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Shelf preparation questions

Gerardo Ochoa-Vargas, MD

Disclaimer: all these questions have been released by the NBM in the source docu!ents listed after the head of each one of the three sections that !a"e this docu!ent# $he questions do not only co!e fro! the %ell Biology and &istology section, but fro! all the other sections in 'here question that 'ere connected 'ith the course 'ere found# $he questions as such are copyrighted !aterial of the National Board of Medical (a!iners as specified in the source docu!ents# $he e(planations that follo' each one, on the other hand, are of !y authorship#

)* +ro! the ,--. NBM boo"let /Sub0ect (a!inations, %ontent Outlines and Sa!ple 1te!s*
Source docu!ent na!e2 NBM ,--.Sub0 (a!s#pdf A 40-year-old woman has reduced two-point discrimination on the distal phalanges of her fingers. Which of the following skin cell types is most likely affected in this patient? (A) Keratinocytes ( ) !angerhans" cells (#) !ymphocytes ($) %elanocytes (&) %erkel"s cells 3e have a question that si!ply could be rephrased as2 4of the follo'ing cells, 'hich one contributes to t'o-point discri!ination56 Discri!ination of any type is a sensory process# 7et8s analy9e the options# Option :2 ;eratinocytes 'ill eventually turn into bags of "eratin, so 'e can quic"ly e(clude this one# Option B2 7angerhans< cells are i!!ature dendritic cells 'ith outstanding antigenpresenting properties# $hey never contribute to any neural reception#

Option %2 7y!phocytes are present in the der!is, but they lac" of the ability to perfor! in sensory scenarios# Option D2 Melanocytes produce !elanin and nothing else# $hey do not receive or send nervous i!pulses# Option 2 Mer"el<s cells are, indeed, !ecanoreceptors# Discri!ination relies upon the integrity of the sensory syste!s of the s"in, and Mer"el<s cells are pivotal in the ability to discri!inate, together 'ith the Meissner corpuscles# $his 'as a rather easy question, as all the other structures aside the Mer"el<s cells are not related 'ith sensation# $he ans'er is # A '(-year-old man de)elops erosi)e lesions in his cartilaginous nasal septum as a result of inhaling cocaine. Which of the following types of collagen makes up the matri* fi+ers that are li+erated during this septal degradation? (A) , ( ) ,, (#) ,,, ($) ,(&) (.) / $his question does not require too !uch analysis# $hey are 0ust as"ing for the type of collagen that 'ould be liberated fro! the septal cartilage being destroyed# $he septal cartilage is !ade of hyaline cartilage, so it has type 11 collagen in its !atri(# $he only possible ans'er is B# A 01-year-old girl with chronic asthma is coughing up large amounts of mucus. Which of the following respiratory structures are the most likely source of the mucus? (A) Al)eolar ducts ( ) Al)eolar sacs (#) 2espiratory +ronchioles ($) 3erminal +ronchioles (&) 3ertiary +ronchi :gain, 'hat see!s to be a tric"y question 0ust requires the !ost basic logic to be approached# +irst, they are 0ust as"ing fro! 'here in the respiratory tract the !ucus in this patient is co!ing# 7et8s see the options# Option :2 :lveolar ducts are 0ust co!!on openings for several alveolar sacs and alveoli# $here are not cells there that produce !ucus# ,

Option B2 :lveolar sacs are co!!on openings for so!e alveoli# $he sa!e !entioned in Option : applies2 there are not cells that produce !ucus there# Option %2 =espiratory bronchioles are very s!all bronchioles that branch into alveolar ducts# $heir 'all is interrupted by alveoli, and has as !ain co!ponents ciliated cells and %lara cells# Other cells present are the brush cells, ;ulchits"y cells and basal cells# Goblet cells are absent, so !ucus is not produced here any!ore# Option D2 $er!inal bronchioles are the structures 0ust before the respiratory bronchioles, and still belong to the conductive portion of the respiratory tract since no proper gas e(change happens here# $rue, there is a structure "no'n as 7a!bert canals, that directly co!!unicate these ter!inal bronchioles 'ith so!e alveoli, but these are not that abundant# :lthough %lara cells are abundant here, there are still so!e goblet cells /and all the others !entioned in Option %*# $his structure could be the source of !ucus, but let8s read the last option# Option 2 $ertiary bronchi are si!ilar to secondary and pri!ary in their cellular constitution# $hat is, all the cells 'e e(pect to e(ist in the respiratory epitheliu!# Goblet cells are still very abundant, and in the la!ina propria !ucus-secreting glands e(ist# $he question as"s for the structure that is 4!ost li"ely the source of !ucus6 and the best possible ans'er is Option # :lthough option D could be also an ans'er, the question as"s for the 4!ost li"ely source6 and any bronchus secretes !ore !ucus than any bronchiole, si!ply because in bronchioles goblet cells start to be replaced by %lara cells# After swimming in cool water4 a woman with fair comple*ion notes that her skin +ecomes pale and cold +ecause the +lood is di)erted away from the capillary +ed in the superficial layers of the dermis. Which of the following structures are most likely responsi+le for this di)ersion? (A) Arterioles ( ) Arterio)enous shunts (#) #apillaries ($) %uscular )enules (&) 5inusoids 1n brief the question should be read as 4'hat structure is !ore li"ely responsible for diverting blood out of the capillary bed in the superficial layer of the der!is56 or >Of the follo'ing structures, 'hich ones have the ability to divert blood5> Option :2 :rterioles are strong and indeed create precapillary sphincters, although their function is not to divert blood but to protect the capillary bed for increases in the hydrostatic pressure# $his does not see! to be the right ans'er, yet the structure diverts blood, so "eep this one in !ind# .

