United States Medical Licensing Examination Step 1 Practice Test

USMLE Exam Format | Course Contents | Course Outline | Exam Syllabus | Exam Objectives

Beginning in May 2020, Step 1 examinations will include an increased number of questions that assess communications skills. The tables below provide information on the content weighting for Step 1 examinations administered before and after May 2020.

Table of Contents
- General Principles of Foundational Science
- Immune System
- Blood & Lymphoreticular System
- Behavioral Health
- Nervous System & Special Senses
- Skin & Subcutaneous Tissue
- Musculoskeletal System
- Cardiovascular System
- Respiratory System
- Gastrointestinal System
- Renal & Urinary System
- Pregnancy, Childbirth, & the Puerperium
- Female Reproductive System & Breast
- Male Reproductive System
- Endocrine System
- Multisystem Processes & Disorders
- Biostatistics, Epidemiology/Population Health
- Interpretation of the Medical Literature
- Social Sciences

Biochemistry and molecular biology
Gene expression: DNA structure, replication, exchange, and epigenetics (eg, imprinting, Xactivation, DNA methylation)
Gene expression: transcription
Gene expression: translation, post-translational processing, modifications, and disposition of
proteins (degradation), including protein/glycoprotein synthesis, intra-extracellular
sorting, and processes/functions related to Golgi complex and rough endoplasmic
reticulum
Structure and function of proteins and enzymes (eg, enzyme kinetics and
structural/regulatory proteins)
Energy metabolism (eg, ATP generation, transport chain)
Biology of cells
Adaptive cell responses and cellular homeostasis (eg, hypertrophy)
Mechanisms of injury and necrosis, including pathologic processes (eg, liquefactive necrosis,
free radical formation)
Apoptosis
Cell cycle and cell cycle regulation (eg, mitosis)
Mechanisms of dysregulation
cell biology of cancer (eg, role of p53, proto-oncogenes)
general principles of invasion and metastasis, including cancer staging
Cell/tissue structure, regulation, and function, including cytoskeleton, organelles,
glycolipids, channels, gap junctions, extracellular matrix, and receptors
Human development and genetics
Principles of pedigree analysis
inheritance patterns
occurrence and recurrence risk determination
Population genetics: Hardy-Weinberg law, founder effects, mutation-selection equilibrium
Principles of gene therapy
Genetic testing and counseling
Genetic mechanisms (eg, penetrance, genetic heterogeneity)
Biology of tissue response to disease
Acute inflammatory responses (patterns of response)
acute inflammation and mediator systems (eg, histamine, prostaglandins, bradykinins,
eosinophilic basic protein, nitric oxide)
vascular response to injury, including mediators
principles of cell adherence and migration (eg, ECAMs, selectins, leukocytic
diapedesis, and rolling)
microbicidal mechanisms and tissue injury (eg, defensins)
clinical manifestations (eg, pain, fever, leukocytosis, leukemoid reaction, chills)
Chronic inflammatory responses (eg, tumor necrosis factor)
Reparative processes
wound healing, repair: thrombosis, granulation tissue, angiogenesis, fibrosis,
scar/keloid formation
regenerative process
Pharmacodynamic and pharmacokinetic processes: general principles
Pharmacokinetics: absorption, distribution, metabolism, excretion, dosage intervals
Mechanisms of drug action, structure-activity relationships (eg, anticancer drugs)
Concentration and dose-effect relationships (eg, efficacy, potency), types of agonists (eg,
full, partial, inverse) and antagonists and their actions
Individual factors altering pharmacokinetics and pharmacodynamics (eg, age, gender,
disease, tolerance, compliance, body weight, metabolic proficiency,
pharmacogenetics)
Mechanisms of drug adverse effects, overdosage, toxicology
Mechanisms of drug interactions
Signal transduction, including structure/function of all components of signal transduction
pathways such as receptors, ligands (eg, general principles of nitric oxide, autocrine
and paracrine signaling)
Microbial biology
Microbial identification and classification, including principles, microorganism
identification, and non-immunologic laboratory diagnosis
Bacteria
structure (eg, cell walls, composition, appendages, virulence factors, extracellular
products, toxins, mechanism of action of toxins)
processes, replication, and genetics (eg, metabolism, growth, and regulation)
oncogenesis
antibacterial agents (eg, mechanisms of action on organism, toxicity to humans, and
mechanisms of resistance)
Viruses
structure (eg, physical and chemical properties, virulence factors)
processes, replication, and genetics (eg, life cycles, location of virus in latent infection)
oncogenesis
antiviral agents (eg, mechanisms of action on virus, toxicity to humans, and
mechanisms of resistance)
Fungi
structure (eg, cell wall, composition, appendages, virulence factors, extracellular
products, toxins, mechanisms of action of toxins)
processes, replication, and genetics (eg, asexual vs. sexual, metabolism, growth)
antifungal agents (eg, mechanisms of action on fungus, toxicity to humans, and
mechanisms of resistance)
Parasites
structure (eg, appendages, macroscopic features, and virulence factors)
processes, replication, and genetics (eg, life cycles, metabolism, and growth)
oncogenesis
antiparasitic agents (eg, mechanisms of action on parasite, toxicity to humans, and
mechanisms of resistance)
Prions
Normal age-related findings and care of the well patient
Infancy and childhood (0-12 years)
Normal physical changes: linear growth, variations in linear growth, including
constitutional delay; weight; head circumference; micturition, defecation,primary
incontinence/bedwetting; normal physical examination; screening; sleep;
teething syndrome
Developmental stages: motor; speech; cognitive; psychosocial; anticipatory guidance
Lifestyle and routine preventive health care: nutrition; exercise (eg, benefits of
exercise); preventive/travel medicine; risk factors and prevention (eg, guns,
swimming, motor vehicles, car seats); routine vaccinations
Adolescence (13-17 years)
Normal physical changes: linear growth, variations in linear growth including
constitutional delay; weight; puberty; normal physical examination; gynecomastia;
autonomy/self-identity; sleep
Developmental stages: cognitive (eg, abstract thought); psychosocial (eg, autonomy, role
confusion, sexual identity); anticipatory guidance
Lifestyle and routine preventive health care: nutrition; exercise (eg, benefits of
exercise); preventive/travel medicine; risk factors and prevention (eg, risk-taking
behavior, helmets, safe sex, motor vehicles, seat belts, distractions); routine
vaccinations
Adulthood (18-64 years)
Normal physical changes: weight; normal physical examination; screening; sleep
Developmental stages: cognitive; intimacy vs isolation; anticipatory guidance
Lifestyle and routine preventive health care: nutrition; exercise (eg, benefits of
exercise); preventive/travel medicine; risk factors and prevention; routine
vaccinations
Senescence (65 years and older)
Normal physical changes, including normal physical exam for age: weight, height
(spinal compression), skin, bruising; normal physical examination; response to
temperature; micturition, defecation;sleep
Developmental stages: motor; cognitive (eg, benign senescent forgetfulness);
psychosocial; integrity vs despair; retrospection; anticipatory guidance
Lifestyle and routine preventive health care: nutrition; exercise (eg, benefits of exercise);
preventive/travel medicine; risk factors and prevention (eg, falls, general medical
condition; polypharmacy, driving, caregiver stress); routine vaccinations
Immune System
Normal processes
Development of cells of the adaptive immune response, including positive and
negative selection during immune development
Structure, production, and function
granulocytes, natural killer cells, macrophages, mast cells, dendritic cells, cell receptors
(eg, complement receptors and toll-like receptors), cytokines, chemokines
T lymphocytes, including T-lymphocyte receptors, accessory molecules (eg, CD3, CD4,
CD8, B7), cell activation and proliferation, cytotoxic T lymphocytes, and memory T
lymphocytes
B lymphocytes and plasma cells, including B-lymphocyte receptors, immunoglobulins, cell
activation and proliferation, including development of antibodies and memory B
lymphocytes
host defense mechanisms, host barriers to infection, mucosal immunity (eg, gutassociated lymphoid tissue and bronchus-associated lymphoid tissue),
anatomical locations of T and B lymphocytes
Cellular basis of the immune response and immunologic mediators
antigen processing and presentation in the context of MHC I and MHC II molecules (eg,
TAP, beta-2 microglobulin), intracellular pathways, mechanisms by which MHC is
expressed on the surface; including distribution of MHC I and MHC II on different
cells, mechanisms of MHC I and MHC II deficiencies, and the genetics of MHC
regulation of the adaptive immune response (eg, peripheral tolerance, anergy,
regulatory T lymphocytes, termination of immune response, and B-T
lymphocyte interactions)
activation, function, and molecular biology of complement (eg, anaphylatoxins)
functional and molecular biology of cytokines (eg, IL 1-15)
Basis of immunologic diagnostics (eg, antigen-antibody reactions used for diagnostic
purposes, ELISA, immunoblotting, antigen-antibody changes over time, ABO
typing)
Principles of immunologic protection
vaccine production and mechanisms of vaccine action
biologically active antibodies (eg, monoclonal antibodies, polyclonal antibodies
including IVIG, VZIG, rabies immunoglobulin)
Effect of age on the function of components of the immune system
Abnormal Processes: Health and Health Maintenance, Screening, Diagnosis,
Management, Risks, Prognosis
Disorders associated with immunodeficiency
deficiency primarily of humoral immunity: common variable immunodeficiency;
hyper IgM syndrome; hypogammaglobulinemia/agammaglobulinemia, X-linked
(Bruton); selective immunodeficiency (eg, IgA, IgM, IgE)
deficiency/dysfunction primarily of cell-mediated immunity: adenosine deaminase
deficiency; DiGeorge syndrome; severe combined immunodeficiency disease
(SCID); Wiskott-Aldrich syndrome; granulomatosis; allergic reactions/skin
complement deficiency: alternative pathway component deficiency (C2, C3b, C3bB,
C36B6); classical pathway component deficiency (C1q, C1r, C1-C5); terminal
component deficiency (C5b-C9; terminal complement complex); C1 esterase
inhibitor deficiency, hereditary angioedema; mannose-binding lectin (MBL)
deficiency; membrane attack complex deficiency
deficiency of phagocytic cells and natural killer cells: Chediak-Higashi disease; chronic
