BLOOD AND CARDIOVASCULAR MCHC is the amount of Hb present in 100 ml of

PHYSIOLOGY packed red blood cells; thus it has the same units
as hemoglobin concentration.
Summaries
1. RBC Indices Concentration = amount of a substance / volume
2. Cardiac output and related definitions of distribution in question. Thus:
3. Blood pressure indices
4. Arterial baroreflex mechanism The concentration of Hb in 1 ml of red blood cells
is Hb/PCV g/dL. Thus, the concentration of Hb in
100 ml of packed red blood cells is [Hb ×
1. RBC Indices 100]/PCV.
Reference ranges for RBC indices
(summarized below) are usually available at the RBC indices are useful in the differential
point of care. diagnosis of anemias. Anemias may be classified
as macrocytic, microcytic or normocytic based on
RBC Derivation Normal
MCV, and normochromic or hypochromic based
Index values
MCH Hb in g/dL × 10 29–32 pg
on MCHC. Hyperchromia is uncommon but it
RBC in may occur in hereditary spherocytosis.
millions/mm3
MCV PCV × 10 80–100 fL
RBC in 2. Cardiac Output (and related terms):
millions/mm3 Cardiac output: The volume of blood ejected by
MCHC Hb in g/dL × 100 32–35 g/dL the left or the right ventricle per minute.
PCV
MCH, mean corpuscular hemoglobin;
Cardiac output = stroke volume × heart rate
MCV, mean corpuscular volume;
MCHC, mean corpuscular hemoglobin concentration;
fL, femtoliter; pg, picogram. Cardiac index is the cardiac output per square
meter of body surface area.
However, if a question requires you to calculate
one or more RBC indices, then, one needs to Regulation of stroke volume: Stroke volume is
remember the formula for each index. influenced by preload, afterload and myocardial
contractility.
One way to remember this easily is as follows.
Remember a RBC count of 5 million/mm3, blood Preload: The load on a muscle before it contracts.
Hb of 15 g/dL, and PCV of 45% as “perfect In the ventricle, the preload (end-diastolic fiber
values”. Second, remember 90 fL as the perfect length) varies directly with the end-diastolic
MCV and 30 pg as the perfect MCH. The volume.
formula for MCV and MCH can then be readily
derived as follows. Afterload: The load which contracting muscle
has to overcome before it shortens. The velocity
Index Formula of shortening varies inversely with afterload. For
MCV = 90 = 450 / 5 = (PCV × 10) the left ventricle, the afterload is the total systemic
= 45 × 10 / 5 RBC vascular resistance.
MCH = 30 = 150 / 5 = Hb × 10
= 15 × 10 / 5 RBC count Within physiologic limits, the energy of cardiac
contraction is directly proportional to preload.
Having derived the formulae, you can plug values This is the Frank-Starling law of the heart. An
at hand to calculate the corresponding RBC index. increase in stroke volume for a given preload and
afterload is due to an increase in myocardial
contractility.
81
E.S.Prakash. Multiple-Choice Questions in Medical Physiology, 2014
The best index of myocardial contractility is the RPP is a useful index because it reflects
rate of pressure rise (dP/dt) in the ventricle during myocardial O2 demand. Greater the HR, greater
isovolumetric contraction. However, clinically, the myocardial oxygen demand; to generate a
the ejection fraction is used as a surrogate of greater systolic pressure, greater wall tension
myocardial contractility. needs to develop (according to Laplace’s law) and
this also increases oxygen consumption.
Myocardial contractility is markedly enhanced by
sympathetic stimulation, digoxin and depressed by
myocardial ischemia, acidosis. 4. The arterial baroreflex mechanism for
regulating blood pressure:
Inotropic effects: the term refers to the effect of a Inputs Mean arterial pressure, pulse
stimulus on myocardial contractility. pressure
Receptor Called “arterial baroreceptors”
Location of Adventitia of the carotid sinus
3. Blood pressure indexes: receptors and aortic arch
Systolic pressure (SBP): the highest pressure in Receptor type Free nerve endings
the arteries during the cardiac cycle. Adequate Stretch (both tonic as well as
stimulus phasic response)
Afferent Via IX (from the carotid sinuses)
Diastolic pressure (DBP): the lowest pressure in
and X nerves (from the aortic
the arteries during the cardiac cycle. Diastolic arch)
pressure reflects the total resistance offered to Termination of NTS in medulla
peripheral run off of blood (specifically, the first order
resistance offered by the arterioles). neurons
Receptor MAP between 70 and 110 mm Hg
Pulse pressure: SBP – DBP operating range
Ejection of blood produces an increment in Receptor Increase in static (mean arterial
arterial blood pressure; this is called pulse characteristics pressure) as well as phasic stretch
pressure. Pulse pressure depends upon volume of (pulse pressure) increase firing
blood ejected (stroke volume) and arterial rate; decrease in stretch decreases
compliance. If arteries are thick and rigid (and firing rate. There are presumably
thus less compliant), a given stroke volume two subtypes of receptors of
which is adapting and the other
produces a greater rise in pulse pressure.
nonadapting.
Conceptually, systolic pressure = diastolic Response to an An increase in BP leads to a
pressure + pulse pressure increase in BP decrease in cardiac output and
TPR through cardiac vagal
Mean arterial pressure = diastolic pressure + 1/3 excitation and inhibition of
(pulse pressure). However, this applies only when sympathetic outflow
HR is in the 60-90 BPM range. MAP is actually Response to a Sympathetic outflow from the
determined by integrating the arterial pressure decrease in BP medulla is “disinhibited”; and
curve. MAP is also equal to (SP + 2DP)/3 vagal outflow to the heart is
disinhibited.
Mean arterial pressure (MAP) = cardiac output × Response time: It takes only about 1 second for a
total peripheral resistance. change in BP to result in a
compensatory change in HR; it
takes a little longer (about 10
Rate-pressure product (RPP): It is calculated as seconds) for changes in TPR to
the product of SBP and HR and generally divided occur following a primary change
by 100 to get a smaller number. If SBP is 120 mm in BP
Hg and HR is 80 BPM, then RPP is 96 mm Hg
BPM 10-2
82
E.S.Prakash. Multiple-Choice Questions in Medical Physiology, 2014
Instructions: Unless otherwise specified, choose 7. Primary hemostasis refers to cessation of
the single best answer. bleeding due to:
A. formation of a definitive clot
1. The most abundant protein in blood is: B. clot retraction
A. albumin C. formation of a temporary platelet plug.
B. hemoglobin
C. fibrinogen 8. Select all correct answers. Platelet aggregation
D. beta-1 globulin is stimulated by:
A. thromboxane A2
2. Macrocytes have a mean corpuscular volume B. fibrinogen
greater than: C. ADP
A. 70 fL D. thrombin
B. 80 fL E. epinephrine
C. 90 fL F. serotonin
D. 100 fL G. Prostaglandin I2

