Board Review Week 3 Test

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Board Review Week 3 Test
Good luck!!
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Question 1 of 40
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B   Amygdaloid nuclei and lumbar system After
the destruction of amygdaloid nucleus and lumbar
system, the normal fear reaction is often absent.
Mammillary bodies are part of the Papez circuit
(of limbic system). Stimulation and ablation
experiments indicate that in addition to its role
in olfaction, the limbic system is concerned with
feeding behavior. Along with the hypothalamus, it
is also concerned with sexual behavior, the
emotion of rage and fear, and motivation. The
functions of cerebral frontal lobes and cerebral
motor cortex include initiating voluntary motor
impulses for the movement of skeletal muscles,
analyzing sensory experiences and providing
responses relating to personality. The frontal
lobes are also involved with responses related to
memory, emotions, reasoning, judgment, planning
and verbal communication. Lesions in cerebral
frontal lobes and motor cortex may affect any or
all of these functions. Removal or lesions of
neocortex will inhibit sexual behavior.
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Question 2 of 40
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C   Meissner's corpuscles Meissner's corpuscles
are specialized receptors that lie in the
papillary dermis, perpendicular to the surface of
the skin. They are primarily found in hairless
skin, particularly the fingers and toes. The
capsule of the corpuscle is an elongated cone,
within which an unmyelinated nerve ending spirals
to the tip of the cone. As in the Pacinian
corpuscle, the unmyelinated nerve ending is
enclosed by Schwann cells.
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Question 3 of 40
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B   Cholinergic sympathetic The term
cholinergic is used to describe any physiologic
or pharmacologic relationship that involves
acetylcholine (ACh). For example, cholinergic
nerve fibers synthesize and release ACh,
cholinergic receptors complex with ACh or
synthetic analogs of ACh, and cholinergic drugs
chemically resemble ACh or interfere with its
inactivation. A sympathetic nerve fiber is part
of the sympathetic division of the autonomic
nervous system. Autonomic control of the
adrenal medulla involves single innervation via
motor fibers of the sympathetic division of the
autonomic nervous system (ANS). This unique
arrangement of single innervation, rather than
dual autonomic innervation through the two
opposing ANS subdivisions requires sympathetic
neurotransmission that is not dependent on
norepinephrine (noradrenaline). The majority of
postganglionic sympathetic fibers of the ANS
release noradrenaline and are termed adrenergic ,
but the sympathetic preganglionic fibers that
innervate the adrenal medulla release ACh,
therefore, such fibers are designated as
cholinergic sympathetic fibers. The adrenal
medulla has its embryological origins as a
sympathetic ganglion that migrates to a location
on the superior aspect of the kidney, but retains
its connection with the sympathetic preganglionic
fiber. (In this regard the cholinergic
sympathetic classification of the autonomic fiber
controlling the adrenal medulla is not unusual
since all preganglionic fibers, both sympathetic
and parasympathetic, are classified as
cholinergic sympathetic fibers.)
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Question 4 of 40
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B   Basement membrane Type IV collagen is
amorphous. It is abundant in the basement
membrane. Distribution of collagen in different
tissues is enumerated as follows Type I Skin,
bone, tendons Type II Cartilage, vitreous
humor Type III Blood vessels, skin, uterus Type
IV Basement membrane Type V Interstitial
tissue Type VII Dermal epidermal junction Type
VIII Endothelium-descemet's membrane Type IX
Cartilage Type X Cartilage Type XI Cartilage
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Question 5 of 40
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D   Oral Bioavailability (F) refers to the rate
and extent to which a drug or a metabolite enters
general circulation. From the bloodstream, the
drug or metabolite is capable of reaching its
site of action. Several variables affect
bioavailability. For example, the formulation and
pH of the drug can affect how rapidly the drug is
absorbed through membranes. In addition, the
route of administration influences
bioavailability because bioavailability is
determined by measuring either the amount of drug
in circulation or the extent of the pharmacologic
response produced by the drug. Either way, the
route of administration plays a critical role.
In theory, the intravenous (IV) and
intra-arterial (IA) routes deliver 100 of the
administered dose to the bloodstream (F 1).
Other parenteral routes such as the intramuscular
(IM) or subcutaneous (SC) routes deliver somewhat
less than 100 of the administered dose (F due to pharmacokinetic factors such as tissue
binding and relatively slow tissue clearance by
the lymphatic system. The inhalational route, due
to the extensive surface area of the
alveolar-capillary interface, can provide a
relatively high bioavailability measurement,
although not as great as that attained through
direct introduction of drug into the bloodstream.
The route yielding relatively low
bioavailabilitya distinct disadvantageis the
oral route. The low bioavailability of drug is
due to the action of gastric enzymes,
gastrointestinal motility, and extensive hepatic
first-pass metabolism effects. First-pass effects
refer to the rapid inactivation of a drug by
hepatic enzymes (e.g. mixed function oxidases)
and the rapid elimination of drug metabolites via
the biliary route of excretion. Drug metabolism
also occurs within the intestinal lumen, the
intestinal mucosal cells, and the hepatic portal
system, but the majority of first-pass effects
are due to the action of hepatic enzymes.