granulomatous disease and other disorders of phagocytosis; leukocyte adhesion
deficiency
HIV/AIDS: HIV1 and HIV2; AIDS; AIDS complications (eg, neuropathy, dementia, renal
insufficiency); immunology of AIDS; immune reconstitution syndrome (IRS);
secondary infections; noninfectious complications
Immunologically mediated disorders
hypersensitivity reactions: type 1, 2, 3, including anaphylaxis; type 4; drug reactions;
serum sickness
transplantation: rejection; graft-vs-host disease
Adverse effects of drugs on the immune system: Jarisch-Herxheimer reaction; drugs
affecting the immune system (eg, prednisone, azathioprine, cyclosporine,
methotrexate, monoclonal antibody drugs [eg, abciximab, adalimumab; bevacizumab,
infliximab, omalizumab, rituximab]); vaccine adverse effects
Blood & Lymphoreticular System
Normal Processes
Embryonic development, fetal maturation, and perinatal changes
Organ structure and function
Cell/tissue structure and function
production and function of erythrocytes, including heme and hemoglobin synthesis;
hemoglobin O2 and CO2 transport, transport proteins, erythropoietin
production and function of platelets
production and function of coagulation and fibrinolytic factors; hemostasis
Repair, regeneration, and changes associated with stage of life
Abnormal Processes: Health and Health Maintenance, Screening, Diagnosis,
Management, Risks, Prognosis
Infectious and immunologic
infectious disorders
bacteria
viral: hemorrhagic fever (Ebola virus, Marburg virus); chikungunya; dengue fever;
Zika virus disease
parasitic: malaria (Plasmodium spp); babesiosis (Babesia species)
primary infections of lymphoid tissue: lymphadenitis (viral, bacterial, fungal,
parasitic); lymphangitis; buboes, bubonic plague (Yersinia pestis); cat scratch
disease (Bartonella henselae)
immunologic and inflammatory disorders: cryoglobinemia, essential mixed
cryoglobinemia; autoimmune hemolytic anemia; paroxysmal nocturnal
hemoglobinuria; thrombotic thrombocytopenic purpura; hemolytic uremic
syndrome
Neoplasms: leukemia, acute (ALL, AML); leukemia, chronic (CLL, CML); lymphomas, Hodgkin
disease, non-Hodgkin lymphoma, Burkitt lymphoma, T-cell lymphoma; multiple myeloma,
dysproteinemias, monoclonal gammopathy of unknown significance (MGUS);
myelofibrosis; myelodysplastic syndrome, myelodysplasias; other immunoproliferative
neoplasms (eg, Waldenstrom macroglobulinemia)
Anemia, cytopenias, and polycythemia anemias
decreased production: anemia of chronic disease
hemolysis: glucose-6-phosphate dehydrogenase deficiency; pyruvate kinase deficiency
disorders of hemoglobin, heme, or membrane: disorders of red cell membranes;
hereditary spherocytosis, elliptocytosis; methemoglobinemia, congenital; sickle
cell disease; sideroblastic anemia; thalassemias
other causes of anemia: blood loss, acute and chronic as a cause of anemia
cytopenias: aplastic anemia; leukopenia; neutropenia, cyclic neutropenia,
agranulocytosis; pancytopenia; thrombocytopenia, quantitative; immune
thrombocytopenic purpura (ITP)
cythemias: leukocytosis; polycythemia vera; secondary polycythemia
Coagulation disorders (hypocoagulable and hypercoagulable conditions)
hypocoagulable: disseminated intravascular coagulation; hemophilia, congenital
factor VIII [hemophilia A] and IX [hemophilia B]; hypofibrinogenemia; von
Willebrand disease; platelet dysfunction, qualitative
hypercoagulable: heparin-induced thrombocytopenia; other coagulopathies (eg,
homocysteinemia, hypoplasminogenemia, antithrombin III, protein C/protein S
deficiency, Factor V Leiden, anticardiolipin antibodies, lupus anticoagulant,
prothrombin G20210A mutation)
reactions to blood components: ABO incompatibility/anaphylaxis; Rh
incompatibility/anaphylaxis; hemolysis, delayed; transfusion reaction; transfusion
contaminated with bacteria; transfusion-related acute lung injury (TRALI);
anaphylactoid reaction (IgA deficiency)
Traumatic, mechanical, and vascular disorders: mechanical injury to erythrocytes (eg, cardiac
valve hemolysis); disorders of the spleen; splenic rupture/laceration; splenic infarct;
splenic abscess; effects/complications of splenectomy (eg, sepsis due to encapsulated
bacteria); hypersplenism
Adverse effects of drugs on the hematologic and lymphoreticular systems: antiplatelet drugs,
antithrombin drugs (eg, dabigatran); chemotherapeutic agents; inhibitors of coagulation
factors; methemoglobinemia, acquired; propylthiouracil; tumor lysis syndrome; warfarin
Behavioral Health
Normal Processes
Psychodynamic and behavioral factors, related past experience (eg, transference,
personality traits)
Adaptive behavioral responses to stress and illness (eg, coping mechanisms)
Maladaptive behavioral responses to stress and illness (eg, drug-seeking behavior, sleep
deprivation)
Patient adherence: general adherence; adolescent adherence
Abnormal Processes: Health and Health Maintenance, Screening, Diagnosis,
Management, Risks, Prognosis
Psychotic disorders: brief psychotic disorder; delusional disorder; psychotic disorder due to
another medical condition; schizophrenia; schizoaffective disorder; substance-induced
psychotic disorder
Anxiety disorders: acute stress disorder; anxiety disorders (generalized anxiety disorder,
anxiety due to another medical condition, social phobia); hyperventilation syndrome;
obsessive-compulsive disorder; panic disorder with and without agoraphobia; phobic
disorders; post-traumatic stress disorder; separation anxiety disorder; substance-induced
anxiety disorder, trichotillomania
Mood disorders: major depressive disorder with and without psychotic features, with and
without seasonal pattern; major depressive disorder, postpartum, with and without
psychotic features, including screening; cyclothymic disorder; persistent depressive
disorder (dysthymia); bipolar disorder, manic/depressed/mixed; premenstrual dysphoric
disorder; bipolar and related disorder or depressive disorder due to another medical
condition; substance/medication-induced bipolar and related disorder or depressive
disorder (illegal or prescribed); suicidal ideation/attempt
Somatoform disorders: body dysmorphic disorder; conversion disorder, including psychogenic
seizures; dissociative disorders; illness anxiety disorder (hypochondriasis); malingering;
pain disorder; somatic symptom disorder
Factitious disorders: factitious disorder imposed on self
Eating disorders and impulse control disorders: anorexia nervosa; binge-eating disorder;
bulimia nervosa; eating disorder; disruptive, impulse-control, and conduct disorders (eg,
gambling, kleptomania, pyromania)
Disorders originating in infancy/childhood: reactive attachment disorder; attentiondeficit/hyperactivity disorder; speech sound disorder or language disorder; learning
disorder/dyslexia; intellectual developmental disorder and developmental delay,
undefined, including school problems, fetal alcohol syndrome; oppositional defiant
disorder, conduct disorder; autism spectrum disorder, Rett syndrome; psychoses with
origin specific to childhood; elimination disorders (incontinence, encopresis); tic
disorders/Tourette disorder
Personality disorders: antisocial personality disorder; avoidant personality disorder;
borderline personality disorder; dependent personality disorder; histrionic personality
disorder; narcissistic personality disorder; obsessive-compulsive personality disorder;
paranoid personality disorder; schizoid personality disorder
Psychosocial disorders/behaviors: adjustment disorder; grief response/bereavement, normal
and persistent complex; parent-child relational problems other than physical or emotional
abuse; other psychosocial stress
Sexual and gender identity disorders: gender dysphoria; psychosexual dysfunction
Substance use disorders: alcohol use disorder/intoxication/dependence/withdrawal;
tobacco/nicotine use disorder/dependence/withdrawal; varenicline use; cannabis use
disorder/intoxication/dependence; hallucinogen use
disorder/intoxication/dependence/withdrawal; inhalant use
disorder/intoxication/dependence/withdrawal; opioid, heroin, including prescription drug,
use disorder/intoxication/dependence/withdrawal; sedative, hypnotic, including
benzodiazepine and barbiturate use disorder/intoxication/dependence/withdrawal;
stimulant, cocaine, methamphetamine use
disorder/intoxication/dependence/withdrawal; other drugs of use disorders (eg, ecstasy,
PCP, bath salts)/intoxication/dependence/withdrawal; polysubstance use
disorder/intoxication/dependence/withdrawal
Nervous System & Special Senses
Normal Processes
Embryonic development, fetal maturation, and perinatal changes, including neural tube
derivatives, cerebral ventricles, and neural crest derivatives
Organ structure and function
spinal cord
gross anatomy and blood supply
spinal reflexes
brain stem (eg, cranial nerves and nuclei, reticular formation, anatomy and blood
supply, control of eye movements)
brain
gross anatomy and blood supply
higher function: cognition, language, memory, executive function
hypothalamic function
limbic system and emotional behavior
circadian rhythm sleep-wake disorder
sensory systems
general sensory modalities, including sharp, dull, temperature, vibratory, and
proprioception
special sensory modalities, including vision, hearing, taste, olfaction, and balance
motor systems
brain and spinal cord (upper motoneuron)
basal ganglia and cerebellum
autonomic nervous system
peripheral nerves
Cell/tissue structure and function, including neuronal cellular and molecular
biology
axonal transport
excitable properties of neurons, axons, and dendrites, including channels
synthesis, storage, release, reuptake, and degradation of neurotransmitters and
neuromodulators
presynaptic and postsynaptic receptor interactions, trophic and growth factors
brain metabolism
glia, myelin
brain homeostasis: blood-brain barrier, cerebrospinal fluid formation and flow,
choroid plexus
Repair, regeneration, and changes associated with stage of life
Abnormal Processes: Health and Health Maintenance, Screening,
Diagnosis, Management, Risks, Prognosis
Infectious, immunologic, and inflammatory disorders
infectious disorders: meningitis: bacterial (Actinomyces israelii; Haemophilus influenzae;
Listeria monocytogenes; Mycobacterium tuberculosis; Neisseria meningitidis;
Staphylococcus aureus, epidermidis; Streptococcus agalactiae; Streptococcus
pneumoniae); viral (adenovirus, arboviruses, echovirus and coxsackie A & B viruses,
polioviruses, herpes simplex virus, varicella zoster, human immunodeficiency virus,
lymphocytic choriomeningitis virus, measles virus, mumps virus, St. Louis encephalitis
virus, California encephalitis virus, Western equine encephalitis virus); fungal
(Blastomycosis dermatitidis, Cryptococcus neoformans/gattii); spirochetal (Borrelia