Option B2 :rteriovenous shunts have indeed as purpose diverting blood# $hey e(ist precisely for that purpose# Option %2 %apillaries can not divert blood# $he only changes they can !a"e is to increase or decrease their dia!eter 'ith the aid of pericytes, but even 'hen !ost contracted, these cells are unable to close the blood flo' in a given capillary bed# Option D2 4Muscular venules6 is a nonsense# $here is not such structure# Option 2 Sinusoids are capillary vessels, but being so 'ide, open and hence 'ea", the blood flo' is 0ust barely affected by the action of pericytes, 1to cells in the liver, etc# So the best option is B# :rteriovenous shunts can and do divert the blood flo' depending on the require!ents# 1n the case of the s"in, 'hen the shunts are closed the blood has to go through the capillary bed, allo'ing heat to be lost# 1f they are open, the blood goes into the shunt and thence on to the venule# 1t is fair to !ention that so!e blood 'ill still go through the capillary vessel, but 0ust a !ini!u! a!ount to "eep the tissues alive# A ((-year-old woman notes a gradually increasing num+er of episodes of cramping a+dominal pain and diarrhea that occur after ingestion of milk products. A decrease in which of the following +est e*plains her condition? (A) A+ility of enterocytes to transport calcium ( ) A+ility of 6aneth cells to secrete lactase (#) A+ility of 6aneth cells to secrete lyso7yme ($) 8-9alactosidase acti)ity at the cell surface of enterocytes (&) 5ucrase acti)ity within lysosomes of enterocytes 3hat happens here5 $his lady has a proble! digesting so!ething# 3hat5 Mil" and !il"-products# $here is so!ething not 'or"ing 'ith the processing and !anage!ent of !il", and this is the typical presentation of a digestive en9y!atic deficiency, in this case a lactose deficiency# No' lets go through the ans'ers# Option :2 : decrease ability of the enterocyte to transport calciu! 'ill correlate !aybe 'ith lo' calciu! in the blood# 1n vita!in D deficiency that happens# But that does not e(plain the signs of the patient# Option B2 :bility of ?aneth cells to secrete lactase# :lthough so!e en9y!atic activity can be detected in ?aneth cells, this is 0ust a residual activity, perhaps due to the co!!on precursor all properly intestinal epithelial cells have# Option %2 $he ability of ?aneth cell to secrete lyso9y!e is pivotal, as this is the !ain secretion of this cell# $his substance is secreted in enough a!ounts that it influences the bacterial content of the intestine, and a chronic disturbance in such content 'ould indeed produce sy!pto!s si!ilar to the ones on this patient, but @

they 'ould not be that closely related 'ith !il" consu!ption as it is e!phasi9ed in the question# Aou can "eep this one in !ind, 0ust in case no better option is found# Option D2 B-Galactosidase activity at the cell surface of enterocytes# 1ts deficiency creates the condition "no'n as >lactose intolerance># $his ans'er see!s to be the right one so far# Option 2 Sucrase activity in the lysoso!es of the enterocytes# Such activity does happen in the lysoso!es, but its e(istence does not relate 'ith the conditions of this patient# So the ans'er is D# A :1-year-old man who has smoked 1 packs of cigarettes daily for 40 years de)elops shortness of +reath4 cough4 and weight loss. An *-ray film of the chest shows a large mass in the right upper lo+e of the lung4 and sputum cytology discloses malignant cells consistent with s;uamous cell carcinoma. 5erum studies show increased calcium le)els in +lood. <ormal serum concentrations of middle and #-terminal parathyroid hormone (63=) are detected +y radioimmunoassay. Which of the following +est e*plains the serum calcium concentration? (A)6roduction of intact 63= +y an ectopic neoplasm ( )6roduction of interleukin-0 (,!-0) +y a neoplasm (#) 6roduction of 63=-like humoral factor +y a neoplasm ($)2enal phosphate retention with compensatory hyperparathyroidism (&)5keletal metastases with +one resorption 1 si!plified this question fro! its original version by e(cluding other ions that 'ould generate confusion, and narro'ing do'n the case to 'hat concern calciu!# 3e observe a high level of blood calciu!, 'hich i!plies, perhaps, increased resorption# &ence, activation of osteoblastic !echanis!s are triggering osteoclastic activation# Of the possible options, only % fits such condition# 1t is indeed the case of s!all cell carcino!as of the lung to be the source of !any endocrine and endocrine-li"e factors, being this ?$&-li"e factor co!!only secreted by the neoplastic cells# So, yet again, the ans'er is %#

,* +ro! the ,--C NBM boo"let /Sub0ect (a!inations, %ontent Outlines and Sa!ple 1te!s*
Source docu!ent na!e2 NBM ,--CSub0 (a!s#pdf +ro! this question on, 1 'ill not analy9e each ans'er ite! but share 'ith you the 'ay to understand the question and ans'er it appropriately#

An oophorectomi7ed monkey is treated with high doses of estrogen. Which of the following changes is most likely to occur in the endometrium after 0 year of treatment? (A) Atrophy ( ) =yperplasia (#) =ypertrophy ($) =ypoplasia (&) %etaplasia 3e "no' that estrogen pro!otes the proliferative phase of the endo!etriu!# : constant sti!ulation 'ith estrogens 'ill create a sustained sti!ulation 'hich 'ill create a highly hyperplasic endo!etriu!# 1n the >Euic" Eui9> section of the +e!ale Genitalia presentation a sa!ple 'ith endo!etrial hyperplasia is sho'n in connection 'ith the proliferative phase-li"e appearance such estrogenic sti!ulation creates# $he ans'er is B# Which of the following muscle cell components helps spread the depolari7ation of the muscle cell mem+ranes throughout the interior of muscle cells? (A) Actin ( ) %yosin (#) 3 tu+ule ($) 3ropomyosin (&) 3roponin (.) > disk Very straightfor'ardF $he $ tubule in both the s"eletal and cardiac !uscle spreads the surface depolari9ation in the depths of the cell# $he $ tubule has a very close relation 'ith the sarcoplas!ic reticulu! /the $ tubule is the central structure of the s"eletal !uscle triad and one of the t'o structures that creates the cardiac !uscle diad*# $he s!ooth !uscle has not $ tubules but caveoli, 'hich are invaginations of the !e!brane that do not reach the sa!e depths the $ tubule does# $he ans'er is %# A new drug is de)eloped that pre)ents the demyelini7ation occurring in the progress of multiple sclerosis. 3he drug protects the cells responsi+le for the synthesis and maintenance of myelin in the central ner)ous system. 3hese cells are most likely which of the following? (A) Astrocyte ( ) &pendymal cell (#) %icroglial cell ($) ?ligodendrocyte (&) 5chwann cell :lso very straightfor'ardF 1t is as if they 'ere as"ing you >'hat cell synthesi9es !yelin in the central nervous syste!> being such the oligodendrocyte# $he ans'er is D# G

