USMLE USMLE Certifications USMLE-STEP-1 Questions & Answers

• Question 841:

  A 4-month-old male infant is brought to the clinic because of excessive noisy respiration. On examination, the infant is within the normal range of growth, appears healthy, and does not show respiratory distress. Phonation is normal, along with head and neck examination findings. However, the child displays stridor (highpitched breathing sound) on inspiration, accentuated in the supine position. The parents report that the same stridor is heard during feeding or when the child is agitated. The attending physician places the child in the prone position and the stridor is relieved. To confirm, she holds the child in a neck extended position, which also relieves the stridor. An endoscopic laryngeal examination reveals bulky arytenoids cartilages and the diagnosis of laryngomalacia is established. During development, the arytenoids cartilages arise from which of the following?

  A. first pharyngeal arch

  B. second pharyngeal arch

  C. third pharyngeal arch

  D. fifth pharyngeal arch

  E. sixth pharyngeal arch

  Correct Answer: E

  Section: Anatomy The arytenoid cartilages arise as swellings from the sixth pharyngeal (branchial) arch at 32 days of gestation. They are located between the caudal end of the hypobranchial eminence and the cranial end of the laryngotracheal tube. The swellings will grow cranially to form the arytenoids and corniculate cartilages along with the primitive aryepiglottic folds. In laryngomalacia, the bulky arytenoids cartilages prolapsed anteromedially on inspiration, resulting in stridor. The first (choice A), second (choice B), and third (choice C) pharyngeal arches do not participate in the development of laryngeal cartilages. The fifth (choice D) pharyngeal arch remains rudimentary and does not give rise to any adult structure.

• Question 842:

  A newborn infant suffers from cyanotic heart disease caused by transposition of the great arteries (TGA). In this situation, the aorta arises from which of the following structures?

  A. ductus arteriosus

  B. left atrium

  C. left ventricle

  D. right atrium

  E. right ventricle

  Correct Answer: E

  Section: Anatomy In TGA, the aorta arises from the right ventricle and the pulmonary trunk arises from the left ventricle (choice C). This is the reverse of the normal situation and gives rise to the cyanotic condition in the newborn. The large arteries arise from the truncus arteriosus in the developing heart and thus could not develop from the atria (choices B and D), which are formed from the sinus venosus. The truncus arteriosus and the sinus venosus are at opposite ends of the heart. The ductus arteriosus (choice A) is the vessel that shunts oxygenated blood from the pulmonary trunk to the arch of the aorta in the fetus. It does not give rise to the aorta.

• Question 843:

  The structure indicated by arrow 1 in Fig. 1-2 is which of the following vessels?

  A. brachiocephalic artery

  B. left brachiocephalic vein

  C. left common carotid artery

  D. right brachiocephalic vein

  E. superior vena cava

  Correct Answer: D

  Section: Anatomy Remember that in viewing axial or transverse CT scans through the body, the right side of the patient is to your left and the left side to your right. In other words, the feet of the patient are toward you and the head away from you. The back of the patient is at the bottom of the image and the front of the patient toward the top. Directional terms are always in reference to the patient. The insert at the bottom right indicates the level of the section. Arrow 1 indicates the right brachiocephalic vein. The left brachiocephalic vein (choice B) is seen as the elongated structure immediately posterior to the manubrium of the sternum and to the left of the right brachiocephalic vein. Immediately posterior to the left brachiocephalic vein is the brachiocephalic artery (choice A, arrow 2). To the left of the latter are the left common carotid artery (choice C) and the left subclavian artery (arrow 3). The superior vena cava (choice E) is not seen at this level because the right and left brachiocephalic veins are still separate.

• Question 844:

  Retinitis pigmentosa is a hereditary disorder, which affects the photoreceptors (the rods and the cones) in the retina. These photoreceptors are located in which of the numbered layers in Figure below

  

  A. 1

  B. 2

  C. 3

  D. 4

  E. 5

  Correct Answer: E

  Section: Anatomy The retina contains three layers of cells. They are, from top to bottom, the ganglion cells (choice A), the bipolar cells (choice C), and the photoreceptor cells (rods and cones, choice E). The internal plexiform layer (choice B) contains the synapses between the bipolar cells and the ganglion cells. The external plexiform layer (choice D) contains the synapses between the photoreceptors and the bipolar cells. Remember that light enters from the top and traverses all the layers to reach the photoreceptors in the bottom layer.