burgdorferi; Leptospira; Treponema pallidum, including neurosyphilis);
protozoal/helminths (Acanthamoeba, Naegleria fowleri, Strongyloides stercoralis,
Angiostrongylus cantonensis, Baylisascaris procyonis); encephalitis (herpesvirus [HSVI], varicella-zoster virus, Epstein-Barr virus, cytomegalovirus, mumps virus,
enterovirus, West Nile virus, St. Louis encephalitis virus, rabies virus, Eastern and
Western equine encephalitis virus, poliovirus, Taenia, Toxoplasma gondii); prion
disease (eg, Creutzfeldt-Jakob disease); botulism (Clostridium botulinum), tetanus
(Clostridium tetani); CNS disorders associated with AIDS (eg, progressive multifocal
leukoencephalopathy)
immunologic and inflammatory disorders: myasthenia gravis, including thymoma;
multiple sclerosis; transverse myelitis
Neoplasms (cerebral, spinal, and peripheral): benign (meningioma, neurofibromatosis);
malignant (glioblastoma multiforme, astrocytoma, medulloblastoma, primary CNS
lymphoma); metastatic (eg, breast, lung, pancreatic, testicular, melanoma)
Cerebrovascular disease: arteriovenous malformations, ectatic cerebral vessels; transient
ischemic attack; stroke, thrombotic: cerebral artery occlusion/cerebral infarction;
stroke, embolic: cerebral embolism; stroke: intracerebral hemorrhage, including
subarachnoid hemorrhage, traumatic intracranial hemorrhage; cerebral artery
aneurysm; carotid artery stenosis/atherosclerosis/occlusion/dissection; vertebral artery
deficiency/dissection; subclavian steal syndrome; vascular dementia; hypertensive
encephalopathy; posterior reversible encephalopathy syndrome; venous sinus
thrombosis
Disorders relating to the spine, spinal cord, and spinal nerve roots: cauda equina syndrome;
spinal artery thrombosis/embolus/infarct; spinal cord compression; spinal cord
transection, paraplegia and quadriplegia, acute and chronic effects (eg, autonomic
dysreflexia); spinal stenosis (cervical, lumbar); syringomyelia
Cranial and peripheral nerve disorders
cranial nerve injury/disorders: cranial nerve injury; Bell palsy; anisocoria, miosis,
mydriasis; internuclear ophthalmoplegia; nystagmus and other irregular eye
movements; vestibular neuritis, labyrinthitis; ptosis of the eyelid; Horner syndrome
peripheral nerve/plexus injury/disorders: peripheral nerve injury, including brachial
plexus; carpal/cubital/tarsal/peroneal tunnel syndrome; mononeuritis, Guillain-Barré
syndrome; Miller Fisher syndrome; neuropathy (eg, Charcot-Marie-Tooth disease);
herpes zoster
Neurologic pain syndromes: complex regional pain syndrome (reflex sympathetic
dystrophy, causalgia); fibromyalgia; postherpetic neuralgia; phantom limb
pain/syndrome; thalamic pain syndrome; trigeminal neuralgia
Degenerative disorders/amnestic syndromes: Alzheimer disease; frontotemporal
dementia, including progressive supranuclear palsy, Lewy body disease; mild
neurocognitive disorder, mild cognitive impairment
Global cerebral dysfunction: altered states of consciousness; delirium; coma/brain death
Neuromuscular disorders: amyotrophic lateral sclerosis/spinal muscular atrophy; muscular
dystrophy (eg, Duchenne, myotonic); muscle channelopathies (eg, hypokalemic period
paralysis)
Movement disorders: acute dystonia; adult tic disease; essential tremor; Huntington
disease; Parkinson disease, including Parkinson dementia
Metabolic disorders: adrenoleukodystrophy; metabolic encephalopathy
Paroxysmal disorders: headache, including migraine, mixed, tension, ice-pick, cluster,
medication withdrawal, caffeine withdrawal; seizure disorders, including generalized
tonic-clonic, partial, absence, febrile
Sleep disorders: cataplexy and narcolepsy; circadian rhythm sleep-wake disorder;
insomnia, primary; sleep terror disorder and sleepwalking; REM sleep behavior
disorder; restless legs syndrome
Traumatic and mechanical disorders and disorders of increased intracranial pressure:
anoxic brain damage, cerebral hypoxia; epidural, subdural hematoma (cerebral and
spinal); intraparenchymal hemorrhage, traumatic subarachnoid hemorrhage; cerebral
edema; pseudotumor cerebri (idiopathic intracranial hypertension); torticollis/cervical
dystonia; hydrocephalus, including normal-pressure; traumatic brain injury
(concussion)/postconcussion syndrome (dementia pugilistica); traumatic brain syndrome
Congenital disorders: Friedreich ataxia; neural tube defects (eg, spina bifida,
holoprosencephaly, anencephaly); microcephaly; Sturge-Weber syndrome; tuberous
sclerosis, von Hippel-Lindau disease; hydrocephalus, obstructive (Arnold-Chiari)
Adverse effects of drugs on the nervous system: acute dystonic reaction; drug-induced
meningitis (eg, NSAIDs, sulfa drugs); drug-induced neuropathy (eg, vincristine,
isoniazid, metronidazole); extrapyramidal adverse effects (eg, akathisia, dystonia,
drug-induced parkinsonism); neuroleptic malignant syndrome; poisoning by
psychotropic agents, including antidepressants; serotonin syndrome; tardive
dyskinesia
Disorders of the eye and eyelid
infectious and inflammatory disorders of the eye: blepharitis/eyelid inflammation;
chalazion; chorioretinitis; conjunctivitis (adenovirus)/keratoconjunctivitis;
dacryocystitis; endophthalmitis; hordeolum; iridocyclitis; optic neuritis; periorbital
cellulitis; uveitis
neoplasms of the eye: melanoma; retinoblastoma
disorders of the eye and eyelid, structural: cataract; glaucoma; lacrimal system
disorders; pterygium; refractive disorders (presbyopia, myopia, hyperopia,
astigmatism)
disorders of the pupil, iris, muscles (extraocular): amblyopia; strabismus
disorders of the retina: hypertensive retinopathy; macular degeneration; papilledema;
retinal detachment; retinitis pigmentosa; vascular disorders affecting the retina,
including central retinal artery embolus, retinal hemorrhage, amaurosis fugax,
embolus, carotid artery stenosis, central retinal vein occlusion; visual
impairment/blindness, night blindness
traumatic and mechanical disorders: black eye; burn of the eye and adnexa; corneal
abrasion, ulcer; dislocated lens; foreign body in eye; hyphema; injury to optic nerve
and pathways; laceration of the eye and eyelid; ocular open wounds; orbital
fracture; subconjunctival hemorrhage
adverse effects of drugs on the eyes: ethambutol; hydroxychloroquine; prednisone
Disorders of the ear
infectious and inflammatory disorders of the ear: chondritis; mastoiditis; otitis,
externa, media, interna, serous, suppurative, malignant otitis externa
neoplasms: acoustic neuroma, neurofibromatosis type 2; cholesteatoma
hearing loss/deafness: hearing loss, including noise-induced; otosclerosis; tinnitus
disorders of balance and spatial orientation: Ménière disease; motion sickness; vertigo,
including benign positional vertigo
traumatic and mechanical disorders: barotrauma; foreign body in ear; impacted
cerumen; laceration, avulsion; perforation of tympanic membrane; eustachian
tube disorders
adverse effects of drugs on the ear: antineoplastic agents, including cisplatin;
aminoglycosides; furosemide; salicylates
Skin & Subcutaneous Tissue
Normal Processes
Embryonic development, fetal maturation, and neonatal changes
Organ structure and function, including barrier function, thermal regulation
Cell/tissue structure and function, eccrine function
Repair, regeneration, and changes associated with stage of life (eg, senile purpura, male
pattern baldness, postmenopausal hair changes)
Skin defense mechanisms and normal flora
Abnormal Processes: Health and Health Maintenance, Screening, Diagnosis,
Management, Risks, Prognosis
Infectious, immunologic, and inflammatory disorders
infectious disorders and infestations
bacterial: cellulitis, erysipelas, impetigo, staphylococcal scalded skin syndrome;
abscess, cutaneous, including septic abscess; anthrax (Bacillus anthracis);
carbuncle; folliculitis; pilonidal cyst, infected; pyoderma gangrenosum; MSSA
and MRSA skin infections; mycobacterial infections (eg, leprosy, draining
sinus); scarlet fever (group A Streptococcus)
viral: herpes simplex type 1 & type 2, herpes zoster, Ramsay-Hunt syndrome;
molluscum contagiosum; hand-foot-and-mouth disease; herpangina;
parvovirus; chickenpox, erythema infectiosum (fifth disease), rubella, measles,
roseola (exanthema subitum); verrucae vulgaris
fungal (deep and superficial): candidiasis, skin; dermatophytosis, tinea corporis;
dermatomycoses; diaper rash; onychomycosis
parasitic: cutaneous larva migrans; cutaneous leishmaniasis
infestations, nonvenomous bites, stings: scabies; lice; insect bites, including bed
bugs
immunologic and inflammatory disorders
papulosquamous and eczematous dermatoses: psoriasis; lichen planus and
lichenoid dermatoses; allergic/irritant contact dermatitis (eg, nickel);
dermatoses caused by plants (poison ivy, poison oak)
vesiculobullous disorders: epidermolysis bullosa; dermatitis herpetiformis;
pemphigus; pemphigoid
urticaria, erythema, exanthema, and purpura: erythema nodosum; atopic
dermatitis; pityriasis rosea; urticaria; Stevens-Johnson syndrome, erythema
multiforme, toxic epidermal necrolysis
autoimmune disorders: vitiligo
Neoplasms
benign neoplasms, cysts and other skin lesions: actinic keratoses; cysts, including
epidermal; hemangiomas; lipoma; pigmented nevi; seborrheic keratosis;
xanthomas
malignant neoplasms: basal cell carcinoma; squamous cell carcinoma; melanoma,
including genital; Kaposi sarcoma; cutaneous T-cell lymphoma, mycosis fungoides
Adnexal disorders (hair and hair follicles, nails, sweat glands, sebaceous glands, oral
mucous membranes)
disorders of the hair and hair follicles: alopecia; seborrhea capitis/seborrheic dermatitis;
tinea barbae and capitis
disorders of the nails (including ingrowing nail)
disorders of sweat and sebaceous glands: acne vulgaris; hidradenitis suppurativa;
hyperhidrosis; ichthyosis; rosacea
Oral disease: aphthous ulcers (stomatitis, canker sores); leukoplakia
Disorders of pigmentation: albinism; lentigo
Traumatic and mechanical disorders: animal bites (dogs, cats, etc); burns or wounds affecting
the skin or subcutaneous tissue (eg, sunburn, other including blast injuries and burns);
cauliflower ear; effects of ultraviolet light; keloids; tattoo; thermal injury, perniosis,
frostbite; ulcers, decubitus
Congenital disorders: xeroderma pigmentosum; benign lesions in neonates, infants,
children (eg, congenital nevi)
Adverse effects of drugs on skin and subcutaneous tissue: drug reactions, eruptions,
including local reaction to vaccine
Musculoskeletal System
Normal processes
Embryonic development, fetal maturation, and perinatal changes
Organ structure and function
Cell/tissue structure and function
biology of bones, joints, tendons, skeletal muscle, cartilage
exercise and physical conditioning/deconditioning
Repair, regeneration, and changes associated with stage of life