A 00-year-old +oy undergoes an appendectomy. 9ranulation tissue de)elops normally at the incision site. 3issue remodeling +egins at this site with degradation of collagen in the e*tracellular matri* +y which of the following proteins? (A) #ytokines ( ) !ipo*ygenases (#) %etalloproteinase ($) <itric o*ide (&) 6lasminogen acti)ator Aet another question that 0ust laterally belongs to the &istology do!ain, because it is actually a Bioche!istry question# :nd, unluc"ily, &istology is taught 'ith :nato!y, 'hile it should be taught 'ith Bioche!istry, 'hich is its best friend /and :nato!y should be taught 'ith ?hysiology###*# So sorry, there is not logic or thought-process here, si!ply because this fact is not covered in your ;ey ?oints# Matri( !etalloproteinases /MM?s*, a !ultigene fa!ily of at least )- !e!bers, are the ones in charge of the first step of collagen degradation in both physiological and pathological conditions# $he ans'er is %# ,n which of the following nuclear structures is $<A acti)ely transcri+ed to r2<A? (A) &n)elope ( ) !amina (#) %atri* ($) <ucleolus (&) 6ore $he nucleolus is the only nuclear structure actively involved in the creation of r=N: and hence of the riboso!es# $he ans'er is D# A 11-year-old man is +rought to the emergency department in respiratory distress 0( minutes after he was stung on the arm +y a wasp. =is pulse is 000@min4 respirations are '0@min4 and +lood pressure is 000@:0 mm =g. 6hysical e*amination shows grunting respirations and su+costal retractions. &*piratory whee7es are heard o)er +oth lung fields. 3here is generali7ed urticaria. 5ecretion of the molecule causing this patientAs symptoms is most likely mediated +y which of the following? (A) Acti)ation of complement ( ) Acti)ation of mast cell (#) Acti)ation of 3 lymphocytes ($) 6roduction of ,gA (&) 6roduction of ,g9 (.) 6roduction of ,g% +or it to be truly &isto-friendly, 'e 'ould appreciate so!e e(tra leads# Still, this is a classic case of an allergic reaction follo'ing a sting# Massive release of hista!ine, H

'hich is the substance causing this clinical presentation, happens as the !ast cell degranulates follo'ing its activation# $he ans'er is B# A ::-year-old man with >ollinger-&llison syndrome undergoes a gastrectomy. =e is informed that he will re;uire treatment with intramuscular )itamin 01 (cyanoco+alamin) for the rest of his life. 3his therapy is necessary +ecause this patient lacks which of the following types of cells? (A) #hief ( ) 9 (gastrin) (#) 9o+let ($) %ucous neck (&) 6arietal $his patient see!s to have lost the cell population that allo'ed vita!in B), to be absorbed and no' 'e need to provide it as a drug# 1n nor!al circu!stances, the parietal cell is the one that secretes intrinsic factor that is the substance needed in the ileu! to absorb vita!in B),# $he other i!portant function of the parietal cell 'as to secrete hydrochloric acid# $he ans'er is # eginning with protein synthesis in mem+rane-+ound ri+osomes4 hepatocytes secrete proteins into the circulation )ia which of the following mechanisms? (A) Acti)e transport through the cell mem+rane ( ) $iffusion through the cell mem+rane (#) 3ransport +y microtu+ules and e*ocytosis ($) 3ransport in )esicles and e*ocytosis (&) 3ransport through pores in the cell mem+rane %ells that secrete proteins have a basal basophilia due to their high content of rough endoplas!ic reticulu!# Such cells also have an apical eosinophilia, related 'ith the content of secretory granules that by e(ocytosis 'ill secrete the synthesi9ed protein in the e(tracellular space# $he hepatocyte does not sho' basal basophilia or apical eosinophilia because it has !any other functions and !any organelles, but 'hen it synthesi9es protein for secretion /albu!in 'ould be the best e(a!ple* it follo's the sa!e path described# $he ans'er is D# Which of the following is re;uired to transport fatty acids across the inner mitochondrial mem+rane? (A) Acyl carrier protein ( ) Al+umin (#) #arnitine ($) #hylomicrons (&) #reatinine (.) !ecithin-cholesterol acyltransferase Aou should re!e!ber 'e !entioned carnitine as having precisely this function 'hen dealing 'ith the internal !e!brane of the !itochodria*# $he ans'er is %# C

An e*periment is conducted in which the mitochondrial content of )arious tissues is studied. ,t is found that the mitochondrial content is directly proportional to the amount of energy one cell is re;uired to generate and e*pend. 3he mitochondrial content is most likely greatest in which of the following types of cells? (A) #ardiac muscle cells ( ) #hondrocytes (#) &ndothelial cells ($) &pidermal cells (&) =epatocytes (.) ?steocytes (9) White adipocytes Of these cell types, the !ost active is the cardiac cell, 'hich never ceases to 'or" and can not beco!e quiescent for the person to be alive# :ll the other cell types have a lesser activity, being the less active of the! the osteocytes# $he ans'er is :# A 4(-year-old man without a history of +leeding or e*cessi)e +ruising dies suddenly due to rupture of an aortic dissection. 9enetic analysis at autopsy shows a defect in the gene for fi+rillin. Which of the following e)ents most likely occurs with defecti)e fi+rillin? (A) &lastic fi+ers in the e*tracellular matri* are not correctly formed ( ) =yaluronic acid in proteoglycans is not sulfated on the proper hydro*yl residues (#) ,ntermediate filaments are not assem+led in the endothelial cells ($) 5horter side chains of chondroitin sulfate are present on proteoglycans (&) 3u+ulin is not polymeri7ed correctly due to the lack of 936 in endothelial cells : !utation in the gene for fibrillin is the "ey feature of Marfan syndro!e# lastic fibres are thoroughly affected in the body, creating 'ea" elastic arteries as in this case, 'ay too elastic synovial 0oints and 'ea"ness of the 9onula fibres in the eye, a!ong other traits# Notice that you do not need to "no' anything about Marfan syndro!e# =ead the question and after all it is phrased in the last portion of the question2 4Which of the following e)ents most likely occurs with defecti)e fi+rillin? 6 $he ans'er is :# A 41-year-old woman comes to the physician for a follow-up e*amination after two separate 6ap smears ha)e shown dysplastic epithelial cells. 2esults of a molecular diagnostic test show $<A that encodes high-risk )ersions of the human papilloma)irus &: and &B proteins. 3he )iral &: protein +inds to the cellular p(' tumor suppressor gene4 causing it to +e degraded. Which of the following +est descri+es the mechanism +y which the &: protein causes cer)ical cancer? (A) Arrests the cell cycle I