3. The amount of hemoglobin contained in 9. The adhesion of platelets to subendothelial

normocytes is approximately: collagen is impaired in the absence of:
A. 20 pg A. von Willebrand factor
B. 25 pg B. plasmin
C. 30 pg C. heparin
D. 35 pg D. antithrombin III

4. The amount of hemoglobin present in 100 ml of 10. Which of the following clotting factors is not
red blood cells is defined as: vitamin K dependent?
A. MCH A. Factor II
B. MCHC B. Factor V
C. hemoglobin index C. Factor VII
D. RDW D. Factor IX
E. Factor X
5. In an individual with a blood hemoglobin
concentration of 10 g/dL and a hematocrit of 40, 11. The extrinsic pathway is triggered by the
MCHC is approximately: release of:
A. 20 g/dL A. factor VII
B. 25 g/dL B. tissue factor
C. 30 g/dL C. tissue factor pathway inhibitor
D. 35 g/dL D. contact factor

6. A lab technician determines RBC count by 12. The extrinsic pathway is inhibited by:
manual hemocytometry, blood hemoglobin A. tissue factor
concentration by Sahli’s acid hematin method, B. thromboplastin
and hematocrit using a microcentrifuge. He C. tissue factor pathway inhibitor (TFPI)
follows all procedures correctly. Which of the D. contact factor
following RBC indices calculated from these
measurements would likely be the most reliable? 13. The test that screens the extrinsic pathway is:
A. Mean corpuscular volume A. prothrombin time (PT)
B. Mean corpuscular hemoglobin B. activated partial thromboplastin time (aPTT)
C. Mean corpuscular hemoglobin concentration C. thrombin time
D. Mean cell diameter D. urea solubility test
E. clot lysis time
83
E.S.Prakash. Multiple-Choice Questions in Medical Physiology, 2014
 21. The red blood cells of a person with the
14. The enzyme that ultimately lyses fibrin is: Bombay blood group do not have:
A. plasminogen A. GLUT
B. TPA B. H substance
C. urokinase C. spectrin
D. plasmin D. ankyrin