Abnormal Processes: Health and Health Maintenance, Screening, Diagnosis,
Management, Risks, Prognosis
Infectious, inflammatory, and immunologic disorders
infectious disorders: gangrene, dry and wet, clostridial myonecrosis (Clostridium
perfringens); discitis; myositis, infective; necrotizing fasciitis; osteomyelitis; septic
arthritis; spondylitis, tuberculous
immunologic disorders: ankylosing spondylitis; dermatomyositis/polymyositis;
juvenile idiopathic arthritis; rheumatoid arthritis, Felty syndrome; psoriatic
arthropathy
inflammatory disorders: adhesive capsulitis of shoulder (frozen shoulder syndrome);
ankylosis/spondylopathy (inflammatory); bursitis; fasciitis; osteochondritis,
osteochondritis dissecans; tendinitis, supraspinatus syndrome, enthesopathy of spine,
elbow, ankle; temporomandibular joint disorders; fibrositis, myofascial pain
syndrome; synovitis; tenosynovitis; myositis
Neoplasms: benign neoplasms (e.g., ganglion cyst); malignant neoplasms of bone (eg,
osteosarcoma, sarcoma, leiomyosarcoma, rhabdosarcoma); metastases to bone,
secondary malignant neoplasm of bone
Degenerative and metabolic disorders
degenerative/metabolic disorders of bone, tendon, and cartilage: chondromalacia; disc
degeneration, herniated disc; Legg-Calvé-Perthes disease; Osgood-Schlatter disease;
osteodystrophy; osteomalacia; osteonecrosis (avascular), bone infarct; osteoporosis;
osteopenia; osteitis deformans (Paget disease of bone); pathologic fracture;
radiculopathies; spondylolisthesis/spondylosis (degenerative)
degenerative/metabolic disorders of joints: gout, gouty arthritis, pseudogout; joint
effusion; osteoarthritis
degenerative/metabolic disorders of muscles, ligaments, fascia: Dupuytren contracture;
muscle calcification and ossification; muscle wasting and diffuse atrophy;
rhabdomyolysis
Traumatic and mechanical disorders: amputation and care of amputees; backache, including
low back pain; blast injuries; compartment syndrome; contractures, hospital-acquired;
contusions; dislocations; fractures; sprains, strains; kyphoscoliosis, scoliosis; rotator cuff
syndrome; slipped capital femoral epiphysis; dislocation of hip
Congenital disorders: achondroplasia/dwarfism; disorders of limb development (HOX gene
mutation, phocomelia); developmental dysplasia of the hip; dislocation of hip in
infantile spinal muscular atrophy; genu valgum or varum; foot deformities (flat foot,
valgus/varus deformities); osteogenesis imperfecta; McArdle disease; mitochondrial
myopathies
Adverse effects of drugs on the musculoskeletal system: drug-induced myopathy (eg,
steroids, statins, cocaine, AZT); malignant hyperthermia
Cardiovascular System
Normal Processes
Embryonic development, fetal maturation, and perinatal transitional changes
Organ structure and function
chambers, valves
cardiac cycle, mechanics, heart sounds, cardiac conduction
hemodynamics, including blood volume and systemic vascular resistance
circulation in specific vascular beds, including pulmonary and coronary
Cell/tissue structure and function
heart muscle, metabolism, oxygen consumption, biochemistry, and secretory function
(eg, atrial natriuretic peptide)
endothelium and secretory function, vascular smooth muscle, microcirculation, and
lymph flow
neural and hormonal regulation of the heart, blood vessels, and blood volume,
including responses to change in posture, exercise, and tissue metabolism, and
autonomic responses
Repair, regeneration, and changes associated with stage of life
Abnormal Processes: Health and Health Maintenance, Screening, Diagnosis,
Management, Risks, Prognosis
Infectious, immunologic, and inflammatory disorders
infectious disorders: bacterial endocarditis, myocarditis
immunologic and inflammatory disorders: atherosclerosis (eg, atherosclerosis of the
aorta)
Neoplasms: myxoma, metastases
Dysrhythmias: premature beats (PACs, PVCs); atrial flutter/fibrillation; multifocal atrial
tachycardia; paroxysmal tachycardias; ventricular tachycardia/fibrillation; wide complex
tachycardia; torsades de pointes; bradycardias; atrioventricular block (first-, second-,
third-degree); conduction disorder (LBBB, RBBB); cardiac arrest; sick sinus syndrome;
prolonged QT syndrome; Wolff-Parkinson-White syndrome; carotid sinus hypersensitivity;
pacemaker dysfunction, including failure to sense, capture
Heart failure: chordae tendineae rupture; congestive heart failure; cor pulmonale; diastolic
dysfunction; systolic dysfunction; mitral valve dysfunction; heart failure secondary to
myocardial infarction; high-output heart failure, including thyrotoxicosis-induced,
anemia-induced; tachycardia-induced; cardiogenic pulmonary edema
Ischemic heart disease: acute coronary syndrome, acute myocardial infarction; angina
pectoris, stable and unstable/coronary artery disease/coronary insufficiency;
coronary artery spasm
Diseases of the myocardium: cardiomyopathy, dilated, including alcoholic, viral, takotsubo;
cardiomyopathy, obstructive hypertrophic; cardiomyopathy, familial dilated;
cardiomyopathy, restrictive; hypertensive heart disease, left ventricular hypertrophy,
right ventricular hypertrophy; complications of myocardial infarction; nontraumatic
tamponade post-myocardial infarction; papillary muscle rupture/dysfunction; ventricular
free wall rupture; myocarditis
Diseases of the pericardium: chronic constrictive pericarditis; pericardial effusion; pericardial
tamponade; acute pericarditis; pericarditis, following myocardial infarction, surgery,
trauma
Valvular heart disease: valve disorders, mitral/aortic/tricuspid, pulmonic (eg,
regurgitation, stenosis, prolapse, insufficiency, vegetation); functional murmurs;
rheumatic heart disease; complications of artificial valves
Hypotension: orthostatic hypotension
Hypertension: elevated blood pressure reading without diagnosis of hypertension; essential
hypertension; malignant hypertension; secondary hypertension
Dyslipidemia: hypercholesterolemia; hyperlipidemia; hypertriglyceridemia;
lipoproteins/lipoprotein lipase deficiency
Vascular disorders
disorders of the great vessels: aneurysm, aortic (abdominal/thoracic), dissection,
ruptured; aneurysm, iliac, other peripheral vascular, ruptured; aortoiliac disease
peripheral arterial vascular disease: arterial embolus/thrombosis; arteriovenous
fistula; atheroembolic disease; claudication; cholesterol emboli; hypertensive
vascular disease; peripheral arterial disease; thromboangiitis obliterans
diseases of the veins: deep venous thrombosis, venous thromboembolism;
phlebitis/thrombophlebitis; varicose veins; venous insufficiency; stasis ulcers,
stasis dermatitis
Traumatic and mechanical disorders: ventricular puncture; myocardial contusion;
myocardial rupture; traumatic aortic dissection; traumatic tamponade
Congenital disorders, including disease in adults: anomalous left coronary artery; atrial
septal defect; coarctation of the aorta; endocardial cushion defect; patent foramen
ovale; patent ductus arteriosus; tetralogy of Fallot; transposition of the great vessels;
ventricular septal defect
Adverse effects of drugs on the cardiovascular system: adriamycin; cocaine, amphetamine,
PCP; ACE inhibitors, calcium channel blockers, alpha blockers, minoxidil
Respiratory System
Normal Processes
Embryonic development, fetal maturation, and perinatal changes
Organ structure and function
airways, including mechanics and regulation of breathing
lung parenchyma, including ventilation, perfusion, gas exchange
pleura
nasopharynx, sinuses
Cell/tissue structure and function, including surfactant formation, and alveolar structure
Repair, regeneration, and changes associated with stage of life
Pulmonary defense mechanisms and normal flora
Abnormal Processes: Health and Health Maintenance, Screening, Diagnosis,
Management, Risks, Prognosis
Infectious, immunologic, and inflammatory disorders
infectious, immunologic, and inflammatory disorders of the upper airways: acute
upper respiratory infection; viral infections (adenovirus, coronaviruses,
coxsackievirus, influenza virus, parainfluenza virus, rhinoviruses); sinusitis;
nasopharyngitis; epiglottitis; Bordetella pertussis pneumonia; croup; acute
laryngitis; acute laryngotracheitis; tracheitis; pharyngitis; streptococcal throat
infections; tonsillitis; peritonsillar abscess; rhinitis, allergic, chronic; ulcers of nasal
cavity/sinuses
infectious, immunologic, and inflammatory disorders of the lower airways: hospitalacquired pneumonia; ventilator-associated pneumonia, community-acquired
pneumonia, acute bronchiolitis; bronchiolitis obliterans with organizing pneumonia
(BOOP); anthrax, pulmonary (Bacillus anthracis); aspiration pneumonia, pneumonitis;
bronchitis, acute; bronchopneumonia; pneumonia (Burkholderia pseudomallei,
Chlamydophila pneumoniae, Coxiella burnetii, Francisella tularensis, Haemophilus
influenzae, Klebsiella pneumoniae, Legionella, Moraxella catarrhalis, Mycoplasma
pneumoniae, Pseudomonas aeruginosa, Streptococcus, MSSA, MRSA, other
gram‐negative bacteria); viral infection (eg, influenza A, B, adenovirus, H1N1,
respiratory syncytial virus, parainfluenza virus); fungal infection (aspergillosis, including
allergic bronchopulmonary aspergillosis and aspergilloma, histoplasmosis,
coccidioidomycosis, Pneumocystis jirovecii); pulmonary tuberculosis; lung abscess;
viral infection (eg, influenza A, B, adenovirus, respiratory syncytial virus,
parainfluenza virus, avian influenza virus); fungal infection (aspergillosis, including
allergic bronchopulmonary aspergillosis and aspergilloma, histoplasmosis,
coccidioidomycosis, Pneumocystis jirovecii)
Neoplasms
benign neoplasms: upper airways (eg, vocal cord polyps, nasal polyps, juvenile
papillomatosis); lungs and pleura (eg, solitary pulmonary nodule, bronchial
carcinoid tumors)
malignant neoplasms
upper airways: lip, oral cavity, and pharynx; head and neck cancer; larynx;
trachea
lower airways and pleura: malignant neoplasms of bronchus and/or lung (squamous
cell, adenocarcinoma, large cell, small cell); malignant neoplasms of pleura
(mesothelioma); secondary malignant neoplasms of lung; secondary malignant
neoplasms of pleura
metastatic neoplasms including pleural
Obstructive airway disease: asthma, reactive airway disease; bronchiectasis; chronic airway
obstruction; chronic obstructive pulmonary disease (COPD), chronic bronchitis,
emphysema
Pneumoconiosis/fibrosing/restrictive pulmonary disorders/interstitial lung disease:
pneumoconiosis; asbestosis; silicosis; silo-filler's lung, byssinosis, bagassosis,
berylliosis; hypersensitivity pneumonitis; hypereosinophilic syndromes, Loeffler
syndrome; interstitial pneumonia, usual (UIP), desquamative (DIP), nonspecific
Respiratory failure/respiratory arrest and pulmonary vascular disorders: acute respiratory