( ) &nhances tissue in)asion and metastasis (#) ,nhi+its telomerase e*pression ($) 6re)ents apoptosis (&) 5ustains angiogenesis ScaryF :nd yet the question is less tric"y than it see!s at first glance# =ead it carefully and you 'ill understand that they are as"ing 'hat is the !echanis! of action of this viral protein G, that by binding to a certain tu!our suppressor gene, creates the condition for cancer to appear# 1n brief, this protein G 'ill pro!ote cancer by shutting off a tu!our suppressor gene# $his !eans that protein G is actually interfering 'ith a gene that 'ould "ill a tu!our /the tu!our suppressor*# No', focus in the 4tu!our suppressor gene6# 3hat that !eans5 1f a gene is pro!oting a tu!our to die, it !eans it pro!otes apoptosis# &ence, protein G prevent apoptosis by interfering 'ith the nor!al e(pectancies fro! pD. tu!our suppressor gene# Options B, % and are related 'ith tu!our progression and e(tension# Option : 'ill also be against tu!our progression, but only option D is related 'ith the degradation of a tu!our suppressor gene# $he ans'er is D# 0'. Which of the following is the correct se;uence of e)ents in the initiation of contraction of a skeletal muscle fi+er?
Depolarization of Sarcolemma Conformation al Change in TroponinTropomyosin Complex Release of Ca2+ from Sarcoplasmi c Reticulum Propagation into Transverse Tubules cetylcholine !in"ing to Receptors

(A ) ( ) (# ) ($ ) (& )

0 1 ' 4 (

1 ( ( 1 '

' 4 1 ( 4

4 ' 4 ' 0

( 0 0 0 1

1f you re!e!ber, the events that lead to contraction start 'ith the release of acetylcholine by the neuron, follo'ed by the binding of such acetylcholine to receptors# $his 'ill create the depolari9ation of the !uscle fibre !e!brane /sarcole!!a*, and 'ill be i!!ediately follo'ed by the propagation of the depolari9ation deep into the cell by the $ tubules# $he release of calciu! by the sarcoplas!ic reticulu! 'ill follo', and the intracytoplas!ic increase of the calciu! levels 'ill allo' the binding of calciu! to troponin, 'hich 'ill !ove the tropo!yosin and e(pose the active sites of actin# Once e(posed, the interaction bet'een actin and !yosin 'ill occur, and it 'ill be follo'ed by the bending of the !yosin heads


/by turning :$? into :D?*# Of the options presented the only one that !atches the above order of events is B# A C0-year-old woman is +rought to the emergency department '0 minutes after she fell while clim+ing the steps into her house. 6hysical e*amination shows tenderness o)er the right shin area. An *-ray of the right lower e*tremity shows a fracture of the ti+ia. A $&/A scan shows decreased +one density. ,ncreased acti)ity of which of the following cell types is the most likely cause of the decrease in +one mass in this patient? (A) #hondrocytes ( ) ?steo+lasts (#) ?steoclasts ($) ?steocytes (&) ?steoprogenitor cells Bone density can decrease by a lo'er production of ne' bone or by a higher resorption of already produced bone# :s in the last part of the question it is stated that the cell in question is sho'ing >increased activity> 'e need to conclude that in this patient osteoporosis is due to a higher osteoclastic activity, since the osteoclast is the only cell that resorbs bone# $he ans'er is %# A (0-year-old man comes to the physician +ecause of a cough producti)e of large ;uantities of mucus for : months. =e has smoked 0 pack of cigarettes daily for 1( years. Which of the following cell types is the most likely cause of the increase in this patient"s secretion of mucus? (A) #olumnar ciliated epithelial cells ( ) 9o+let cells (#) ,nterstitial cells ($) %acrophages (&) 6neumocyte epithelial cells :s 'e described !any ti!es, goblet cells proliferate if chronically e(posed to irritants# Of course, being its secretion !ucus, the hyperplasia derived fro! the chronic e(posure to irritants 'ill increase the a!ount of !ucus secreted by the patient# $he ans'er is B# A :(-year-old man with se)ere atherosclerotic coronary artery disease comes to the emergency department +ecause of a 01-hour history of chest pain. 6lasma acti)ity of the % iso7yme of creatine kinase (% -#K) is markedly increased. Which of the following processes is the most likely e*planation for the increased plasma % -#K? (A) #ell mem+rane damage ( ) &ndoplasmic reticulum dilation (#) %itochondrial swelling ($) 6olysome dissociation (&) 5odium pump dysfunction


Before frea"ing out due to the 'eird na!es, read 'hat they actually as"ing2 'hy is the 'eird-na!ed en9y!e outside of the cytoplas!# :nd then re!e!ber2 in necrosis intracellular products 'ill lea" outside the cell# 1n such process the lea"age 'ill be produce due to cell !e!brane da!age# $he ans'er is :# $uring an e*perimental study4 an in)estigator finds that the regulation of cell cycle and programmed cell death may +e initiated +y the mitochondrion. 3he interaction of the mitochondrion with the acti)ation of the caspase family of proteases and su+se;uent apoptosis is most likely mediated +y which of the following? (A) #alcium release ( ) cA%6 production (#) #ytochrome c release ($) 936 +inding (&) <itric o*ide release 3e "no' that due to its pivotal role in the cellular !etabolis!, the !itochondrion is in charge of initiating apoptosis# 1t is the release of the cytochro!e c fro! the inter!e!brane space 'hat 'ill activate the caspase proteases 'ithin the cell# $he ans'er is %# A 4D-year-old man has hepatic cancer that is unresponsi)e to standard therapy. =e enrolls in a clinical study of a no)el chemotherapeutic agent that4 as a side effect4 +locks kinesin4 a component of the cellular microtu+ular transport system. ?ne week later4 he de)elops skeletal muscle weakness. An alteration in which of the following components of the neuromuscular Eunction is the most likely cause of the muscle weakness? (A) A decrease in the num+er of postsynaptic neurotransmitter receptors ( ) A decrease in the num+er of presynaptic neurotransmitter )esicles (#) A decrease in the presynaptic neuron calcium permea+ility ($) ,mpaired a-motoneuron action potential conduction (&) ,mpaired skeletal muscle action potential conduction 3hat is "inesin for5 1t e(ecutes the anterograde transport, that is, the one fro! the pery"aryon to the a(on# :!ong other things, it carries the vesicles pac"ed 'ith neurotrans!itter synthesi9ed in the pery"aryon to'ard the nerve ending that e(ists before the synaptic space /hence presynaptic*# Of all the options, 0ust B relates 'ith all things consider here# Jse this approachK it 'or"s very 'ell 'hen !any confusing ter!s pac" the ans'er options# So the ans'er is B# A polysome is acti)ely in)ol)ed in translation. 3he ri+osomes are attached to which of the following? (A) 5ingle-stranded $<A ( ) $ou+le-stranded $<A (#) m2<A ($) r2<A (&) t2<A ),

