhibitors have proved to be more or
less equally effective when administered in oral form within the first week of the ischemic event in
post-myocardial infarction trials.[346] [347] [348] This observation leads to the conclusion that the
effects of ACE inhibition on the natural history of chronic HF or post-myocardial infarction left
ventricular dysfunction are class effects.
In summary, an ACE inhibitor is considered mandatory treatment in chronic HF or in asymptomatic
left ventricular systolic dysfunction. The doses employed should be at least the average dose used to
lower mortality in heart failure or post-myocardial infarction trials. The only consistent adverse effect
noted with ACE inhibitors is a low-level (5 percent greater than placebo) increase in cough. In such
patients, an angiotensin II AT1 receptorblocking agent can be substituted.

ENDOCRINE
48. The concentration of sodium in the blood is affected by a hormone secreted by cells in which
labeled zone in the photomicrograph?

A)
B)
C)
D)
E)
CARDIO
1.
A 28-year-old woman is brought to the emergency department after a motor vehicle accident
in which her chest struck the steering wheel. Pulse is 125/min and blood pressure is 90/60 mm Hg.
She is diaphoretic and has dyspnea on exertion. Head and neck veins are distended. Heart sounds
are distant and there are no murmurs. The radial pulse pressure decreases abnormally during
inspiration. The most likely diagnosis is
A)

cardiac tamponade

B)

hemorrhage from a ruptured descending aorta

C)

mitral valve prolapse

D)

pulmonary embolism

E)

rupture of a papillary muscle

ENDOCRINE
7. Which of the following hormones acts through receptors that contain tyrosine kinase?
A)
ADH (vasopressin)
B)
Aldosterone
C)
Calcitonin
D)
1,25-Dihydroxycholecalciferol
E)
Epinephrine
F)
Insulin
G)
Parathyroid hormone
H)
Thyroxine (T4)
CELL/HISTO
10. The binding specificity for extracellular matrix proteins, such as fibronectin and laminin, to cell
membranes depends on which of the following classes of proteins?
A) Collagen
B) Elastin

C) Integrin
D) Microfibrillin
E) Proteoglycan
CELL/GENETICS
22. Mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) protein alter
which of the following ion transport mechanisms?
A

Ca2+-activated Cl secretion

Ca2+-activated Cl uptake

Cyclic AMP (cAMP)-stimulated Cl secretion

cAMP-stimulated Na+ secretion

E
)
cAMP-stimulated Na+ uptake
MUSCULOSKELETAL
25. Which of the following components of the second-messenger cascade is directly responsible
for release of intracellular stores of Ca2+?
A)
B)
C)
D)
E)
F)

Cyclic AMP
Diacylglycerol
G-protein
Inositol 1,4,5-trisphosphate
Nitric oxide
Protein kinase

RESPIRATORY
A 40-year-old man is brought to the emergency department after being exposed to ozone and
nitrogen dioxide at a factory. He dies shortly thereafter. At autopsy, examination of tissue taken
38. from a lung biopsy suggests damage to his alveolar epithelium. If he had survived, this layer
would have likely been regenerated within several weeks by which of the following cells?
A)

Clara cells

B)

Endothelial cells

C)

Reticular cells

D)

Type I pneumocytes

E)

Type II pneumocytes

CELL-INFLAMMATION
44.
The ability of endothelial cells to inhibit platelet aggregation is mediated in part by the
metabolism of cell membrane-derived arachidonic acid by which of the following?
A

Anaerobic glycolysis

Cyclooxygenase pathway

Glutathione reductase pathway

Lysosomal enzymes pathway

Mixed function oxidase pathway

Tricarboxylic acid pathway

ENDOCRINO
3. A 30-year-old woman has a 10-month history of a whitish discharge from both breasts. Her last
menstrual period was 9 months ago. She had a bilateral tubal ligation 4 years ago after the birth
of her third child. Palpation of the breasts discloses no masses. Whitish fluid is expressed
bilaterally on compression of the nipples. The most likely diagnosis is
A)

bilateral mastitis

B)

intraductal carcinoma of the breast

C)

metastatic carcinoma of the breast

D)

pituitary adenoma

E)

premature menopause

ENDOCRINO
Over the past 6 months, a 54-year-old woman has had several episodes of nervousness in which
5. her heart pounds and her skin becomes clammy. She has also had difficulty sleeping and recently
developed hypertension. The most likely cause is a neoplasm in which structure labeled on the
cross-sectional drawing of the abdomen at the level of T-12 to L-1?