(Although inhalational drugs are not directly
affected by hepatic first-pass effects, they are
subject to lung first-pass effects, including
metabolism and excretion.) Passage through
general circulation or through the kidney does
not contribute to first-pass effects in
pharmacokinetics. Different routes of
administration exhibit different advantages and
disadvantages. The intravenous route delivers
drug to the bloodstream nearly instantaneously as
evidenced by the short time required to reach
peak plasma concentration (Tmax) and maximal
serum levels (Cmax). By contrast, the oral route
requires a much longer time to reach Tmax and
Cmax. The intravenous route provides precise
control of dose via IV infusion and provides the
means to deliver water-soluble drugs such as
aminophylline in large volumes. A significant
drawback to the rapid onset and distribution of
drug through the IV route is the simple fact that
the delivered dose is not retrievable should a
dosage miscalculation or an unforeseen drug
reaction occur. The enteral route, on the other
hand, allows the retrieval of a portion of orally
administered drug through induction of emesis or
gastric lavage. In addition, orally administered
drugs, because of their dosing convenience, are
ideal for chronic outpatient use.
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Question 6 of 40
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B   Delusions A delusion is an idea that is not
fixed in reality. A hallucination is a perception
without a stimulus. Depression involves a
depressed mood and lack of interest in life.
Euphoria is an elevated mood. Delirium involves
confusion and disorientation.
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Question 7 of 40
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• C   Respect her decision if she can demonstrate
  and communicate ability to reason
• Competence is a legal term, capacity is a medical
  term. Physicians are often called on to make a
  determination of a patient's capacity to make
  medical decisions. The patient's primary care
  provider is an ideal person to make the
  assessment as they have background knowledge of
  the patient's educational level, values, and
  medical history.
• A psychiatrist may be needed if overlying
  psychiatric problems make it difficult to
  determine capacity for judgment or ability to
  reason. Courts make the ultimate determination of
  competence, although there is usually concordance
  with the medical determination of capacity. Only
  lack of competence has legal ramifications,
  however.
• A bedside mental status examination may help to
  determine capacity, but in and of itself does not
  determine competence. If the patient is deemed to
  have the capacity to make her own decisions, it
  may be detrimental to encourage family member
  involvement in the decision making process.
• Adult protective services are usually called to
  investigate cases of abuse or neglect, not issues
  of capacity or competence. If still unclear, a
  psychiatrist or ethics board consultation could
  be utilized to help determine the patient's
  capacity to make her own decisions.
• Four main criteria should be used to determine a
  patient's capacity to make medical decisions.
• They can demonstrate understanding of the
  treatment options.
• They can demonstrate understanding of how the
  different options affect their own individual
  situation.
• 3) They can demonstrate ability to reason with
  the above information, using either evidence
  based in fact, or personal beliefs rooted in
  their value system.
• 4) They are able to demonstrate 1-3 and can
  communicate a choice.

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Question 8 of 40
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A   Frontal lobe The brain, or cerebrum, is
divided into two hemispheres the right
hemisphere and the left hemisphere. Connecting
the two hemispheres are the corpus callosum,
anterior commissure, hippocampal commissure,
posterior commissure, and the habenular
commissure. The outermost portion of the brain,
characterized by convolutions and grooves, is the
cerebral cortex of which the right hemisphere
controls the motor and sensory processes of the
left side of the body and the left hemisphere
controls the right side of the body
(contralateral control). The cerebral cortex
may be anatomically divided into four lobes the
frontal, parietal, temporal and occipital lobes.
The frontal lobe is responsible for planning and
for motor functions. Specifically, the area
within the frontal lobe that controls voluntary
body movements is called the motor cortex. Thus,
frontal lobe is the correct answer to the
question. The parietal lobe is largely
concerned with somatic sensation (somatosensory
cortex), the occipital lobe with vision, and the
temporal lobe with audition as well as other
functions. Thus, in the above question, these are
incorrect answers. The limbic lobe is a ring of
cortical structures surrounding the central core
of the brain and is itself encircled by the
frontal, parietal, temporal and occipital lobes.
It is part of the limbic system which is
generally associated with emotion, learning and
memory. As it is not associated with motor
function, limbic lobe is an incorrect answer.
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Question 9 of 40
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D   Spleen Based upon their ultrastructural
characteristics, capillary endothelia may be
described as being continuous, fenestrated or
discontinuous (sinusoidal). Discontinuous
capillaries characteristically have larger
diameter and more irregularly shaped lumen than
that of other capillaries. Furthermore, these
large diameter capillaries may have gaps between
endothelial cells and have sparse or absent basal
lamina underlying the endothelium. These types of
capillaries are common to the spleen, but are
also found in the liver and in bone marrow.
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Question 10 of 40
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B   Anti-idiotype Each immunoglobulin consists
of light chains and heavy chains. Isotypic
differences are those between types such as IgG
and IgM, and allotypes are allelic variants in
the individual C genes of antibodies. Idiotypes
are antigenic determinants of the variable
regions linked to the specificity towards the
antigen. Long ago it was shown that the
heterogeneity and average affinity of antibodies
increase with time in response to an antigen. The
population of idiotypes produced during an immune
response evolves so that the response is more
specific and more effective. The study of
idiotypes is essential for the analysis of the
genetic origin of variability.
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Question 11 of 40
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A   Drug A Dose-response curves that show the
interaction between an agonist drug and an
antagonist drug are those that compare the ED50
of the agonist alone with the ED50 of the agonist
after an antagonist is added. In both the Drug A
and Drug B graphs, it can be seen that the ED50
(median effective dose) of the agonist drug has
increased from approximately 20 mg to
approximately 50 mg. This increase in the median
effective dose is due to the pharmacologic
antagonism between agonist and antagonist as both
drugs attempt to bind the same pharmacologic
receptor. A drug response is related to the
number of complexes formed between receptor and
agonist. An agonist exhibits affinity plus
efficacy whereas an antagonist shows affinity for
a receptor, or the ability to form a complex with
it, but possesses no intrinsic activity, or
efficacy. The noncompetitive nature of
pharmacologic antagonism is seen in the graph of
Drug A in which the potency and the efficacy of
the agonist are both decreased. This type of
interaction shows a sigmoid ED50 curve displaced
downwards and to the right. The median effective
dose increases from 20 mg to 50 mg, indicating a
loss of agonist potency. In other words, more
drug is required to bind available receptors and
evoke a particular response. The maximal drug
response, however, cannot be restored, no matter
how high the dose of agonist drug administered.