3e "no' that polyso!es are chains of riboso!es# :s they are reading the sa!e !olecule, it 'or"s as the attach!ent or connecting factor that 0oins the!# $hat !olecule that riboso!es are reading is !essenger =N: /!=N:*, 'hether isolated, as polyso!es or in the = =# $he ans'er is %# A pathologist uses monoclonal anti+odies against se)eral intermediate filament proteins and finds that a tumor section stains positi)e for cytokeratin only. 3he tumor most likely originated from which of the following tissues? (A) #onnecti)e ( ) &pithelial (#) 9lial ($) %uscle (&) <eural $his question see!s to be quite straightfor'ard# :s 'e "no', cyto"eratins are inter!ediate fila!ents rather specific for cells of epithelial origin, and that is precisely the ans'er here# $he ans'er is B# <ati)e collagen is composed almost entirely of which of the following types of structures? (A) a-=eli* ( ) 8-6leated sheet (#) 2andom coils ($) 3riple heli* (&) 3wo peptides connected +y a disulfide +ond :s you re!e!ber, a triple heli( characteri9es the 4native6 or co!!on collagen, synthesi9ed and secreted by the fibroblast but, as you already "no', other cell types, 'hether in their nor!al or abnor!al e(pression, are able to synthesi9e collagen# &o'ever, in all these cases, provided genetic nor!ality and precursors /i#e# a!inoacids, vita!ins*, the collagen 'ill have this triple heli( organisation# A 4(-year-old woman has the sudden onset of se)ere headaches. $uring one of these episodes4 her +lood pressure is 0C0@00( mm =g. =er usual +lood pressure is 0'0@C0 mm =g. =er sister had similar episodes se)eral years ago. Frinalysis shows increased concentrations of metanephrine and )anillylmandelic acid. 3he patient is most likely to ha)e a neoplasm that secretes which of the following? (A) A#3= ( ) Aldosterone (#) #ortisol ($) &pinephrine (&) 2enin


1n this case you notice the elevated blood pressure# 3e did not co!!ent on the !etabolic by-products of the adrenal !edulla secretions /!etanephrine and vanillyl!andelic acid, both catechola!ine !etabolites*, listed above# $he case points to a neoplas!, clearly a pheochro!ocyto!a, 'hich secretes epinephrine /option D*# $uring the processing of particular <-linked glycoproteins4 residues of mannose :-phosphate are generated. Which of the following proteins is most likely to undergo this step in processing? (A) Apo receptor ( ) 3he citrate transport protein of the inner mitochondrial mem+rane (#) ,g9 ($) !ysosomal a-fucosidase (&) %itochondrial isocitrate dehydrogenase $his is clearly a purely bioche!istry-based question 1 got fro! the corresponding section of the source docu!ent# :nd yet, that !annose G-phosphate should ring a bell2 lysoso!es# $he ans'er should be /and is* D# A 4-month-old +oy is +rought to the physician +y his mother for a well-child e*amination. =e is at the CDth percentile for head circumference. 6hysical e*amination shows dilation of the scalp )eins and spasticity of the lower e*tremities. 3he physician suspects e*cessi)e cere+rospinal fluid accumulation in the )entricular system of the +rain. 3he source of this fluid is most likely which of the following? (A) #horoid ple*us ( ) $ura mater (#) 6ia mater ($) 2oof of the third )entricle 1f 'ritten in a straightfor'ard !anner, the question could be e(pressed as 4'hich of the follo'ing structures secretes cerebrospinal fluid56 $he ans'er is, obviously, :# A new drug is de)eloped that pre)ents the demyelini7ation occurring in the progress of multiple sclerosis. 3he drug protects the cells responsi+le for the synthesis and maintenance of myelin in the central ner)ous system. 3hese cells are most likely which of the following? (A) Astrocyte ( ) &pendymal cell (#) %icroglial cell ($) ?ligodendrocyte (&) 5chwann cell $he drug in question is targeting the cell type responsible for !yelin synthesis in the central nervous syste!2 the oligodencrocyte# $he ans'er is D#


A '4-year-old woman is +rought to the emergency department +y her hus+and +ecause of confusion for 1 hours. 5he is unconscious on arri)al. =er hus+and says that she has a 0-year history of episodes of ner)ousness4 light-headedness4 and di77iness that resol)e after she eats a meal. 6hysical e*amination shows no other a+normalities. =er serum glucose concentration is 1( mg@d!. After an intra)enous infusion of 0.CG saline and glucose4 she regains consciousness. Which of the following is the most likely diagnosis? (A) #ushing syndrome ( ) ,nsulinoma (#) %ultiple endocrine neoplasia syndrome ($) 6ancreatic gastrinoma (&) 6heochromocytoma Granted, you still do not "no' the nor!al level of blood glucose, but 'ithin all NBM e(a!s there is an available reference of the nor!al values# Nor!al glucose levels e(pressed in !gLd7 are found in the range of C- to ))-# $hus, ,D !gLd7 is, by far, a significant lo' level# Given the possible causes in the options, 'e select insulino!a based in the follo'ing consideration2 an e(cess of insulin 'ould be ta"ing all available blood glucose and getting it into the cells# $he ans'er is B# A :0-year-old man comes to the physician +ecause of a cough for 1 months. =e says that he has noticed changes in his face during the past ' months. =e has smoked 1 packs of cigarettes daily for '0 years. =is temperature is 'BH# (CD.:H.)4 pulse is B1@min4 respirations are 0C@min4 and +lood pressure is 0:0@C( mm =g. 6hysical e*amination shows a round face4 central o+esity4 e*cess fat o)er the posterior neck and +ack4 and a+dominal striae. =is serum calcium concentration is C mg@d!. Frine dipstick of a clean-catch midstream specimen shows 'I glucose. A chest *-ray shows a '-cm mass in the left upper lo+e with enlargement of hilar nodes. A +iopsy specimen of the mass shows small cell carcinoma. .urther serum studies are most likely to show an increased concentration of which of the following proteins? (A) Adrenocorticotropic hormone ( ) &pidermal growth factor (#) ,g% ($) 6arathyroid hormone-related protein (&) 5erotonin 3e already !ade a si!ilar consideration2 the high calciu! level /nor!al M D !gLd7* co!es fro! a parathyroid hor!one-li"e factor secreted fro! the neoplastic cells of the lung cancers of this chronic s!o"er# Such parathyroid hor!one-li"e factor indirectly activates the osteoclasts, 'hich are degrading bone and hence releasing calciu! into the circulation# $he ans'er is D#