• Question 845:

  A 10-year boy is examined because his parents noticed that "his eyes never seem to look in the right direction." On examination, the left eye of the child is unable to move laterally (abduction) and when asked to look toward the nose (adduction), the eyeball retracts into the socket and the eye opening narrows. Sometimes, the eye also moves superiorly. The child is diagnosed with Duane syndrome, a congenital ocular motility disorder characterized by limited abduction of the affected eye. This is due to absence of the abducens (fifth cranial) nerve with aberrant innervation by the oculomotor (third cranial) nerve. Which of the following muscles is normally innervated by the abducens nerve?

  A. inferior oblique

  B. lateral rectus

  C. medial rectus

  D. superior oblique

  E. superior rectus

  Correct Answer: B

  Section: Anatomy The abducens (sixth cranial) nerve normally innervates the lateral rectus muscle. The inferior oblique (choice A), medial rectus (choice C), and superior rectus (choice E) are all innervated by the oculomotor (third cranial) nerve. The superior oblique (choice D) is innervated by the trochlear (fourth cranial) nerve. In Duane syndrome, the absence of lateral rectus innervations by the abducens (sixth cranial) nerve is replaced by an aberrant innervation of the oculomotor (third cranial) nerve. Thus when the patient is asked to adduct the affected eye, there is cocontraction of the lateral and medial recti with globe retraction.

• Question 846:

  A 2-year-old male patient develops progressive generalized weakness and muscle atrophy. The impairment first began with the muscles of the hips, and then progressed to the pelvic area, thigh, and shoulder muscles. The patient is diagnosed with Duchenne's muscular dystrophy, a congenital disorder where the protein dystrophin is deficient. Which of the following describes the role of dystrophin in muscle tissue?

  A. anchors actin to the sarcolemma

  B. endows the myosin filaments with elastic recoil properties

  C. extends from Z disk to Zdisk, forming a supportive network

  D. inhibits the binding of myosin to actin

  E. protects desmin filaments from stressinduced damage

  Correct Answer: A

  Section: Anatomy Dystrophin anchors actin to the sarcolemma, reinforcing and stabilizing the latter during muscle contraction. Titin is a large protein which associates with myosin filaments and endows them with elastic recoil properties (choice B). Desmin filaments form a supportive network extending from Z disk to Zdisk (choice C). Troponin I inhibits the binding of myosin to actin (choice D). AlphaB-crystallin protects desmin filaments from stress-induced damage (choice E).

• Question 847:

  The third week of development is characterized by the appearance of the branchial apparatus, the embryonic primordium from which head and neck structures will be derived. The apparatus consists of five branchial arches, numbered 1, 2, 3, 4 and 6. Second arch anomalies represent 95% of all branchial anomalies and are classified into four types with types IIII being the most common. The anomalies manifest as cysts or fistulae in the lateral neck, located anterior and deep to the sternocleidomastoid muscle. Which of the following structures develop from the second branchial arch?

  A. anterior digastric muscle

  B. posterior cricoarytenoideus muscle

  C. posterior digastric muscle

  D. stylopharyngeus muscle

  E. superior constrictor muscle

  Correct Answer: C

  Section: Anatomy The posterior digastric muscle is derived from the second branchial arch and thus is innervated by its nerve, the facial (Seventh cranial) nerve. The anterior digastric muscle (choice A) is derived from the first branchial arch and is innervated by its nerve, the mandibular division of the trigeminal (fifth cranial) nerve. The posterior cricoarytenoideus muscle (choice B) and the superior constrictor muscle (choice E), derived from a combination of the fourth and sixth branchial arches, are innervated by the vagus (tenth cranial) nerve. The stylopharyngeus (choice D) is derived from the third branchial arch and is the only voluntary muscle innervated by the glossopharyngeal (ninth cranial) nerve.