This decrease in effectiveness is visible
graphically as a shift downwards in the ED50
curve and is typical of the irreversible
competition occurring between an agonist drug and
a noncompetitive antagonist. Each receptor bound
by the noncompetitive antagonist is no longer
available to the agonist, thereby decreasing
agonist efficacy, or the ability to produce an
effect relative to a given number of
drug-receptor complexes. In the Drug B graph
the ED50 curve has undergone a parallel
displacement to the right but no displacement
downwards. This shift denotes a decrease in
potency of the agonist but no change in its
efficacy. Potency refers to the relative ability
of a drug to produce a particular response at a
given dose. It should be remembered that
comparisons of potency are only useful if made at
equieffective doses. In competitive antagonism,
an optimal number of agonist-receptor complexes
can be formed and a maximal response (100) can
still be achieved, but the dose necessary to
elicit this level of response is higher as
evidenced by the increased median effective dose.
The pharmacologic blocking effect of the
competitive antagonist can be reversed by
increasing the dose of the agonist. This provides
additional agonist drug to bind available
receptors as the competitive antagonist
"uncouples" from them. A classic example of
this type of reversible pharmacologic antagonism
is the competition for cholinergic receptors
(N2-nicotinic) at motor end plates of
neuromuscular junctions that occurs between
acetylcholine acting as agonist and curarelike
neuromuscular blockers acting as competitive
antagonists.
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Question 12 of 40
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B   Increase the morphine until she is
comfortable, even if she dies in the process
Much literature has been published on the fact
that terminal cancer patients are often
inadequately treated when it comes to pain
control. Many possible explanations have been
proposed to explain this phenomenon. Some
practitioners may fear they will be reprimanded
by the Drug Enforcement Administration (DEA) for
prescribing too many controlled substances. Some
may believe that the patient really isn't in
"that much" pain. Others fear that the side
effects of the medication will cause further
problems such as constipation, confusion,
respiratory depression, or addiction (even in a
patient that has days or weeks to live!) The
literature emphasizes that narcotics can be dosed
as high as it takes to achieve adequate pain
control in terminally ill cancer patients. It is
a common misconception that a practitioner will
be criminally prosecuted when a terminal patient
dies while receiving narcotics. If the patient in
the aforementioned case inadvertently died while
receiving high doses of morphine, it would not be
considered murder or assisted suicide. The use of
adequate pain medication for this patient is
completely justified, especially in view of the
patient's advanced directives, terminal
diagnosis, and supportive family. An ethics
consultation or risk management assessment would
be an option if either the physician or the
family were uncomfortable with the situation.
Physician assisted suicide (the intentional
administration of life-ending medication) is
currently legal in Oregon, and other
jurisdictions may legalize it or prohibit it in
the future.
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Question 13 of 40
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C   Schizoaffective disorder Zelda's symptoms
best describe the criteria for schizoaffective
disorder. She presents with prominent
schizophrenic and affective symptoms. As the name
implies, schizoaffective disorder combines
features of both disorders a period where there
is either a major depressive episode, a manic
episode, or a mixed episode along with Criterion
A symptoms for schizophrenia (i.e., delusions,
hallucinations, etc.).
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Question 14 of 40
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C   Duodenum While villi, intestinal glands,
and goblet cells might be found in the duodenum
and ileum, submucosal glands, in combination with
the former characteristics, could be found only
in the duodenum. The submucosal glands, or
Brunner's glands, secrete alkaline glycoproteins
and bicarbonate ions to bring the pH of the
intestinal contents to that optimal for action of
the pancreatic enzymes. The esophagus does not
possess villi on the cells of the stratified
squamous epithelium. It may have mucosal glands,
however. The colon does not have villi or
submucosal glands, but does have extensive
numbers of goblet cells.
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Question 15 of 40
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A   Blocking the release of acetylcholine at the
synapse and thereby producing paralysis
Botulinum toxin produced by Clostridium
botulinum is a neurotoxin that blocks the release
of acetylcholine at the synapset , producing
paralysis. The genes for this toxin are encoded
by a temperate bacteriophage. It is composed of 2
polypeptide subunits held together by disulfide
bonds and one of the subunits binds to a receptor
on the neuron.
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Question 16 of 40
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A   Liver and gall bladder The photomicroscopic
image depicts the histological appearance of two
organs in close contact the liver and gall
bladder. Inspection of the epithelial lining of
the gall bladder shows the presence of simple
columnar cells. Underlying the epithelium is a
loose connective tissue core, the lamina propria,
thrown into irregular folds. A fairly prominent
layer of smooth muscle is seen underlying the
lamina propria, forming the muscularis layer of
the gall bladder. Glisson's capsule is absent at
the position where the liver and gall bladder are
in contact, however, the characteristic hepatic
plates with intervening sinusoids can be seen.
The intervening area common to the liver and
gall bladder is composed of connective tissue
adventitia. Note that one of the folds of
epithelium in the lumen of the gall bladder is
pronounced and appears like a gland in the
sectioned organ. Without careful inspection of
the image, the liver may appear similar to the
cells of the parenchyma within the pars distalis
of the pituitary gland, but the pars intermedia
may contain what appear as colloid-filled cysts
or follicles lined by simple squamous or cuboidal
epithelium, not present in this image. The
seminal vesicle may show irregular folds of the
lamina propria, similar to the gall bladder, but
the epithelium is predominantly pseudostratified
columnar lining the lumen. The prostate gland
would show glands, whose lumen possibly contain
concretions, lined by a variety of epithelia,
usually pseudostratified columnar. Underlying the
glands are a fibromuscular connective tissue.