A 4(-year-old man with chronic pancreatitis has a C-kg (10-l+) weight loss and diarrhea. Analysis of a 14-hour stool sample shows 1D g of fat. A deficiency of which of the following en7ymes is the most likely cause? (A) Amylase ( ) #ar+o*ypeptidase (#) !actase ($) !ipase (&) !ipoprotein lipase Note the e!phasis the question !a"es on fat as "ey cause of the digestive disturbances# $his high fat lu!inal content is related, apparently, to chronic pancreatitis# :s e(pected, chronic pancreatitis 'ill cause a persistent deficiency of pancreatic en9y!es# :nd in this case, the diarrhea of the patient see!s to be related 'ith that e(cess of fat /'hen induced by fat, the diarrhea is specifically "no'n as steatorrhea*# $he only possible ans'er is D, lipase /it is understood that is pancreatic lipase*# $he only option that could be source of certain confusion, !ostly due to its na!e, is lipoprotein lipase, but such en9y!e is found in the vascular endotheliu! and hydroly9es triglycerides into lipoproteins# &ence, it has nothing to do 'ith diarrhea of this patient# So the ans'er is D# A 00-year-old +oy is +rought to the emergency department 0( minutes after he sustained a+dominal inEuries in a motor )ehicle collision. 6hysical e*amination shows massi)e ecchymoses o)er the trunk and a+domen. A #3 scan shows internal +leeding. 3he patient undergoes operati)e remo)al of a portion of the lower left lo+e of the lung4 the left lo+e of the li)er4 half of the left kidney4 half of the spleen4 and a 1-foot section of the small intestine. Assuming sur)i)al of the acute trauma4 which of the following organs is likely to ha)e the most complete regeneration in this patient? (A) Kidney ( ) !i)er (#) !ung ($) 5mall intestine (&) 5pleen 1n the 4repair casino6, al'ays bet on the liver# ven if 0ust ,- percent of the liver !ass is "ept, the re!aining C- of the cell pool 'ill be recovered# $he other options have fro! fe' repair /"idney, !ostly due to the highly differentiated podocyte pool* to !oderate and slo' /lung, spleen, s!all intestine* repair capabilities# $he ans'er is B# A '0-year-old woman comes to the physician +ecause of a 1-month history of unsteady gait and num+ness of +oth legs. &ight years ago4 she underwent resection of the terminal ileum +ecause of se)ere #rohn disease. 6hysical e*amination shows mild spastic weakness. 5ensation to pinprick4 )i+ration4 and fine touch is decreased in the upper and lower e*tremities. A deficiency of which of the following is the most likely underlying cause of these findings? )G

(A) .olic acid ( ) ,ron (#) 6rotein ($) -itamin 0 (thiamine) (&) -itamin 01 (co+alamin) 1n su!!ary, this patient has neurological signs apparently as consequence of having undergone resection of the ter!inal ileu!# 3e never studied the neurological i!portance of vita!in B), and 0ust addressed it in regards of its contribution to erythropoiesis# 1n the absence of such "no'ledge, the vignette has another "ey leading factor2 surgical resection of the ter!inal ileu!# By analy9ing the ite! list presented as possible ans'er, 'e could ans'er by focusing in the nutrient specifically absorbed in the ileu!5 So the ans'er is # A 'D-year-old woman with an 0D-year history of type 0 dia+etes mellitus and progressi)e renal failure is +eing considered for dialysis. !a+oratory studies show normocytic4 normochromic anemia. Which of the following medications is most appropriate to treat the anemia in this patient? (A) &rythropoietin ( ) .olic acid (#) .olinic acid ($) -itamin 0 (thiamine) (&) -itamin 01 (cyanoco+alamin) ;ey factor to ans'er this question2 the patient has renal failure# &er ane!ia is caused by a secretory deficit due to the loss of a given cell population, a consequence of renal failure# 1n the "idney corte( interstitiu! 'e 'ould have the "ey cause of renal-based ane!ia2 depletion of the erythropoietin-secreting cells# $he ans'er is :# A :0-year-old woman comes to the physician +ecause she recently was diagnosed with non-small cell lung carcinoma and she wants to discuss possi+le treatment options. 5he tells the physician that she is concerned a+out the possi+le ad)erse effects of chemotherapy. 3he physician says that serious to*icity caused +y antineoplastic drugs is seen in the +one marrow. Which of the following +est e*plains this finding? (A) #ells in the marrow di)ide rapidly ( ) #ells in the marrow ha)e specific surface targets for most of these drugs (#) #ells in the marrow lack the en7ymes to protect against the drugs ($) #hemotherapy drugs act preferentially against cells with no nucleus (&) #hemotherapy drugs penetrate well into the marrow +ecause it is )ery )ascular (.) #hemotherapy drugs tend to +e lipid-solu+le and concentrate in the marrow