CARDIO
An 85-year-old woman who was admitted to the hospital 3 days ago for myocardial infarction has a
radionuclide scan that shows damage to the anterior wall of the left ventricle. Which of the following
coronary vascular structures was most likely occluded?
A)
B)
C)
D)
E)
F)

Circumflex artery
Coronary sinus
Left anterior descending artery
Posterior descending artery
Right coronary artery
Right marginal artery

ENDOCRINE
8. A 22-year-old woman is concerned about her risk for developing diabetes because her mother
has type 2 diabetes mellitus. Which of the following is the primary defect thought to predispose
individuals towards the development of type 2 diabetes mellitus?
A)

Anti-insulin receptor antibodies ------Tipo 1

B)

Autoimmune destruction of pancreatic cells

C)

Dysregulation of pancreatic cells

D)
Increased peripheral insulin resistance
[MHC: DR3-DR4 + risk DBM]
E)

Suppressed hepatic glycogen synthesis

CARDIOVASCULAR
11. A 55-year-old man with a 10-year history of poorly controlled hypertension has had increasing
dyspnea for the past 3 days. Last night he slept sitting in a chair. Vital signs are:
Pulse
Respirations
Blood pressure, sitting

110/min
30/min and regular
120/80 mm Hg

The apical impulse is felt 2 cm lateral to the midclavicular line in the sixth intercostal space.
Over the apex, there is an early diastolic low-frequency sound after S2. This sound is most
likely
A)
B)
C)
D)
E)

a midsystolic click
an opening snap
a pericardial rub
a splitting of S2
an S3
***

PHYSIO PHARM GYNECO

14. A 25-year-old woman at 32 weeks' gestation begins taking a drug to delay the onset of preterm
labor. After the first dose, she notices tremulousness in her hands. Which of the following
types of receptors is most likely to be involved in this effect?
A

1-Adrenergic

2-Adrenergic

Dopaminergic (D1)

Muscarinic (M1)

NMDA

CELL
15. Which of the following best describes the movement of Na+ and K+ during one cycle of the Na+K+ pump (ATPase) in neurons?
Na+

K+

A)

2 in

2 out

B)

2 in

3 out

C)

3 in

2 out

D) 2 out

2 in

E) 3 out

2 in

MUSCULOSKELETAL
16. The increase in the intracellular concentration of AMP in muscle after 15 minutes of strenuous
exercise has which of the following effects?
A) Increased activity of adenylyl cyclase
B) Increased breakdown of glycogen
C) Increased release of insulin
D) Inhibition of PFK phosphofructokinase activity
E) Inhibition of pyruvate kinase activity

RENAL
A 22-year-old woman is participating in a study that measures renal function.
19. Evaluation of serum and urine shows the following:
Na (mEq/L)
K+ (mEq/L)
Glucose (mg/dL)
Creatinine (mg/dL)
p-Aminohippuric acid (mg/mL)
+

Serum
140
4
100
1
0.1

Urine
100
50
0
100
50

Assuming a urine flow of 1 mL/min, which of the following best represents her filtration
fraction?
A)
B)
C)
D)
E)

.10
.20 ***
.30
.40
.50

23. Which of the following is the unique function of the central aggregate of particles
(marked by X) in the freeze-fracture image?

A) Adhesion
B) Communication
C) Motility
D) Permeability
E) Secretion
FLUIDS/ BODY COMPARTMENTS
31. A 5-year-old girl from sub-Saharan Africa is brought to the health clinic by her mother
because of diarrhea for the past 4 weeks. Her pulse is 150/min, and blood pressure is
80/40 mm Hg. Physical examination shows edema of the face, abdomen, and legs. She
is listless and has reddish hair. Serum albumin concentration is 1.2 g/dL. Compared
with a healthy child, which of the following findings is most likely in this girl?
A) Decreased interstitial fluid volume
B) Decreased interstitial hydrostatic pressure
C) Decreased plasma oncotic pressure
D) Increased capillary hydrostatic pressure
E) Increased plasma volume
RESPIRATORY
An adult's hemoglobin is 98% saturated with oxygen, but arterial oxygen content is
36. decreased. The most likely cause of this condition is
A) anemia
B) an arteriovenous shunt
C) hemoglobinopathy
D) high-altitude hypoxia
E) pulmonary diffusion defect
CELL
37. Actively dividing fibroblasts in culture are transferred from a 37 C incubator to a 0 C ice
bath, and 10-6 M colchicine is added to the culture medium. After 30 minutes, many cells
have been arrested in mitosis. Which of the following cytoskeletal proteins is most likely to
be involved?
A) Actin
B) Desmin
C) Dynein
D) Keratin
E) Kinesin
F) Lamins
G) Myosin
H ) Neurofilament proteins
I) Tubulin
Colchicina is antimitotic substance

NEURON AXN POT

44. The graph shows the action potential in a typical nerve cell. Which of the following
best describes the relationship between membrane permeabilities (P) in the hatched
region of the curve? Which correspond to Repolarization;)
A) PCa2+ < PNa+
B) PCa2+ > PNa+
C) PNa+ < PK+
D) PNa+ is approximately equal to PK+
E) PNa+ > PK+
RENAL/Pharma
47. A 40-year-old woman has recurrent calcium-containing renal calculi. Which of the following
strategies is most likely to decrease her risk for forming additional calculi?
A) Administration of a thiazide diuretic
B) Alkalinization of the urine
C) Ingestion of a high-oxalate diet
D) Ingestion of a high-protein diet
E) Restriction of fluid intake
PHARMA/PHYSIO
50. A 23-year-old woman is scheduled to undergo surgical repair of an aortic malformation. A
ganglionic blocking agent is administered before the procedure to decrease her blood pressure.
The hypotension is achieved by binding of the drug at which of the following receptors?
A

1-Adrenergic

2-Adrenergic

1-Adrenergic

2-Adrenergic

Muscarinic

Nicotinic