The gall bladder also may be confused with the
uterine tube, since the uterine tube is lined
with a simple columnar epithelium, and has folds
of lamina propria. However, many of the
epithelial cells of the uterine tube are
ciliated. The ovary does not resemble the
liver, since the parenchyma of the ovary contains
ova in various stages of maturation interspersed
throughout connective tissue.
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Question 17 of 40
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B   Stage 2 Sleep comprises approximately 1/3
of our lives and its function is far from being
completely understood. Normally, sleep is an
active (not passive) process where the brain
activity fluctuates over about 45 cycles per
night. Distinct sleep stages can be measured by
EEG as patients pass through stages 1-4 (non-REM)
and then enter REM sleep. Patients enter REM
sleep (dream sleep) approximately every 90
minutes and the duration of this stage lengthens
as the night progresses. The characteristic EEG
pattern of the various sleep stages is listed
below along with some physiological observations.
Waking - alpha waves (8-12 cps) NREM Sleep -
(Nonrapid eye movement) - low level of activity
lowered BP, heart rate, temperature, and
respiratory rate. Good muscle tone and slow,
drifting eye movements. Stage 1 - lightest
sleep, a transition stage low voltage,
desynchronized waves. Stage 2 - sleep spindles,
(13-15 cps) and high spikes (K complexes).
Stage 3 - some delta waves (high voltage at
0.5-2.5 cps). Stage 4 - deepest sleep, mostly
in first half of night mostly delta waves. REM
Sleep - active sleep characterized by rapid
synchronous eye movement, twitching of facial and
extremity muscles, penile erections, and
variation in pulse, BP, and respiratory rate.
Muscular paralysis is present. Depth is similar
to stage 2. Dreaming can occur in several stages
but is most common in REM sleep.
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Question 18 of 40
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D   Affect Affect is the visible expression of
emotions. In this patient the affect is
inappropriate to the content of his speech.
Thought process denotes the connections between
thoughts, and thought content is the actual
thoughts themselves, which may be delusional or
hallucinatory. Mood is emotion that is
pervasive and long-lasting. Mood is best
described in the patient's own words. Impulse
control is a description of the patient's ability
-or inability- to forego action in light of a
particular feeling or urge.
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Question 19 of 40
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B   Reversibility of effect can be rapidly
achieved Bioavailability (F) refers to the rate
and extent to which a drug or a metabolite enters
general circulation. From the bloodstream, the
drug or metabolite is capable of reaching its
site of action. Several variables affect
bioavailability. For example, the formulation and
pH of the drug can affect how rapidly the drug is
absorbed through membranes. In addition, the
route of administration influences
bioavailability because bioavailability is
determined by measuring either the amount of drug
in circulation or the extent of the pharmacologic
response produced by the drug. Either way, the
route of administration plays a critical role.
In theory, the intravenous (IV) and
intra-arterial (IA) routes deliver 100 of the
administered dose to the bloodstream (F 1).
Other parenteral routes such as the intramuscular
(IM) or subcutaneous (SC) routes deliver somewhat
less than 100 of the administered dose (F due to pharmacokinetic factors such as tissue
binding and relatively slow tissue clearance by
the lymphatic system. The inhalational route, due
to the extensive surface area of the
alveolar-capillary interface, can provide a
relatively high bioavailability measurement,
although not as great as that attained through
direct introduction of drug into the bloodstream.
The route yielding relatively low
bioavailabilitya distinct disadvantageis the
oral route. The low bioavailability of drug is
due to the action of gastric enzymes,
gastrointestinal motility, and extensive hepatic
first-pass metabolism effects. First-pass effects
refer to the rapid inactivation of a drug by
hepatic enzymes (e.g. mixed function oxidases)
and the rapid elimination of drug metabolites via
the biliary route of excretion. Drug metabolism
also occurs within the intestinal lumen, the
intestinal mucosal cells, and the hepatic portal
system, but the majority of first-pass effects
are due to the action of hepatic enzymes.
(Although inhalational drugs are not directly
affected by hepatic first-pass effects, they are
subject to lung first-pass effects, including
metabolism and excretion.) Passage through
general circulation or through the kidney does
not contribute to first-pass effects in
pharmacokinetics. Different routes of
administration exhibit different advantages and
disadvantages. The intravenous route delivers
drug to the bloodstream nearly instantaneously as
evidenced by the short time required to reach
peak plasma concentration (Tmax) and maximal
serum levels (Cmax). By contrast, the oral route
requires a much longer time to reach Tmax and
Cmax. The intravenous route provides precise
control of dose via IV infusion and provides the
means to deliver water-soluble drugs such as
aminophylline in large volumes. A significant
drawback to the rapid onset and distribution of
drug through the IV route is the simple fact that
the delivered dose is not retrievable should a
dosage miscalculation or an unforeseen drug
reaction occur. The enteral route, on the other
hand, allows the retrieval of a portion of orally
administered drug through induction of emesis or
gastric lavage. In addition, orally administered
drugs, because of their dosing convenience, are
ideal for chronic outpatient use.