3hen tal"ing about labile cells and the cell cycle, 'e !entioned that cells that quic"ly divide are the ones !ore affected by che!otherapy2 hair bulb in the hair follicle, intestinal epitheliu! and bone !arro'# $he ans'er is :# A (-year-old girl falls through the ice while skating on an outdoor pond. 5he is remo)ed from the water within 0 minute4 +ut dry clothing is not a)aila+le4 and she is still cold and wet 10 minutes later. Which of the following mechanisms helps maintain the patientAs core temperature during the period following her rescue? (A) #utaneous )asodilation ( ) $i)ing response (#) ,ncreased thermoregulatory set point ($) 2elease of endogenous pyrogen (&) 5hi)ering $his is !ostly a ?hysiology-oriented question, and 'e do not address ther!ogenesis as such in our course# &o'ever, 'e do "no' that the bro'n adipocyte has ther!ogenin, 'hich uncouples the respiratory chain fro! the phosphorative o(idation# $hese electrons are lost and !anifested as heat# $his process 'as addressed as non-shivering ther!ogenesis# So by pure option eli!ination, shivering is the ans'er for this question2 option # A 'C-year-old woman comes to the physician for a follow-up e*amination +ecause she recently was diagnosed with hypertension. =er +lood pressure is 0(:@000 mm =g. 6hysical e*amination shows no other a+normalities. 5erum studies show normal findings. A 14-hour urine collection shows three times the normal e*cretion of epinephrine and metanephrine. 3he e*cessi)e epinephrine production in this patient is most likely caused +y which of the following cell types? (A) #hromaffin ( ) Ju*taglomerular (#) >ona fasciculata ($) >ona glomerulosa (&) >ona reticularis :gain, a pheochro!ocyto!a scenario# So the only possible ans'er is :# After an o)ernight fast4 a (1-year-old man undergoes infusion of acid through a catheter into the upper duodenum. 3his most likely will increase pancreatic secretion mainly through the action of which of the following su+stances? (A) #holecystokinin ( ) 9astrin (#) 9lucagon ($) 5ecretin (&) -asoacti)e intestinal polypeptide


:s e(pected, acid influ( in the duodenu! 'ill trigger the secretion of bicarbonate to achieve neutrali9ation# Secretin is the hor!one that induces such 'atery and bicarbonate-rich secretion in the pancreas /duct syste!, starting in the centroacinar cell*# $he ans'er is D# A '(-year-old man has an adenoma of the parathyroid gland4 with increased serum concentrations of parathyroid hormone (63=) and calcium. ,n this patient4 63= induces which of the following processes to cause hypercalcemia? (A) 6roduction of 1(-hydro*ycholecalciferol ( ) 5hift of #a1I from the intracellular to the e*tracellular fluid compartment (#) 5timulation of osteoclast acti)ity ($) 5uppression of renal production of 041( dihydro*ycholecalciferol $he patient has a hypersecretion of nor!al parathyroid hor!one /?$&* due to an adeno!a# Such hypersecretion is pro!oting hypercalce!ia /increased blood calciu!* due to its indirect activation of the osteoclasts# $he ans'er is %# :s for the other ans'ers, production of ,D-hydro(ycholecalciferol happens in the liver and is independent of ?$&# 1ntracellular calciu! 'ill never be pu!ped to the e(terior in response to any hor!onal sti!ulation# ?$& is actually the factor 'hose presence grants the renal production of ),,D -dihydro(ycholecalciferol# A 4-hour-old female new+orn deli)ered at '0 weeks" gestation has respiratory distress. =er temperature is ':.(H# (CB.BH.)4 pulse is 0:0@min4 respirations are D(@min4 and +lood pressure is :D@40 mm =g. Arterial +lood gas analysis on room air shows a low +lood o*ygen saturation. &ndotracheal intu+ation and mechanical )entilation are re;uired. 3he primary cause of this patient"s condition is a dysfunction of which of the following cell types? (A) Al)eolar macrophages ( ) 6neumocytes (#) 6ulmonary chondrocytes ($) 6ulmonary )ascular endothelial cells (&) 5mooth muscle cells Ne'borns 'ith respiratory distress have al'ays this e(pressive clinical presentation# :lveoli are beco!ing unable to perfor! o(ygen saturation since they cannot re-e(pand once they are collapsed# $he ans'er is B# 1f both pneu!ocytes 'ere present as separated options, it 'ould be necessary to select the type , alveolar cell, but 'e 'ould require getting !ore data conveying that deficient e(pansion due to the absence of a substance 'ith the potential of lo'ering the surface tension /i#e# surfactant*# $his is not the case, so again, the ans'er is B# A 1(-year-old woman comes to the physician +ecause of a 1-day history of muscle cramps and profuse4 watery stools. 5he returned from a trip to 6akistan ' days ago. =er temperature is 'BH# (CD.:H.)4 pulse is 010@min4 and +lood pressure is D0@(0 mm =g. 5tool culture shows numerous cur)ed4 )I

gram-negati)e +acteriaK there are no erythrocytes or leukocytes. ?ral rehydration is initiated. 3he +lood pressure increases4 and the pulse decreases. 3he oral hydration formula most likely promotes sodium a+sorption )ia the gut +y allowing cotransport with which of the following? (A) Al+umin ( ) .atty acid (#) 9lucose ($) %agnesium (&) 6otassium =e!e!ber that glucose is absorbed via an active transport using NaN-dependent glucose transporters /SG7$)*# $he base of oral hydration is to sei9e this glucose absorption that also brings sodiu! /hence 'ater* into the enterocyte# $he ans'er is %# A BB-year-old man comes to the physician +ecause of swelling of his legs and feet for : months. =e has a 40-year history of alcoholism and a (-year history of hepatic disease. 6hysical e*amination shows ascites and a 1I edema of the lower e*tremities. A decrease in which of the following most likely promotes edema formation in this patient? (A) #apillary hydrostatic pressure ( ) .iltration coefficient (#) ,nterstitial colloid osmotic pressure ($) ,nterstitial fluid hydrostatic pressure (&) 6lasma colloid oncotic pressure %hronic hepatic diseases course 'ith hypoalbu!ine!ia /lo' albu!in concentration in blood*# $his question co!es fro! the pathology section of the NMB docu!ent, so it assu!es you already "no' this# 1n ?hysiologyL&istology shelf e(a!s, such question 'ould !a"e an overt e!phasis of this lo' albu!in content# &aving agreed in this datu!, the ans'er is # :lbu!in !a"es !ost of the oncotic /and the oncotic !a"es !ost of the os!otic* vascular pressure, 'hich drags bac" into the blood vessel the e(tracellular fluid# A '0-year-old woman comes to the physician for a routine health maintenance e*amination. 5he takes no medications. 6hysical e*amination shows no a+normalities. 5erum studies show a calcium concentration of 01 mg@d!. An increase in which of the following su+stances is the most likely cause of the serum finding in this patient? (A) one morphogenic protein ( ) #alcitonin (#) ,ntegrins ($) 6arathyroid hormone (&) -itamin A By no', you are 'ell a'are that, of the options available, parathyroid hor!one is the only possible factor underlying this calciu! increase# $he ans'er is D# ,-