distress syndrome (ARDS); pulmonary hypertension; pulmonary vascular disorders,
arteriovenous fistula; pulmonary edema, pulmonary cause and unspecified; pulmonary
embolism; air and fat embolism; respiratory failure due to enteral feeding
Metabolic, regulatory, and structural disorders: disorders of gas exchange; hypoventilation;
hypoxia; pulmonary alveolar proteinosis; ventilation-perfusion imbalance
Disorders of the pleura, mediastinum, and chest wall: chylothorax; costochondritis;
empyema; hemothorax; mediastinitis; pleural effusion; pleuritis;
pneumomediastinum; pneumothorax
Traumatic and mechanical disorders
upper airways: epistaxis; barotrauma, sinus; laryngeal/pharyngeal obstruction;
tracheoesophageal fistula; tracheal stenosis; tracheomalacia; trauma (eg, tracheal
injury); foreign body (nose, pharynx, larynx, trachea); traumatic/mechanical
disorders of the nasal cavity/sinuses (eg, septal perforation)
lower airways and pleura: atelectasis; diaphragm/chest wall injury; drowning and neardrowning; foreign body, upper and lower respiratory tract; penetrating chest wounds;
pulmonary contusion; sleep apnea, obstructive and central; hypoventilation
syndrome, obesity-hypoventilation syndrome
Congenital disorders: bronchogenic cysts; congenital cysts; congenital diaphragmatic
hernia; pulmonary sequestration; immotile cilia syndrome
Adverse effects of drugs on the respiratory system: bleomycin, amiodarone; adverse
effects of 100% oxygen; acute effects of tobacco/nicotine, inhalants, cocaine
Gastrointestinal System
Normal Processes
Embryonic development, fetal maturation, and perinatal changes
Organ structure and function
anatomy of the alimentary canal, including mouth, pharynx, esophagus, stomach, small
intestine, large intestine, anus, peritoneal cavity
liver and biliary system, including enterohepatic circulation
salivary glands and exocrine pancreas
gastrointestinal motility, including defecation digestion and absorption
Cell/tissue structure and function
endocrine and neural regulatory functions, including GI hormones (eg, gastrin)
salivary, gastrointestinal, pancreatic, hepatic secretory products, including enzymes,
proteins, bile salts, and processes
synthetic and metabolic functions of hepatocytes
Repair, regeneration, and changes associated with stage of life
Gastrointestinal defense mechanisms and normal flora
Abnormal Processes: Health and Health Maintenance, Screening, Diagnosis,
Management, Risks, Prognosis
Infectious, immunologic, and inflammatory disorders
infectious disorders
bacterial: pseudomembranous colitis (Clostridium difficile); enteritis/enteric infections
(includes gastroenteritis) (eg, Staphylococcus aureus, Escherichia coli, Listeria
monocytogenes, Yersinia enterocolitica, Campylobacter species, Vibrio cholerae,
Salmonella species, Shigella species, traveler's/infectious diarrhea); hepatic
abscess, subhepatic abscess, subphrenic abscess; peritonitis, primary and
secondary; Whipple disease
viral: infectious esophagitis (eg, CMV, herpes); hepatitis A, B, C, D, E; coxsackievirus
enteritis/colitis; Echovirus enteritis/colitis; rotavirus enteritis; mumps;
gingivostomatitis, herpetic
fungal: thrush
parasitic: Cryptosporidium, Cyclospora, Entamoeba histolytica, Giardia, Isospora belli,
Strongyloides stercoralis
immunologic and inflammatory disorders: autoimmune hepatitis; celiac disease;
eosinophilic esophagitis; granulomatous enteritis; inflammatory bowel disease,
including Crohn disease, regional enteritis, microscopic colitis (collagenous and
lymphocytic colitis), ulcerative colitis, toxic megacolon
Neoplasms
benign neoplasms, including polyps, cysts: stomach; small intestine; colon, rectum, and
anus, including polyps
malignant neoplasms and pre-malignant conditions: oral cancer (eg, lips, mouth, tongue,
salivary glands); esophageal, squamous and adenocarcinoma; Barrett esophagus;
gastrinoma, Zollinger-Ellison syndrome; gastrointestinal carcinoid tumors;
gastrointestinal stromal tumors; small intestine; stomach, adenocarcinoma,
lymphoma, MALT; colon, rectum, anus; hereditary colon cancer syndromes, familial
adenomatous polyposis (eg, Peutz-Jeghers syndrome, Gardner syndrome, Turcot
syndrome, ); MUTYH-associated polyposis; gallbladder, cholangiocarcinoma,
adenocarcinoma of the ampulla of Vater; liver, including hepatoma; peritoneal
cancer, including metastatic studding with cancer; pancreas
metastatic neoplasms
Signs, symptoms, and ill-defined disorders: upper gastrointestinal bleeding; lower
gastrointestinal bleeding; constipation; diarrhea; hematochezia; bright red rectal
bleeding; melena; nausea, vomiting, rumination
Disorders of the oral cavity, salivary glands, and esophagus
oral cavity and salivary glands: abscessed tooth; dental caries; malocclusion;
disorders of the salivary glands (eg, stones, sialadenitis, parotitis)
esophagus: achalasia and cardiospasm; dysphagia; diverticulum (eg, Zenker);
esophageal periapical abscess without sinus; esophagitis/esophageal reflux
(GERD); esophagitis, pill; Mallory-Weiss syndrome; paraesophageal (hiatal) hernia;
stricture and stenosis of esophagus
Disorders of the stomach, small intestine, colon, rectum, anus
stomach: dyspepsia/hyperacidity; gastric ulcer; gastritis; peptic ulcer; peptic ulcer
perforation; gastroparesis
small intestine, colon: appendicitis; angiodysplasia; diverticula, diverticulitis,
diverticulosis; duodenitis, duodenal ulcer, peptic ulcer; gastroenteritis and colitis
(noninfectious); granulomatous enterocolitis; Hirschsprung disease; impaction of
intestine; intestinal obstruction/stricture; intussusception; irritable colon/irritable
bowel syndrome; mesenteric ischemia/ischemic bowel/ischemic colitis; necrotizing
enterocolitis; paralytic ileus; volvulus; malnutrition and malabsorption, including
lactose intolerance, short bowel syndrome
rectum and anus: abscess of anal and rectal regions; anal fissure; anal fistula; ulcer;
fecal incontinence; hemorrhage (rectum, anus); proctitis; hemorrhoids; rectal
prolapse
Disorders of the liver and biliary system, noninfectious
liver: cirrhosis; Dubin-Johnson, Rotor syndromes; end-stage liver disease, including
indications for transplantation; Gilbert syndrome, Crigler-Najjar syndrome; hepatic
coma/hepatic encephalopathy; hepatitis, noninfectious; hepatitis, fatty liver,
alcoholic; hepatorenal syndrome; hepatopulmonary syndrome; jaundice; nonalcoholic fatty liver disease; portal hypertension/esophageal varices
biliary system: bile duct obstruction/cholestasis; cholangitis, including ascending;
choledocholithiasis; cholelithiasis/cholecystitis; cholestasis due to parenteral
nutrition; gallstone ileus; Mirizzi syndrome; primary biliary cirrhosis; primary
sclerosing cholangitis
Disorders of the pancreas: pancreatitis, acute; pancreatitis, chronic; pancreatitis,
hereditary; pancreatic cyst/pseudocyst; pancreatic duct obstruction; pancreatic
insufficiency
Disorders of the peritoneal cavity: ascites
Traumatic and mechanical disorders: abdominal wall defects; adhesions, postsurgical;
digestive system complications of surgery; post-gastric surgery syndromes (eg, blind loop
syndrome, adhesions); duodenal tear; foreign body in digestive system; inguinal, femoral,
and abdominal wall hernias; open wound, abdominal; perforation of hollow viscus and
blunt trauma; perforation/rupture of esophagus (Boerhaave syndrome); umbilical hernia
Congenital disorders: annular pancreas, biliary atresia, cleft lip and palate, esophageal
atresia, malrotation without volvulus, Meckel diverticulum, pyloric stenosis,
tracheoesophageal fistula
Adverse effects of drugs on the gastrointestinal system: drug-induced changes in motility
(chronic laxative abuse, opioids); drug-induced gastritis, duodenitis, peptic ulcer disease
(NSAIDs); drug-induced hepatitis (eg, acetaminophen, isoniazid); drug-induced
pancreatitis (eg, thiazide diuretics)
Renal & Urinary System
Normal Processes
Embryonic development, fetal maturation, and perinatal changes
Organ structure and function
kidneys, ureters, bladder, urethra
glomerular filtration and hemodynamics
urine concentration and dilution
renal mechanisms in acid-base balance
renal mechanisms in body fluid homeostasis
micturition
Cell/tissue structure and function
renal metabolism and oxygen consumption
tubular reabsorption and secretion, including transport processes and proteins
hormones produced by or acting on the kidney (eg, renin, aldosterone, angiotensin II,
vasopressin)
Repair, regeneration, and changes associated with stage of life
Abnormal Processes: Health and Health Maintenance, Screening, Diagnosis,
Management, Risks, Prognosis
Infectious, immunologic, and inflammatory disorders
infectious disorders
upper urinary tract: granulomatous pyelonephritis; perinephric abscess;
pyelonephritis; pyonephrosis; renal abscess; renal tuberculosis
lower urinary tract and urinary tract infections of unspecified location: cystitis;
chlamydial and nonchlamydial
immunologic and inflammatory disorders
upper urinary tract
glomerular disorders: Alport syndrome; glomerular disease due to hepatitis
B, C; glomerulonephritis, including poststreptococcal; IgA nephropathy;
lupus nephritis; minimal change disease; nephrotic syndrome; thin
basement membrane disease
tubular interstitial disease: acute tubular necrosis (ATN); acute
interstitial nephritis; papillary necrosis; HIV nephropathy
lower urinary tract: interstitial cystitis
Neoplasms
benign neoplasms and cysts: polycystic kidney disease
malignant neoplasms: renal (eg, Wilms tumor/nephroblastoma, renal cell carcinoma,
renal tumors associated with congenital/hereditary conditions); urinary bladder and
collecting system
Signs, symptoms, and ill-defined disorders: dysuria; hematuria; oliguria, anuria; proteinuria
Metabolic and regulatory disorders: acute kidney injury; renal insufficiency; azotemia,
uremic syndrome; chronic kidney disease, including end-stage renal disease;
cystinuria; Fanconi syndrome; hypertensive renal disease (renal complications of
hypertension); renal calculi, ureteral calculi, nephrolithiasis; renal tubular acidosis
Vascular disorders: renal artery stenosis (atherosclerosis, fibromuscular dysplasia,
nephrosclerosis); renal vein thrombosis; renal infarction
Traumatic and mechanical disorders: bladder rupture; neurogenic bladder; obstructive
uropathy; posterior urethral valves; renal laceration; renal vascular injury; ureteral
laceration/avulsion/disruption; urethral diverticulum; urethral/ureteral
obstruction/stricture/prolapse; urinary incontinence, including secondary enuresis;
vesicoureteral reflux
Congenital disorders: double ureters/ureteral duplication/double collecting system;
horseshoe kidney; hydronephrosis/reflux; renal agenesis, renal hypoplasia, renal