40
Question 20 of 40
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B   First node of Ranvier Pacinian corpuscles,
which are touch receptors, have been studied in
detail. Because of their relatively large size
and accessibility in the mesentery of
experimental animals, they can be isolated,
studied with microelectrodes, and subjected to
microdissection. Each capsule consists of the
straight, unmyelinated ending of a sensory nerve
fiber, 2 µm in diameter, surrounded by concentric
lamellas of connective tissue that give the organ
the appearance of a minute cocktail onion. The
myelin sheath of the sensory nerve begins inside
the corpuscle. The first node of Ranvier is also
located inside, whereas the second is usually
near the point at which the nerve fiber leaves
the corpuscle. Deformation of the capsule
causes a sudden change in the membrane potential
by increasing its permeability and allowing
positively charged sodium ions to leak to the
interior of the fiber. This change in local
potential causes a local circuit of current flow
that spreads along the nerve fiber to its
myelinated portion. At the first node of Ranvier
the local current flow initiates action
potentials in the nerve fiber.
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Question 21 of 40
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C   IgG1 Opsonization is an enhancement of
phagocytosis through the binding to the surface
of a pathogen. IgG antibodies, in particular IgG1
are very effective opsonins. Phagocytes express
Fcg receptors on their surface. These receptors
bind IgG antibodies, especially IgG1. Phagocytes
also distinguish between free antibodies, to
which they do not bind, and aggregated or
multimeric antibodies on the surfaces of bacteria
and viruses, to which they do bind.
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Question 22 of 40
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B   Interval shorter than T1/2 The T1/2 is the
time required to reduce the blood level of a drug
by one half, thus after one T1/2 only 50 of the
drug remains. After two T1/2 intervals only 25
of the drug remains. If the dosage interval is
more frequent than the T1/2 time, accumulation is
guaranteed. The Kel is the elimination constant
in concentration units eliminated per each time
unit. This value cannot be used to assure
accumulation since the starting blood level is
not known. Four half-times will reduce the
beginning blood concentration to about 6 of the
starting concentration.
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Question 23 of 40
47
B   Inhibition of acetylcholinesterase Of the
above only the inhibition of acetylcholinesterase,
the enzyme that breaks down acetylcholine into
acetate and choline and effectively stops
cholinergic signaling between two cells, would
increase levels of acetylcholine in the synaptic
cleft.
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Question 24 of 40
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A   Gunshot wounds Physicians in most
jurisdictions are obligated to violate patient
confidentiality when it is for the greater good
or is required by law. The most common
circumstances included are gunshot wounds, wounds
secondary to crimes, communicable diseases,
including venereal diseases and tuberculosis,
child abuse, elder abuse, abuse of the mentally
impaired, animal abuse, and driving impairment
secondary to physical conditions. A notable
exception to these rules is AIDS, despite the
fact that it is a communicable disease, and that
lack of notification of exposed individuals may
result in more people contracting this disease.
The reasons for this are social and political,
and the devastating effect on the individual that
would result from having his or her AIDS status
become public knowledge are felt, at this time,
to outweigh the rights of others to be protected
from exposure. Obviously, this subject is quite
controversial and not likely to be resolved in
the near future. Other conditions that are
generally not reported in violation of patient
confidentially are intravenous drug abuse,
spousal abuse, and psychosis.
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Question 25 of 40
51
A   Schizophrenia Schizophrenia is
characterized by psychotic disturbances that
affect such areas of functioning as thought
content (e.g., delusions), form of thought (e.g.,
bizarre or unfocussed thoughts), perception
(e.g., hallucinations), affect (e.g., labile
mood, flat affect), identity (e.g., confusion
regarding self, poor boundaries between self and
external world), volition (e.g., loss of
motivation), interpersonal relationships (e.g.,
social withdrawal), and psychomotor behavior
(e.g., rigidity, hyperactivity). The diagnosis of
schizophrenia requires that the characteristic
symptoms be present for at least 1 month (e.g.,
that there be an active phase) and that
functioning be impaired with respect to premorbid
functioning for a period of at least 6 months.
DSM-IV identifies 5 types of schizophrenia
paranoid, disorganized, catatonic,
undifferentiated, and residual, based on their
respective prominent features. Onset of
schizophrenia is usually in the late teens to
mid-30s, and the course of the disease is
normally chronic. If an acute first episode
occurs and lasts less than 6 months, the
diagnosis of Schizophreniform disorder must be
made. If the course continues beyond 6 months and
all other criteria are met, the diagnosis may be
the changed to Schizophrenia of the appropriate
subtype. Schizophreniform disorder is identical
in presentation to Schizophrenia, however
Schizophreniform disorder, by definition, lasts
less than 6 months. The prognosis of
Schizophreniform disorder is therefore better
than that of Schizophrenia because the former is
an acute, rather than chronic, condition.
Childhood schizophrenia is similar to
schizophrenia but it has an earlier onset. In
addition, a significant difference is that
children do not have to specifically show a
sustained deterioration from a previous level of
functioning to partially fulfill the diagnostic
criteria for Schizophrenia. Rather, children must
demonstrate a failure to develop normally in
social, interpersonal, or affective areas and
fulfill the remaining diagnostic criteria for
Schizophrenia in order to qualify for a diagnosis
of Childhood Schizophrenia. Schizo-affective
disorder is characterized by a combination of the
symptoms of a Mood disorder (e.g., depression)
and Schizophrenia, in individuals who do not meet
the full diagnostic criteria of either disorder.
Individuals who are suspected to be suffering
from a form a Schizophrenia on first glance,
therefore, but who have significant symptoms
related to mood, might be more accurately
diagnosed as having Schizo-affective disorder.