.* +ro! the ,-), JSM7 4%ontent Description and General 1nfor!ation6 boo"let for the Step )
Source docu!ent na!e2 S O%ontentOutlineandSa!ple1te!s#pdf A :-year-old +oy is +rought to the physician +y his parents +ecause of a 'day history of fe)er4 headache4 and cough producti)e of a green4 foulsmelling discharge that also e*its from his nose. =e has had repeated episodes of similar symptoms during the past 4 years. =e appears pale and lethargic. =is height and weight are +oth +elow the 00th percentile. #oarse rhonchi are heard +ilaterally. An *-ray of the chest shows scattered peripheral opacities4 dilated and thickened airways consistent with +ronchiectasis4 and a cardiac ape* that is directed toward the right. 3he most likely cause of his recurrent infections is a dysfunction of which of the following cell types? (A) Al)eolar capillary endothelial cell ( ) Al)eolar macrophage (#) #hondrocyte ($) #iliated columnar epithelial cell (&) #lara cell (.) 9o+let cell (9) Kulchitsky cell (=) 5;uamous epithelial cell (,) 3ype , pneumocyte (J) 3ype ,, pneumocyte =ule of thu!b2 if there are 'ay too !any options, the question is less difficult than it loo"s at first glance /that is 'hy they put so !any options there, for you to get lost*# $his is also a Step ) question and you still !ay not have all the required data to ans'er it 'ithout guessing# &o'ever, the presentation is so!e'hat classic and this is 'hy 1 brought it here# ;artagener syndro!e, 'hich has all the features in this patient, is a syndro!e related 'ith dynein deficiencyLdefect, !a"ing cilia unable to !ove /and !ost ti!es but not al'ays the flagellu! too*# $he cellular defect creates a condition in 'hich !ucus accu!ulates in the air'ays, beco!es stagnant dilating the bronchi /bronchiectasis* and also a sanctuary for bacteria and thus chronic infections# Of the cells listed here, 0ust one has the cellular structure 'hose dynein deficiencyLdefect 'ould create that !ucus-stagnant condition2 the ciliated colu!nar epithelial cell# $he ans'er is /D* A 04-year-old girl is +rought to the physician +ecause of a recent growth spurt of 0( cm (: in) during the past year. 5he also has had increasing fatigue and palpitations during this period. =er paternal aunt has a history of palpitations and se)ere myopia. 5he is at the C(th percentile for height and (0th percentile for weight. 6hysical e*amination shows a long4 thin face.


?phthalmologic e*amination shows dislocated lenses. #ardiac e*amination shows a hyperdynamic precordium with early click and systolic murmur. &chocardiography shows an enlarged aortic root and mitral )al)e prolapse. A+normal synthesis of which of the following proteins is the most likely cause of this patient"s disorder? (A) #ollagen4 type , ( ) &lastin (#) .i+rillin-0 ($) .i+ro+last growth factor 2' (&) !aminin (.) <eurofi+romin (9) 6A/ : +or this ?athology question to be &isto-friendly, they 'ould require to tell you that 'e are dealing 'ith a Marfan syndro!e case, in 'hich a proble! in the synthesis of elastic fibres occurs# By the ti!e you ta"e ?athology, all this prologue is o!itted since you are e(pected to "no' it# So they are si!ply as"ing 'here 'ould you find the underlying defect in this syndro!e 'ith deficient elastic fibres# $he ans'er is %# A :0-year-old man comes to the physician +ecause of a '-month history of episodes of headache4 heart palpitations4 and e*cessi)e sweating. =e has had a 00-kg (11-l+) weight loss during this period. While +eing e*amined4 during an episode his +lood pressure is 100@000 mm =g. 6hysical e*amination shows no other a+normalities. Frine studies show increased catecholamine concentrations. A #3 scan of the a+domen is most likely to show a mass in which of the following locations? (A) Adrenal glands ( ) Appendi* (#) Kidneys ($) 6ancreas (&) 5tomach :nother pheochro!ocyto!a# $his question see!s to be fro! :nato!y /but connects 'ith the histological addressing 'e have done in regards of this tu!our*# ?heochro!ocyto!as are !ost li"ely found in the adrenal !edulla# &ence, the %$ scan 'ould sho' a !ass in the adrenal gland# $he ans'er is :# A male new+orn deli)ered at 1: weeks" gestation de)elops respiratory distress immediately after a spontaneous )aginal deli)ery. =is respirations are 40@min. 6hysical e*amination shows cyanosis and lower ri+ retractions with respiration. =eart sounds are normal. ilateral +reath sounds are heard on auscultation. A chest *-ray shows +ilateral lung opacities. 3he most likely cause of this patient"s +reathing difficulties is insufficient production of which of the following su+stances? (A) #ollagen4 type ,,, ( ) a-.etoprotein (#) %econium ,,

($) 2etinoic acid (&) 5urfactant $his is another ne'born 'ith 'hat you 'ill learn as signs of respiratory distress# +or this one to be &isto-friendly, an e!phasis should be !ade in regards of the increase of the intra-alveolar surface tension, or the type , alveolar cell secretory deficiency# 1f so, you 'ould quic"ly conclude that 'hat this patient is !issing is surfactant# $he ans'er is # A (-year-old +oy is +rought to the physician +y his parents +ecause of an Dmonth history of difficulty walking. =is parents say that he limps when he walks and has a waddling gaitK he also has difficulty standing. When getting up from a sitting position4 he uses his hands to walk up his thighs and push his +ody into a standing position. =is parents ha)e not noticed any weakness of his arms. =is mother is an only child4 +ut she has an uncle who +ecame +edridden as a child and died of respiratory arrest. 6hysical e*amination shows prominent calf muscles. %uscle strength is 4@( at +oth hips +ut normal elsewhere. 3his patient most likely has a mutation in the gene coding for which of the following proteins? (A) Actin ( ) $ystrophin (#) .rata*in ($) %yelin (&) %yosin Definitely not &isto-friendly, but still let8s try# $his is a classic presentation of the Duchenne !uscular dystrophy# Do you re!e!ber that, in striated !uscle, P discs are anchored to the sarcole!!a by vinculin and dystrophin5 $his latter !olecule got its na!e actually fro! the disease# So that is the ans'er, option B#