15. Prolongation of prothrombin time does not 22. Most of the iron in the body is present in:
occur when there is a deficiency of only: A. hemoglobin
A. factor VIII B. myoglobin
B. factor IX C. ferritin
C. factor X D. transferrin
D. vitamin K
23. In an Rh-negative mother not previously
16. Select all correct answers. Mutations in which sensitized by the Rh antigen, Rh incompatibility
of the following have been implicated in the does not usually have a serious consequence
pathogenesis of hypercoagulable states? during the first pregnancy because:
A. Protein C A. antibodies are not able to cross placenta
B. Protein S B. the titer of IgG is low during the primary
C. Factor V immune response
D. Antithrombin III C. IgG is ineffective against fetal red cells
D. massive hemolysis in the fetus is compensated
17. Factor V Leiden: by increased erythropoiesis
A. is a mutated form of factor IX
B. is inactivated by protein C 24. In the context of blood transfusions, ABO
C. is present in a large subset of patients with compatibility is important because:
venous thromboembolism A. there are 3 antigens in this system
B. the A and B antigens are present in all cells
18. Select all correct answers. Which condition(s) C. when an individual’s RBC lacks the A or B
is / are characterized by an increase in both antigen, the corresponding antibody is
bleeding time and clotting time? invariably present in serum.
A. Afibrinogenemia D. O is a strong antigen
B. Hypoprothrombinemia
C. Hemophilia A 25. A 55-year-old male accident victim in the ED
D. von Willebrand’s disease urgently requires a transfusion. His blood group
could not be determined as his red cell group and
19. Red cell antigens A and B are chemically: plasma group did not match. Emergency
A. phospholipids transfusion should be done with:
B. glycosphingolipids A. RBC corresponding to his red cell group and
C. glycopeptides colloids and crystalloids
D. polypeptides B. Whole blood corresponding to his plasma
group.
20. Select all correct answers. Red blood cell C. O positive RBC, colloids and crystalloids
antigens A and B are also present in: D. AB negative blood
A. saliva
B. semen 26. In the adult, most of the circulating
C. amniotic fluid erythropoietin originates from:
D. pancreas A. interstitial cells (fibroblasts) surrounding
peritubular capillaries in the renal cortex
B. perivenous hepatocytes
84
E.S.Prakash. Multiple-Choice Questions in Medical Physiology, 2014
C. Kupffer cells of liver 34. Which of the following plasma proteins are
protease inhibitors?
27. Osmotic fragility of red blood cells is A. α1 antitrypsin
decreased in: B. Transferrin
A. sickle cell anemia C. C-reactive protein
B. hereditary spherocytosis D. Antithrombin III
C. microcytic hypochromic anemia
D. macrocytic anemia 35. Which of the following is a ‘negative’ acute
phase reactant?
28. Hereditary spherocytosis occurs due to A. Albumin
mutations in genes coding for: B. C-reactive protein
A. spectrin and ankyrin C. α2 macroglobulin
B. Na-K ATPase D. Transferrin
C. glucose 6 phosphate dehydrogenase
D. pyruvate kinase 36. ESR is increased in:
A. anemia
29. CO is formed as an end product of: B. hypofibrinogenemia
A. heme metabolism C. spherocytosis
B. arginine metabolism D. polycythemia
C. oxidation of acetoacetate
37. The average half-life of neutrophils in the
30. Heme is converted to bilirubin mainly in the: circulation is:
A. kidneys A. 6 hours
B. liver B. 5 days
C. spleen C. 2 weeks
D. bone marrow D. 1 month

31. The protein that binds extracorpuscular 38. The protein content of lymph draining from
hemoglobin is: the _______ is highest.
A. hemin A. choroid plexus
B. haptoglobin B. skeletal muscle
C. hemopexin C. liver
D. haptopexin D. gastrointestinal tract

32. When a serum sample is electrophoresed, 39. Which of the following is incorrect about
which of the following bands is normally absent? fetal hemoglobin (Hb F)?
A. Albumin A. In comparison to HbA, Hb F has greater
B. α1 globulin affinity for 2,3–BPG
C. α2 globulin B. The oxygen dissociation curve of HbF is
D. Fibrinogen shifted to the left relative to HbA.
E. γ-globulin C. At low PO2, Hb F gives up more oxygen to
tissues than Hb A.
33. Which of the following is not synthesized in
the liver? 40. The viscosity of blood is constant at all flow
A. IgG velocities. True/False.
B. α2 macroglobulin
C. Albumin 41. The heart continues to beat even after all
D. Angiotensinogen nerves to it are sectioned. This property is called:
A. excitability
B. conductivity
85
E.S.Prakash. Multiple-Choice Questions in Medical Physiology, 2014
C. automaticity C. Purkinje fibers
D. contractility D. working myocardial cells

42. What is the primary ionic basis of the 48. Cardiac muscle cannot be tetanized because
prepotential in the SA node? of:
A. Ca influx through transient T Ca channels A. accommodation
B. Inwardly directed long-lasting Ca current B. its slow rate of repolarization
C. Outward Na current C. calcium influx during phase II
D. Potassium efflux through leak channels D. voltage inactivation of Na channels at
membrane potentials < 80 mV
43. Normally, the impulse that excites the left
ventricular myocardium originates in the: 49. Intrinsic heart rate is determined by:
A. SA node A. vagotomy
B. Purkinje system B. administration of atropine
C. left bundle branch C. beta-adrenergic receptor blockade
D. ventricle D. IV administration of atropine and atenolol