dysplasia; single kidney
Adverse effects of drugs on the renal and urinary system: ACE inhibitors; aminoglycosides;
amphotericin B; cisplatin; furosemide; gadolinium (nephrogenic systemic fibrosis);
heroin; iodinated contrast dye; lithium; NSAIDs; penicillins; sulfa drugs; tenofovir; drug -
induced urinary retention
Pregnancy, Childbirth, & the Puerperium
Normal Processes
Organ structure and function: pregnancy, including fertilization, implantation, development
of embryo, labor and delivery, the puerperium, lactation, gestational uterus, placenta
Abnormal Processes: Health and Health Maintenance, Screening, Diagnosis,
Management, Risks, Prognosis
Prenatal care
preconception counseling and care: folate deficiency prevention; immunizations;
nutritional assessment, including vitamins; Rh screening
prenatal risk assessment/prevention: adolescent pregnancy; antepartum fetal
evaluation, including biophysical profile; genetic screening; α-fetoprotein; diabetes
mellitus; neural tube defects; Rh isoimmunization
supervision of normal pregnancy: assessment of gestational age; iron deficiency
prevention; nutrition, including weight management; surveillance, including
ultrasonography and assessment of fetal growth; vitamin deficiency prevention;
infections, maternal, fetal, newborn (focus on prevention and screening):
cytomegalovirus, coxsackievirus, hepatitis B virus, herpes simplex viruses, HIV,
influenza virus, parvovirus B19 virus, rubella virus, varicella-zoster virus, Chlamydia
trachomatis, Treponema pallidum, Streptococcus agalactiae, Toxoplasma gondii,
amnionitis; asymptomatic urinary tract infection
Obstetric complications: abortion, induced, septic, missed, spontaneous, threatened; acute
fatty liver of pregnancy; anemia of pregnancy, sickle cell disease, thalassemia in
pregnancy; antepartum hemorrhage, including third-trimester bleeding; cardiomyopathy
of pregnancy; cervical incompetence, cervical shortening; cholestasis of pregnancy,
intrahepatic; congenital abnormalities, maternal (eg, bicornuate uterus); ectopic
pregnancy; fetal abnormality affecting management of mother (eg, hydrocephalus, spina
bifida); fetal growth restriction; gestational diabetes; maternal mortality; multiple
gestation; placental abnormalities (abruptio placentae, placenta previa, premature
separation of placenta); polyhydramnios, oligohydramnios; preeclampsia, eclampsia,
HELLP syndrome, gestational hypertension; prolonged pregnancy; Rh isoimmunization
affecting management of mother; vomiting in pregnancy (morning sickness, hyperemesis
gravidarum); trauma in pregnancy; infections complicating pregnancy
Labor and delivery: labor and delivery, uncomplicated; labor and delivery, complicated,
including shoulder dystocia; cesarean delivery, including complications; cord
compression, cord prolapse; fetal malpresentations (eg, breech); intrapartum fetal
evaluation, including fetal heart tones; intrapartum prophylaxis (eg, HIV, Chlamydia,
gonococcal prophylaxis); premature rupture of membranes; preterm (before 37 weeks'
gestation) and postdates labor and delivery; threatened preterm labor
Puerperium, including complications: lactation problems; breast-feeding problems; lochia;
postpartum cardiomyopathy; postpartum blues; postpartum hemorrhage; postpartum
sepsis; retained placenta, products of conception (eg, placenta accreta); uterine atony
Newborn (birth to 4 weeks of age)
normal newborn
examination of liveborn at admission to hospital
screening, newborn
disorders of the newborn: screening, newborn; ABO incompatibility in newborn;
hemolytic disease due to Rh incompatibility; birth asphyxia syndrome (liveborn
neonate); birth trauma (eg, cord compression, brachial palsy, lacerations); drug
withdrawal syndrome in newborn; feeding problems in newborn; fetal growth and
development abnormalities, including fetal growth restriction; gastrointestinal
obstruction; hypocalcemia of newborn; infections, congenital or peripartum
(cytomegalovirus, herpes simplex viruses, HIV, hepatitis B, rubella virus, parvovirus
B19 virus, varicella zoster virus, Chlamydia trachomatis, Streptococcus agalactiae,
Treponema pallidum, Toxoplasma gondii); intrapartum fetal distress/death
including stillborn; jaundice, fetal/neonatal/perinatal; laryngomalacia; macrosomia
(large for gestational age); meconium aspiration syndrome; neonatal acne; neonatal
Candida infection (thrush); neonatal hypoglycemia; neonatal conjunctivitis and
dacryocystitis; ophthalmic gonorrhea; phenylketonuria; premature infant; postterm infant; pseudomembranous colitis of infancy; respiratory distress syndrome
(hyaline membrane disease); respiratory problems after birth (eg,
bronchopulmonary dysplasia, tracheomalacia; tracheoesophageal fistula in
neonates); retinitis of prematurity; seizures in newborn; sudden infant death
syndrome (SIDS), apparent life-threatening event (ALTE); tetanus neonatorum
Congenital disorders, neonatal: congenital malformations and anomalies; neonatal
hydrocele
Adverse effects of drugs on pregnancy, childbirth, and the puerperium: alcohol, tobacco,
and other drugs (ATOD); prenatal radiation exposure; teratology (eg, ACE inhibitors,
SSRIs, warfarin, infections, toxins)
Systemic disorders affecting pregnancy, labor and delivery, and puerperium:
appendicitis; asthma; carpal tunnel syndrome in pregnancy; cirrhosis; deep venous
thrombosis (DVT); diabetes mellitus; heart failure, valvular heart disease;hypertension;
myasthenia gravis; obesity; pancreatitis; psychiatric disorders; renal calculus/calculi;
renal failure/renal disease, including SLE; seizure disorders; thyroid disorders,
hypothyroidism, hyperthyroidism
Female Reproductive System & Breast
Normal Processes
Embryonic development, fetal maturation, and perinatal changes, gametogenesis
Organ structure and function
female structure, including breast
female function (eg, ovulation, menstrual cycle, puberty)
intercourse, sexual response
Cell/tissue structure and function: hypothalamic-pituitary-gonadal axis, sex steroids,
and gestational hormones
Reproductive system defense mechanisms and normal flora
Repair, regeneration, and changes associated with stage of life
Abnormal Processes: Health and Health Maintenance, Screening, Diagnosis,
Management, Risks, Prognosis
Breast
infectious, immunologic, and inflammatory disorders: breast abscess; inflammatory
disease of breast, fat necrosis; mastitis; nipple discharge
neoplasms
benign and undefined neoplasms: breast cyst, solitary; fibrocystic changes;
fibroadenoma; hypertrophy of breast; intraductal papilloma
malignant neoplasms (including screening): breast cancer; intraductal carcinoma;
Paget disease of breast; phyllodes tumors
Female reproductive system
infectious, immunologic, and inflammatory disorders: bacterial vaginosis; Bartholin gland
abscess; cellulitis, pelvic; candidiasis of the vulva or vagina; lichen sclerosus; sexually
transmitted infections and exposure; cervicitis and endocervicitis; chancroid
(Haemophilus ducreyi); genital herpes; gonorrhea (Neisseria gonorrhoeae); human
papillomavirus infection, genital/venereal/anal warts, condylomata acuminata;
lymphogranuloma venereum (Chlamydia trachomatis), non-lymphogranuloma
venereum; pelvic inflammatory disease; Fitz-Hugh–Curtis syndrome; salpingitis and
oophoritis; syphilis (Treponema pallidum); trichomoniasis (Trichomonas vaginalis);
urethritis; vaginitis; vulvovaginitis
Neoplasms of the cervix, ovary, uterus, vagina, and vulva
benign neoplasms and cysts: abnormal Pap smear; benign neoplasm of ovary;
endocervical and endometrial polyps; leiomyomata uteri; ovarian cyst
malignant and precancerous neoplasms: cervical cancer; HPV causing cancer; cervical
dysplasia, HPV causing dysplasia; endometrial hyperplasia; endometrial/uterine
cancer; gestational trophoblastic disease (hydatidiform mole); ovarian cancer;
vulvar dysplasia and cancer
Fertility and infertility: assisted reproductive techniques (ART); contraception (eg, oral
contraceptives, IUD, vaginal cap, cervical sponge, diaphragm, implant, morning-after
pill, male and female condoms); female infertility; gonadal dysgenesis 45,X (Turner
syndrome); sterilization; tubal factors; infertility
Menopause: ovarian failure, premature menopause; perimenopause; premenopausal
menorrhagia; postmenopausal atrophic vaginitis (vaginal atrophy); postmenopausal
bleeding; vasomotor symptoms
Menstrual and endocrine disorders: abnormal uterine bleeding, including
perimenopausal; absence of menstruation (primary amenorrhea, secondary
amenorrhea including undiagnosed pregnancy); anovulation; dysmenorrhea;
endometriosis; hirsutism, virilization; mittelschmerz; pelvic pain; polycystic ovarian
syndrome; postcoital bleeding; premenstrual syndrome
Sexual dysfunction: dyspareunia; orgasmic dysfunction; sexual desire/arousal
syndrome; vaginismus
Traumatic and mechanical disorders: Asherman syndrome; chronic inversion of uterus;
chronic pelvic pain syndrome; cystocele; imperforate hymen; injuries, wounds, and burns
affecting the female reproductive system and injuries, wounds, burns, and blast injuries;
ovarian torsion; pelvic relaxation; prolapse, vaginal walls, uterine, uterovaginal; rectocele;
urethrocele
Congenital disorders: müllerian agenesis; uterus didelphys, bicornuate uterus; short cervix
Adverse effects of drugs on the female reproductive system and breast: antihistamines,
H2-receptor blockers; benzodiazepines; beta-adrenergic blockers; hormone
replacement; opioids; spironolactone; selective serotonin reuptake inhibitors;
tricyclic antidepressants
Male Reproductive System
Normal Processes
Embryonic development, fetal maturation, and neonatal changes, gametogenesis
Organ structure and function
structure, male genitalia and prostate
function, male genitalia and prostate (eg, spermatogenesis, puberty)
intercourse, orgasm, erection
Cell/tissue structure and function, including hypothalamic-pituitary-gonadal axis, sex
steroids, and gestational hormones
Reproductive system defense mechanisms and normal flora
Repair, regeneration, and changes associated with stage of life
Abnormal Processes: Health and Health Maintenance, Screening, Diagnosis,
Management, Risks, Prognosis
Infectious, immunologic, and inflammatory disorders
infectious disorders: balan

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United States Medical Licensing Examination Step 1
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QUESTION 834
A 68-year-old postmenopausal female with a history of osteoprosis and essential hypertension is placed on the thiazide diuretic chlorothiazide, which
has a beneficial action toward both conditions. Which letter in below figure depicts the tubular location of epithelial cells containing a / cotransport
protein inhibited by thiazide diuretics?