The psychotic features of Schizo-affective
disorder are generally more prominent than would
be seen in an individual diagnosed with a Mood
Disorder with Psychotic Features, and the
diagnosis requires that the psychotic symptoms be
present for at least 2 weeks during which time
there are no mood symptoms. Mood symptoms are,
however, required to be present for most of the
duration of the illness. A Brief Psychotic
disorder is characterized by the sudden onset of
at least 1 psychotic symptom, which lasts for up
to, but not exceeding, 1 month. When the symptoms
subside, the individual returns to his or her
full premorbid level of functioning. Onset of
Brief Psychotic disorder frequently occurs after
a severe stressor in which case the stressor
should be noted, and in cases related to
childbirth, symptoms must occur within 4 weeks
postpartum. The absence of the recent or heavy
use of alcohol or other drugs distinguishes Brief
Psychotic disorder from Substance-Induced
Psychotic disorder.
52
Question 26 of 40
53
E   Determine whether she is competent to
understand the ramifications of her refusal for
screening Hereditary syndromes with a greatly
increased risk for adenomatous polyps and colon
cancer include familial polyposis, Gardner's
syndrome, and Peutz-Jeghers syndrome. These
patients need careful follow-up, with family and
genetic counseling so they understand the risks
of their condition for them and their family.
In familial polyposis, there is a mutation on
chromosome 5 (the FAP gene), which is transmitted
in an autosomal dominant pattern. Nearly all
untreated patients will develop colon cancer
before age 40. These individuals are treated with
surgical removal of the colon if they choose to
have a subtotal colectomy, they require
aggressive surveillance of the rectal remnant
every 3 to 6 months to have new polyps removed.
Gardner's syndrome is a variant of family
polyposis. It is associated with sebaceous cysts,
desmoid tumors, and osteomas of the skull or
mandible. Peutz-Jeghers syndrome is an autosomal
dominant disease associated with pigmentation of
the skin and mucous membranes, as well as
multiple hamartomatous polyps in the stomach and
small and large intestines. Patients with
familial polyposis syndromes, like those with any
condition increasing the risk for malignancy,
must have adequate surveillance to try and
identify pre-malignant polyps before they develop
into cancer. However, patient autonomy allows
patients to refuse care, if they are competent to
make decisions for themselves. The clinician must
determine (with the assistance of other
professionals if needed) the patient's competence
before trying to force or coerce her compliance.
Additionally it would be very useful to spend
time to educate her further about the importance
for colonoscopic surveillance, particularly given
her learning disability. If she is in fact
determined to be incompetent to make decisions
about her own care, then other tactics may be
employed to care for her as needed.
54
Question 27 of 40
55

• B   Pharmacokinetic phase
• The sequence of events set in motion following
  introduction of a drug into the body is commonly
  divided into three phases
• The pharmaceutical phase of drug action is
  concerned with the various formulations of drugs
  and the different routes of administration
  available for their introduction. Formulations,
  or forms of drugs, often influence how readily a
  drug becomes available or how quickly it is
  absorbed across cell membranes. The route of
  administration determines, in part, how rapidly a
  drug is introduced to the body.
• (2) Following introduction of a drug, movement of
  the drug through cell membranes from one body
  compartment to another normally occurs. This
  pharmacokinetic phase is responsible for the
  movement of drugs from a plasma protein-bound
  state to a free state in the plasma, and from the
  plasma into cell and tissue depot sites and into
  organs such as the liver and kidneys.
  Pharmacokinetics deals with the rate of drug
  metabolism in organs of biotransformation such as
  the liver and with the rate of clearance by
  organs of excretion such as the kidneys. The
  complex interplay of absorption mechanisms (e.g.
  aqueous, lipid, and facilitated diffusion,
  endocytosis, pH of fluids), storage (e.g.
  plasma-binding, tissue-binding, or
  cellular-binding), distribution systems (e.g.
  blood, lymph, cerebrospinal fluid), enzymes (e.g.
  gastrointestinal, hepatic, pulmonary), and
  hemodynamics (e.g. glomerular filtration
  pressure) contributes to the plasma half-life of
  drugs (t 1/2 ) and their ultimate clearance from
  the body. In short, pharmacokinetics is concerned
  with the "fate of drugs" after they have been
  introduced to the body.
• (3) The pharmacodynamic phase is concerned with
  the physiologic and biochemical mechanisms of
  action of drugs. This final phase of drug action
  is initiated by drug molecules that have
  "survived" the different mechanisms of
  pharmacokinetics such as storage,
  biotransformation, and elimination. The remaining
  drug molecules are free to interact at specific
  target sites such as membrane, enzyme,
  cytoplasmic, or nuclear receptors.

56
Question 28 of 40
57
B   IgM and IgA The immunoglobulins include
IgG, IgM, IgA, IgE, and IgD. Certain groups of
streptococci secrete a variety of streptolysins
or hemolysins that lyse red blood cells and are
much more active weight for weight than
hemolysins such as bile salts or saponin, but
which have a more important toxic action on
polymorphs and macrophages. Various hemolysins
are released also by pathogenic staphylococci,
and these can kill phagocytes. The
immunophilins are a family of intracellular
proteins that bind to certain compounds forming
complexes that interfere with signaling pathways
important for the clonal expansion of
lymphocytes. Endotoxins are part of the outer
membrane of Gram-negative bacteria. Some of the
diseases in which endotoxins may play a part are
typhoid fever, tularemia, plague and brucellosis,
and a variety of hospital-acquired infections
caused by opportunistic Gram-negative pathogens.
Endotoxin is a complex lipopolysaccharide that
displays a large array of biological effects.
Although all immunoglobulin molecules are
constructed from a basic unit of two heavy and
two light chains, both IgM and IgA can form
multimers. IgM molecules are found as pentamers,
and occasionally hexamers, in plasma, and IgA is
found in mucous secretions, but not plasma, as a
dimer. IgM and IgA C regions contain a
"tailpiece" of 18 amino acids that contains a
cysteine residue essential for polymerization. In
the case of IgA, polymerization is required for
transport through epithelia.
58
Question 29 of 40
59
D   REM Sleep comprises approximately 1/3 of
our lives and its function is far from being
completely understood. Normally, sleep is an
active (not passive) process where the brain
activity fluctuates over about 45 cycles per
night. Distinct sleep stages can be measured by
EEG as patients pass through stages 1-4 (non-REM)
and then enter REM sleep. Patients enter REM
sleep (dream sleep) approximately every 90
minutes and the duration of this stage lengthens
as the night progresses. The characteristic EEG
pattern of the various sleep stages is listed
below along with some physiological observations.
Waking - alpha waves (8-12 cps) NREM Sleep -
(Nonrapid eye movement) - low level of activity
lowered BP, heart rate, temperature, and
respiratory rate. Good muscle tone and slow,
drifting eye movements. Stage 1 - lightest
sleep, a transition stage low voltage,
desynchronized waves. Stage 2 - sleep spindles,
(13-15 cps) and high spikes (K complexes).
Stage 3 - some delta waves (high voltage at
0.5-2.5 cps). Stage 4 - deepest sleep, mostly
in first half of night mostly delta waves. REM
Sleep - active sleep characterized by rapid
synchronous eye movement, twitching of facial and
extremity muscles, penile erections, and
variation in pulse, BP, and respiratory rate.
Muscular paralysis is present. Depth is similar
to stage 2. Dreaming can occur in several stages
but is most common in REM sleep.
60
Question 30 of 40
61
D   A measure of the maximal agonist effect
Efficacy is a term used to describe the ability
of an agonist to elicit a maximal response. It is
a pharmacological parameter used to signify the
relation between occupancy of receptor sites and
the pharmacological response. Drugs may have any
degree of efficacy greater than zero, with zero
efficacy denoting an antagonist. Full agonists
have higher efficacy than partial agonists
because the latter do not elicit the maximal
response of full agonists occupying the same
number of receptor sites. Potency is the
relative amount of a drug required to produce a
given response. It is usually illustrated by a
graph of ED50 values of two agonists. The smaller
the ED50, the more potent the drug. The
therapeutic index is a measure used to relate the
dose of a drug needed to produce a desired effect
to that which produces an undesired effect. It
evaluates the safety and usefulness of a drug and
is the ratio of the LD50/ED50. Affinity is term
denoting the ability of a drug to bind to a
receptor. A drug can bind to a receptor and not
produce a pharmacological response.
62
Question 31 of 40
63
E   Direct causation of effect by the defendant's
negligence Negligence torts against health care
providers must fulfill four criteria for success.
A duty, or obligation, by the defendant (health
care provider) must be owed to the plaintiff
(patient). Dereliction of duty, or performance
significantly below the standard of care, must
have occurred. The plaintiff must have been
damaged by the action in a physical or
psychological manner, or via loss of reputation.
Economic losses are not generally recoverable.
The defendant's negligence must be the direct and
proximate cause of the plaintiff's injuries.
Fraud or deceit on the part of the defendant is
grounds for deliberate torts. Other types of
deliberate torts are battery, assault, breach of
confidentiality, and bad faith breach of
contract.
64
Question 32 of 40
65
C   Cloned hybridoma cell are of a single class
and directed towards the same epitope in the
protein Monoclonal antibodies are antibodies
produced by a cloned hybridoma cell in culture.
Therefore, each antibody is identical and
directed towards the same epitope of the antigen.
An epitope is the antigenic determinant. A
protein can have many epitopes. In contrast,
polyclonal antibodies, such as those obtained
after injection of the protein into a rabbit or a
goat, are heterogeneous. These antibody molecules
are produced by different B-lymphocytes in the
animal in response to the antigen. This
represents a mixture of different antibodies each
of which recognizes different epitopes on the
antigen.
66
Question 33 of 40
67
C   Glomerular basement membrane The basement
membrane of the glomerulus is formed by the fused
basal lamina of the podocyte foot processes and
the endothelial cells of the glomerulus. The
membrane contains Type IV collagen which acts as
a physical barrier to large particles such as
proteins or albumen during filtration. In
addition to size of the molecule,
glycosaminoglycans associated with the basement
membrane restrict the movement of smaller sized
cationic molecules across the membrane.
Podocytes are modified simple squamous cells
that comprise the visceral layer of Bowman's
capsule. These cells also possess foot processes,
or pedicels that extend around the glomerular
capillaries and interdigitate with the pedicels
of neighboring podocytes. Capillary endothelial
cells line the glomerular capillary upon which
the podocytes reside. The outer layer of simple
squamous epithelial cells of Bowman's capsule
comprise the parietal layer, which is continuous
with the cuboidal epithelium of the proximal
convoluted tubule at the urinary pole.
Mesangial cells also are found in association
with the renal corpuscle most within the
corpuscle as intraglomerular mesangial cells, but
some outside of the corpuscle along the vascular
pole. The mesangial cells function as phagocytic
cells and provide structural support for
podocytes. Smooth muscle cells circling the
afferent arteriole of the glomerulus are modified
and contain secretory granules of renin. These
modified muscle cells are called the
juxtaglomerular cells and are best visualized
with histochemical stain for the renin.
68
Question 34 of 40
69
D   Dopamine beta-hydroxylase Monoamine oxidase
(MAO) and catechol-O-methyltransferase (COMT) are
involved in the degradation of catecholamines.