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A. A
B. B
C. C
D. D
E. E
Answer: D
Section: Physiology
Explanation
Explanation:
The epithelial cells of the early portion of the distal tubule contain a / cotransporter that is
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inhibited by thiazide diuretics which promote a diuresis and a natriuresis, and which secondarily, promote increased renal reabsorption of filtered
calcium. Choices A and B denote the proximal and thin loop of Henle segments, respectively; which do not have the properties of the early distal tubular
segment. Likewise, choices C and E denote the thick ascending loop of Henle and the collecting duct, which also do not have the same properties as
the early distal tubular segment.
QUESTION 835
Worldwide, one of the most common parasitic infections is schistosomiasis. Assume a complete blood cell count is performed in a patient with this
condition. Which of the following blood cells would most likely be present in elevated amounts?
A. eosinophils
B. erythrocytes
C. monocytes
D. neutrophils
E. platelets
Answer: A
Section: Physiology
Explanation
Explanation:
Eosinophils normally constitute about 2% of all blood leukocytes. These cells are phagocytic and exhibit chemotaxis. Their primary role is in fighting
parasitic infection. In schistosomiasis the eosinophil attaches to the immature parasite and, by releasing various cytotoxic compounds, is able to kill the
parasite. Erythrocytes (choice B) are the most numerous blood cells. They are not leukocytes, but function in blood gas transport. Erythrocyte number
would not be increased in schistosomiasis. Monocytes (choice C) are leukocytes found in the blood. They are immature cells which migrate to the
tissues, where they mature into macrophages. These cells are very active in phagocytosis and play a prominent role in the inflammatory response. They
are not, however, particularly important in parasitic infections. Neutrophils (choice D) are another type of leukocyte that, though essential to combat
bacterial infections, are not particularly sensitive to parasitic challenge. Platelets (choice E) are not leukocytes. The platelet is a cell fragment that
functions in hemostasis.
QUESTION 836
After total thyroidectomy as a result of a car accident, a 47-year-old woman is positive for Trousseau sign. It is manifested as carpopedal spasm
occurring after an inflated blood pressure cuff is held above systolic blood pressure for a few minutes. Which of the following would best describe her
postoperative condition when compared to preoperative?
A. decreased deep tendon reflexes
B. higher serum calcitonin levels
C. lower serum calcium levels
D. lower serum phosphate levels
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E. shorter Q-T interval of her ECG
Answer: C
Section: Physiology
Explanation
Explanation:
A positive Trousseau sign indicates increased neuromuscular irritability, which is caused by low serum calcium levels. Apositive Trousseau sign or a
positive Chvostek sign (spasms of facial muscles) can often diagnose hypocalcemia before other gross manifestations develop. Serum calcium is
regulated by parathyroid hormone produced by the parathyroid glands. During the woman's accident, the glands, or their vasculature, were most likely
damaged enough so that they could not be saved during the total thyroidectomy. If total thyroidectomy occurs as a consequence of thyroid cancer,
damage to all four parathyroid glands would be considered an operative mishap. A consequence of hypocalcemia is hyperreflexia and not hyporeflexia
(choice A). Calcitonin is secreted by parafollicular or "C" cells in the thyroid gland. Since no other cells of the body make this hormone, serum calcitonin
levels do not rise (choice B), but instead go to zero postoperative. Low serum phosphate levels (choice D) typically signify secondary
hyperparathyroidism or low dietary phosphate intake. In the current case, high or unchanged serum phosphate would be expected. The Q-T interval of
the ECG represents the time for both ventricular depolarization and repolarization to occur. It therefore roughly estimates the duration of an average
ventricular action potential. Hypocalcemia leads to a long Q-T interval, not a short Q-T as in choice E. In severe cases, this can lead to arrhythmias,
hypotension, and heart failure.
QUESTION 837
A 60-year-old woman is admitted to the hospital with a fever and severe diarrhea for the last 24 hours. Cultures of blood, cerebrospinal fluid, urine, and
stool are all negative for pathogens. The profile of gut hormones reveals elevated levels of VIP. An analogue of which of the following would most likely
lower her VIP levels?
A. erythromycin
B. histamine
C. motilin
D. somatostatin
E. trypsin
Answer: D
Section: Physiology
Explanation
Explanation:
VIP is a neurotransmitter in the brain and in the parasympathetic nerves of the digestive tract. It also acts as a hormone. VIP has a secretin-like effect
on the pancreas. It increases the volume of water and bicarbonate output and affects GI blood flow and motility. All this contributes to severe secretory
diarrhea in the case of VIP overproduction. Somatostatin is the best choice because it has a broad range of inhibitory effects, inhibiting GI secretions,
slowing GI motility, and reducing splanchnic blood flow. An analogue of somatostatin, called octreotide, was found useful for treatment of syndromes
related with VIP overproduction. Octreotide has a longer half-life than physiologic somatostatin. Erythromycin (choice A) is known to have antibiotic
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features. This is not the best choice, since no pathogens were found. Histamine (choice B) is a physiologic stimulant of gastric hydrochloric acid
secretion, potentiating the effects of acetylcholine and gastrin. Motilin (choice C) stimulates gastric motility, which is contraindicated for diarrhea. Trypsin
(choice E) is a protease released by pancreatic cells, breaking peptide bonds as well as converting many other proteolytic enzymes to their active form.
All of the negative choices will not affect, and in fact may even worsen the VIPrelated symptoms.
QUESTION 838
Malignant hyperthermia is a relatively rare genetic disorder, found in approximately one in 10,000 individuals. Affected individuals can exhibit a life-
threatening response to inhalation anesthetics, which entails elevated core body temperature, skeletal muscle rigidity, and elevated blood carbon
dioxide levels. Based on these observed symptoms, which of the following is most likely present in malignant hyperthermia?
A. decreased release of acetylcholine at the neuromuscular junction
B. increased activation of myosin light chain kinase
C. increased activation of skeletal muscle potassium channels
D. increased activation of the calcium release channels of the sarcoplasmic reticulum
E. inhibition of skeletal muscle sodium channels
Answer: D
Section: Physiology
Explanation
Explanation:
Malignant hyperthermia is caused by a mutation to the calcium release channel of the skeletal muscle sarcoplasmic reticulum (the socalled ryanodine
receptor). Increased calcium release into the myoplasm causes strong, sustained skeletal muscle contraction. This causes excessive ATP hydrolysis,
increased metabolic activity to replenish ATP levels, heat generation, and carbon dioxide production. Decreased acetylcholine release would decrease
muscle contraction (choice A). Myosin light chain kinase is involved in contractile activation in smooth muscle (choice B). Activation of K channels would
hyperpolarize muscle fibers and tend to decrease susceptibility to contractile activation (choice C). Inhibition of sodium channels would diminish the
ability of skeletal muscle to generate action potentials and thus decrease excitability (choice E).
QUESTION 839
Below figure shows the conversions of cholesterol into the hormones C and D within follicular cells of the ovary (large arrows) and the regulation of
these processes (small arrows) by pituitary hormones (A, B, E), when binding to their receptors on the cell surfaces (dark squares). Which of the letters
in the figure best represents the hormone the concentration of which in serum changes in the following way?
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A. A
B. B
C. C
D. D
E. E
Answer: D
Section: Physiology
Explanation
Explanation:
It represents the estrogen estradiol, which is produced from androgen by granulosa cells of the ovaries and released into the capillaries. A woman's
estradiol serum concentration roughly reflects the activities of her ovaries. Estradiol levels rise during the follicular phase of the menstrual cycle (days 0
13). They reach peak levels shortly before ovulation on day 1314, and drop back during the luteal phase (days 1428). They reach menstrual/follicular
levels at the end of the luteal phase unless there is a pregnancy. After menopause, the ovaries atrophy and estradiol levels become very low. During
reproductive cycles, androgens are the main substrate for estrogen synthesis in the granulosa cells. The androgen-estrogen conversion is under the
influence of FSH (choice E). FSH concentrations are high after menopause compared to their premenopausal concentrations. The source of androgens
is theca cells. They produce it from cholesterol under the influence of LH (choice B). LH concentrations, like FSH, are high postmenopausal. Both, FSH
and LH levels are used as a diagnostic tool to determine menopause. Granulosa cells also produce progesterone (choice C) from cholesterol.
Progesterone serum levels are low during follicular phase of the menstrual cycle and high during the luteal phase of the menstrual cycle. The transition
of cholesterol to progesterone is under the influence of LH (choice A).
QUESTION 840
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During a marathon attempt a runner collapses and is admitted with severe acute dehydration. Which of the following is most likely to occur in this
patient?
A. decreased baroreceptor firing rate
B. decreased plasma osmolarity
C. high renal water excretion
D. low plasma ADH levels
E. low water permeability of collecting duct tubular cells
Answer: A
Section: Physiology
Explanation
Explanation:
Acute dehydration results in decreased plasma volume, cardiac output, and arterial pressure, which leads to a lower firing rate of the baroreceptors.
Plasma osmolarity increases (choice B) because more water than salt is lost in sweat. The increase in plasma osmolarity leads to increased ADH
secretion (choice D). High plasma ADH levels cause increased water permeability of collecting duct cells (choice E). Therefore, more water is
reabsorbed by the kidneys and renal water excretion is low (choice C).
QUESTION 841
When glucose is chronically elevated in poorly controlled diabetes mellitus, nonenzymatic glycosylation of various proteins occurs. The change of which
of the following substances is most commonly monitored as indicator for the efficiency of blood glucose control?
A. hemoglobin A1c (HbA1c)
B. lipoprotein A.
C. modified albumin
D. myoinositol
E. sorbitol
Answer: A
Section: Physiology
Explanation
Explanation:
The hallmark of poorly controlled diabetes mellitus is elevated blood glucose, which causes unphysiological glycosylation of proteins. An important long-
term measure of blood glucose control in patients with diabetes mellitus is to monitor the modification of hemoglobin A to form glycated hemoglobins.
HbA1c is the major subfraction, and determination of HbA1c is usually achieved by ion- exchange or gel electrophoresis. The level of glycated
hemoglobins in the blood is directly related to the average blood glucose levels over the life span of the hemoglobin in the circulation. Since the half- life
of red blood cells is about 120 days, a single determination of glycated hemoglobin reflects the average blood glucose level during the preceding 812
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weeks. Lipoprotein A. (choice B) is a lipoprotein particle implicated in atherosclerosis and thrombosis. Albumin (choice C) is the most abundant plasma
protein, but is not significantly affected by glycosylation. Myoinositol (choice D) is a signaling molecule the decrease in response of which to elevated
sorbitol has been suggested as a complication of diabetes. Sorbitol (choice E) is another sugar derivative, unrelated to HbA1c that is believed important
in causing other diabetic complications such as cataracts and peripheral neuropathy.
QUESTION 842
Apatient on intensive care is ventilated with a frequency of 12 per minute and a tidal volume of 0.6 L. His arterial pH increases to >7.5. What is the most
reasonable action to correct this respiratory alkalosis?
A. decrease dead space
B. decrease tidal volume
C. increase minute ventilation
D. increase oxygen fraction
E. use positive end-expiratory pressure (PEEP)
Answer: B
Section: Physiology
Explanation
Explanation:
Respiratory alkalosis is due to hyperventilation, which lowers . Decreasing tidal volume will
reduce alveolar ventilation and correct the respiratory alkalosis. Assuming a dead space of 150 mL, alveolar ventilation in this patient is 450 mL � 12/
min = 5400 mL/min. If the tidal volume were decreased from 600 to 300 mL and the frequency increased from 12 to 24 per minute, then the alveolar
ventilation would decrease to 150 � 24/min = 3600 mL/min even though the minute ventilation (12 � 600 mL/min = 24 � 300 mL/min) remains
unchanged. The fraction of (choice D) in the respiratory
air does not affect respiratory volumes or frequencies in a mechanically ventilated patient. Increasing minute ventilation (choice C) or decreasing dead
space (choice A) would increase alveolar ventilation and worsen respiratory alkalosis. PEEP (choice E) is positive pressure applied during the expiratory
phase to prevent the collapse of alveoli and to increase FRC of the lungs. It is used primarily to improve arterial oxygenation in severely hypoxic
patients.
QUESTION 843
Below figure illustrates the extracellular and intracellular volumeosmolarity status of a patient (broken lines) and that of a normal subject (solid lines) for
comparison. This patient most likely suffers from which of the following conditions?
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A. adrenal insufficiency
B. chronic vomiting
C. iatrogenic fluid overload with 0.9% NaCl
D. iatrogenic fluid overload with hypertonic solution
E. syndrome of inappropriate hypersecretion of antidiuretic hormone (SIADH)
Answer: E
Section: Physiology
Explanation
Explanation:
This patient has increased extra- and intracellular volumes and a decreased osmolarity. SIADH results in inappropriately low water permeability of the
renal collecting duct tubular cells and inappropriate water retention. As a result, patients with SIADH often present with hypotonic overhydration. Adrenal
insufficiency (lack of aldosterone) (choice A) and chronic vomiting (choice B) lead to dehydration. Fluid overload with isotonic NaCl (choice C) results in
volume expansion without change in osmolarity. Fluid overload with hypertonic solution (choice D) results in volume expansion with increased
osmolarity.
QUESTION 844
Gamma-aminobutyric acid (GABA) is an amino acid that functions as a neurotransmitter in the central nervous system. GABA typically causes
increased chloride conductance and functions as an inhibitory transmitter. Assume that the equilibrium potential for chloride (ECl-) in a particular cell is -
80 mV and that application of GABA inhibits the cell without any change in resting membrane potential. What is the resting membrane potential of the
cell?
A. +80 mV
B. 0 mV
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C. -70 mV
D. -80 mV
E. -90 mV
Answer: D
Section: Physiology
Explanation
Explanation:
This problem addresses two issues: (1) the mechanism of action of inhibitory neurotransmitters and (2) the relationship of equilibrium potential and
membrane potential. First, an inhibitory neurotransmitter acts by increasing conductance of an ion the equilibrium potential of which is either equal to or
more negative than the cell resting membrane potential. If the equilibrium potential of the ion is more negative than the resting membrane potential,
increasing the conductance of that ion will hyperpolarize the membrane--will generate an inhibitory postsynaptic potential (IPSP). Second, if the
equilibrium potential of the ion is equal to resting membrane potential, increasing the conductance of that ion will "clamp" the membrane potential more
tightly at its resting level--this will make the cell less excitable. In this problem, the membrane potential must equal -80 mV D.. If, and only if, the resting
membrane potential equals the equilibrium potential for an ion, will an increase in the conductance to that ion not cause a change in membrane
potential.
QUESTION 845
The striped area in below figure indicates a red light on the receptive fields of a red on-center, green off-center surround retina ganglion cell. How will
the light spot be perceived?
A. brown (red + green)
B. green
C. no color
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D. red
E. reddish green
Answer: D
Section: Physiology
Explanation
Explanation:
A light spot exclusively hitting the center would be perceived as deep red. Some of the light hits the inhibitory surround area. In this area, light is
processed coming from cones that are best excited by green light (middle wavelength) and inhibited by red light (long wavelength). In the below figure
the on-response dominates the off-response so that the perceived light is different from deep red, but not green (choice B). At the retina ganglion level,
the trichromate signals from the cones are transferred into the neuronal stage of color processing, the opponent color stage. The cone photoreceptors
are linked together to form opposing color pairs, in this case red versus green. Activation of one member of the pair inhibits the activity in the other so
that a color pair cannot be seen at the same location. We cannot experience reddish green (choice E). Physiological color image formation differs from
the physical process of coloring a piece of paper with a red and green pencil (choice A), one on top of the other, called subtractive color mixture. It starts
with the presence of all colors of light and then dyes subtract some of the reflected light so that adding more dyes results in a darker image such as
brown. For physiological color mixing, the presence of all colors is perceived as white, the absence as black (choice C).
QUESTION 846
Creatinine clearance is often used to evaluate glomerular function. Which of the curves in below figure best represents the relationship between plasma
creatinine concentration and creatinine clearance in a normal healthy person?
A. A
B. B
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C. C
D. D
E. E
Answer: C
Section: Physiology
Explanation
Explanation:
Creatinine clearance is independent of plasma creatinine concentration; otherwise, creatinine would not be a useful measure of GFR. Clearance is
defined as the amount of plasma that delivered the excreted substance, and for a substance that is neither actively secreted nor reabsorbed by the
kidneys; its clearance equals the amount of plasma filtered through the glomerular membrane. All creatinine contained in that amount of plasma is
excreted by the kidney, no matter what the concentration of creatinine in that plasma volume was. Because in the normal person a small amount of
creatinine is secreted by the renal tubules, clearance at low plasma concentrations is slightly higher than at elevated plasma concentration (slight initial
upward bend of curve). Curve Adescribes the relationship between creatinine plasma concentration and renal excretion of creatinine. Note that
excretion and clearance are not synonymous. Curves B and D describe the clearance of a substance that is secreted and filtered, or filtered and
reabsorbed, respectively. At large plasma concentration, the active transporters become saturated and the clearance of these substances approaches
the creatinine clearance. Curve E depicts an improbable event with relatively increased clearance at both low and high concentrations of a substance,
although there is an independent linear clearance at intermediate substance concentrations.
QUESTION 847
The patient is a 43-year-old male. He is anemic, with a hemoglobin level of 12.2 g/dL (normal is 15.5 g/dL). The erythrocytes are microcytic (MCV = 70
fL, with normal MCV = 80100 fL). Which of the following would most likely be present in this patient?
A. acute bleeding
B. folate deficiency
C. iron deficiency
D. vitamin deficiency
E. vitamin K deficiency
Answer: C
Section: Physiology
Explanation
Explanation:
Microcytic anemia can often be associated with defective hemoglobin synthesis. In the case of iron deficiency, heme synthesis is impaired due to the
lack of iron. Acute bleeding (choice A) is normally associated with erythrocytes of normal size, since the anemia is due to simple loss of blood, with
plasma expansion to maintain total volume. Both vitamin and folate (choices B and D) are
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required for DNA synthesis. Due to the extremely active cell division required to sustain the erythrocyte pool, impaired DNA synthesis first normally
manifests as a lack of erythrocyte production. Anemia due to vitamin B12 or folate deficiency is macrocytic. Vitamin K (choice E) is required for
synthesis of several clotting factors. Lack of vitamin K often presents as a problem with coagulation.
QUESTION 848
Which of the following statements concerning total body energy storage is correct?
A. Most of the body's energy store is held as carbohydrate.
B. Most of the body's energy store is held as lipid.
C. Most of the body's energy store is held as plasma glucose.
D. Most of the body's energy store is held as protein.
E. Total body's energy storage approximately equals resting metabolic rate.
Answer: B
Section: Physiology
Explanation
Explanation:
Lipid is the most concentrated form of energy storage, holding 9.4 kcal/g. For a typical 70 kg human over 130,000 kcal is typically stored as fat. Storage
of energy as available protein (choice D) is about 20,000 kcal, while storage as carbohydrate (choice A) is about 3,000 kcal. Though blood glucose
(choice C) is critically important, in particular as a source of energy for the brain, blood glucose does not provide a significant fraction of total body
energy storage. While total body energy stores typically exceed 150,000 kcal, resting metabolic rate (depending on age and body mass) is about 2100
kcal/day (choice E).
QUESTION 849
During a brain surgery, during which the patient remained conscious, a part of the DC/ML (dorsal column, medial lemniscal) system was exposed and
stimulated. Which of the following sensations might the patient most likely experience?
A. a feeling as if his fingers are warming up
B. a feeling as if something were touching his index finger
C. a tingling sensation
D. mild pain but he is unable to explain exactly where it hurts
Answer: B
Section: Physiology
Explanation
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Explanation:
The dorsal column-medial lemniscus (DC/ML) system is the sensory pathway that transmits conscious proprioceptive information with fine gradations
such as a fine touch on the index finger to the cerebral cortex. The brain interprets any signals coming along the "labeled lines," the nerves that carry
messages from the sensory organ to the cortex, as being information about a particular sense. Hence, activation of certain neurons in the somatic
sensory system can cause a sensation as if it originated from mechanical pressure on the finger (choice E). Thermal sensations (choice A), tingling
(choice C), and crude undetermined pain (choice D) are sensory modalities that are processed in the spinothalamic or anterolateral system.
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