MAO is present in the mitochondria of several
tissues and catalyzes the oxidative deamination
of catecholamines and other biogenic amines. COMT
metabolizes catecholamines by transferring a
methyl group from S-adenosylmethionine to its
substrate. COMT is mainly found in the liver and
the kidney. Dopamine beta-hydroxylase and
phenethanolamine-N-methyltransferase (PNMT) are
involved in the synthesis of catecholamines.
Dopamine beta-hydroxylase forms norepinephrine
and norepinephrine is converted to epinephrine by
the action of PNMT, an enzyme which is
exclusively found in the adrenal medulla.
70
Question 35 of 40
71
D   The essential elements of informed consent
are the patient's autonomy and comprehension
The ethical elements of informed consent
require that the patient be adequately informed
about the proposed treatment, its risks and
benefits, as well as the risks and benefits of
alternatives, to include no treatment at all. It
further requires that she give her consent
freely. The ethical basis of informed consent
is that it is a process that recognizes that
patient's benefit from participating in making
decisions about their healthcare. It recognizes
that each person has the right of
self-determination (autonomy). In addition to
autonomy, human beings exist in a variety of
relationships with others. The physician-patient
relationship has a powerful effect upon how the
patient makes healthcare decisions. A
relationship of trust, mutual respect, and
equality will provide the context for decisions
that contribute positively to the patient's well
being. The physician must not coerce the
patient into accepting the treatment that (s)he
favors by counseling in a deceptive or biased
manner. However, the physician may give reasons
why one medical option is favored over another.
And there is room for disagreement among the
medical community with regards to which option is
most appropriate. A second opinion may be
desirable when faced with a serious decision, but
it is not a requirement. The legal criteria for
informed consent varies from state to state.
Documentation may have legal significance, but it
does not necessarily protect against medical
liability claims. Neither does simply obtaining a
signature fulfill the ethical principle of
respect for persons.
72
Question 36 of 40
73
B   Schizophrenia, paranoid type Patients with
schizophrenia, paranoid type usually appear
normal in that disorganized speech, disorganized
behavior, flat affect, and catatonic behavior are
not prominent. However, they are usually able to
take care of themselves and their daily lives are
not very disruptive. They do, however, present
with a theme of suspiciousness or paranoia and
have delusions of persecution that someone is
trying to do harm, poisoning their food,
following them, or trying to kill them.
Schizophrenia, disorganized type has prominent
symptoms of disorganized speech and behavior.
They usually talk gibberish, and are not usually
able to take care of themselves. They have very
poor personal hygiene and appearance. Again,
hallucinations and delusions are not prominent.
Schizophrenia, catatonic type patients have the
stupor or retarded immobility and are sometimes
mute, or display very negative speech. They have
bizarre posturing and grimacing. Schizophrenia,
undifferentiated type, does not meet the criteria
for the other types and it is a diagnosis of
exclusion. It is for patients that do not have
the prominent symptoms of catatonic, paranoia, or
disorganized behaviors. Schizophrenia, residual
type is a diagnosis that is given to patients who
at one time had one of the other types but have
been treated and whose symptoms are no further
pronounced. It often is applied to patients who
have been treated and now they are in the process
of partial remission.
74
Question 37 of 40
75
D   It is in the differential diagnosis for
diarrhea The definition of stress is an
individual's negative emotional response to a
perceived inability to meet demands place on him
or her. It may express itself as anger,
hostility, or feelings of helplessness, loss of
control, or victimization. It is believed to be a
factor in 60-80 of all health problems, and is
the leading cause of disability claims in
California. Major symptoms include fatigue,
exhaustion, tight back and shoulders, insomnia,
anxiety, anger, headaches, depression, sadness,
hopelessness, colds, indigestion, diarrhea, and
ulcer symptoms. Effective prevention and
avoidance techniques include assertiveness
training and the development of communication
skills. Treatment methods include relaxation
techniques, meditation, exercise, and
participation in enjoyable activities.
76
Question 38 of 40
77
A   Glycogen metabolism Smooth ER (sER), when
viewed by an electron microscope, appears as a
complex system of anastomosing or dilated
tubules, but without association with ribosomes.
Cells which contain substantial amounts of SER in
the cytoplasm are associated with functions
relating to glycogen metabolism, steroid
synthesis, or drug metabolism. Cells associated
with muscle contraction may contain small amounts
of SER in the cytoplasm, but the predominant
intracellular feature of these cells are actin
and myosin filaments. Similarly, nerve cells, or
their processes, may contain SER, but the
predominant form of ER present in cells
associated with depolarization and conduction
would be rough endoplasmic reticulum (RER).
Antibody synthesis, such as performed by a plasma
cell, shows extensive RER in the cytoplasm. A
cell that is associated with oxygen transport,
such as the erythrocyte, would have few
cytoplasmic organelles.
78
Question 39 of 40
79

• C   Light chain has one variable and one constant
  region
• The basic unit of an antibody is made up of two
  light chain and two heavy chains.
• Equal number of heavy and light chain
  polypeptides are present in every immunoglobulin
  molecule and can be represented by the formula-
  (H2L2)n. The polypeptide chains are linked
  covalently by disulfide bonds. Additional
  characteristics of structure of an antibody
  molecule are as follows
• Consists of light chain that is common to all
  class
• Heavy chain is different for each class and
  subclass
• Light chain has one variable and one constant
  region
• Fc fragment is on carboxy terminal
• Antigen binding site is present on carboxy
  terminal of the antibody molecule

80
Question 40 of 40
81
B   Sympathetic cholinergic postganglionic
fibers Although most of the sympathetic
postganglionic fibers are adrenergic, the fibers
to the sweat glands, piloerector muscles and a
few blood vessels are cholinergic. The
parasympathetic nervous system does not innervate
sweat glands.