44. Conduction speed is slowest in the: 50. The ability of the AV node to generate its own
A. SA node impulses when the sinus node is “sick” is due to:
B. atrial pathways A. a constant phase 4 membrane potential
C. bundle of His B. slow calcium entry during phase zero
D. Purkinje system C. spontaneous diastolic depolarization
E. Ventricular myocardium D. the absence of prepotentials

45. What is the effect of vagal stimulation on the 51. The propagation of repolarization from the
membrane potential of the SA node? ventricular epicardium to endocardium is
A. It increases an inward calcium current. represented by the
B. It increases the slope of the prepotential. A. QRS complex
C. It activates a hyperpolarizing potassium B. QT interval
current. C. T wave
D. It increases intracellular cAMP. D. TP period

46. Activation of beta-adrenergic receptors in the 52. T wave inversion occurs when ventricular
heart is normally associated with which of the repolarization occurs from:
following? A. endocardium to epicardium
A. Decrease in the slope of phase 4 B. epicardium to endocardium
depolarization in SA nodal cells. C. apex to base of the heart
B. Decrease in conduction speed through AV D. base to apex of the heart
node.
C. Inhibition of Ca induced Ca release following 53. Which of the following is the shortest event in
depolarization in ventricular myocytes. a cardiac cycle?
D. Accelerated sequestration of Ca in the A. QRS interval
sarcoplasmic reticulum by the Ca-ATPase B. ST segment
E. Reduction in the rate of rise in ventricular C. ST interval
pressure during isovolumic contraction D. RR interval
47. Select all correct answers. Prepotentials are 54. Electrical activity in which region of the heart
normally absent from: does not result in deflections on the surface
A. P cells in the SA node electrocardiogram?
B. AV nodal cells A. Atria
86
E.S.Prakash. Multiple-Choice Questions in Medical Physiology, 2014
B. Bundle of His
C. Free wall of the left ventricle 61. Right axis deviation may occur in:
D. Free wall of the right ventricle A. deep inspiration
E. Muscular portion of the ventricular septum B. emphysema
C. dextrocardia
55. In sinus rhythm, the last portion of the D. pulmonary hypertension
ventricle to depolarize is:
A. interventricular septum from left to right 62. In which of the following leads are you most
B. anteroseptal region of the myocardium likely to observe ST segment elevation when there
C. most of the myocardium from endocardium to is an acute and extensive infarction of the anterior
epicardium and lateral wall of the heart?
D. posterobasal portion of left ventricle and the A. Leads I, II and III
pulmonary conus B. Leads aVR, aVL and aVF
C. Leads I, aVL, and V1-V6
56. The most reliable index of AV nodal delay is: D. Leads II, III and aVF
A. AH interval
B. PA interval 63. The AV node does not conduct more than:
C. PR interval A. 180 impulses per minute
D. PR segment B. 230 impulses per minute
C. 280 impulses per minute
57. AH interval is normally: D. 330 impulses per minute
A. 30–50 ms
B. 60–125 ms 64. Select all correct answers. The ST segment is
C. 100–200 ms elevated in acute myocardial infarction because
D. 80–120 ms of:
A. flow of current into the infarct during diastole
58. Hypocalcemia is associated with QT B. TP segment depression
prolongation because: C. late depolarization of infarct
A. it is invariably associated with bundle branch D. early repolarization of infarct
block
B. it increases ventricular activation time 65. During the cardiac cycle, aortic valve closes at
C. it lengthens the duration of ventricular the end of:
repolarization A. isovolumetric systole
D. it accelerates opening of potassium channels B. rapid ejection
C. diastasis
59. Stimulation of sympathetic nerves to the heart D. protodiastole
decreases:
A. heart rate 66. The maximum pressure rise in the ventricle
B. force of cardiac contraction occurs during:
C. speed of conduction A. ejection
D. refractory period B. isovolumetric contraction
C. protodiastole
60. If QRS deflection is highest and upright in D. diastasis
lead I and equiphasic (or null) in lead aVF, then
mean electrical axis of the QRS vector in the 67. Clinical examination of a 45 year old man
frontal plane is about: reveals splitting of the second heart sound as A2
A. 30 degrees followed by P2 during deep inspiration, and the
B. 0 degrees split was not apparent during expiration. S1 is
C. +45 degrees normal in intensity, and there is no cardiac
D. +90 degrees murmur. BP is 130/80 mm Hg and pulse is 80
87
E.S.Prakash. Multiple-Choice Questions in Medical Physiology, 2014
bpm and regular. Which of the following is the
most likely cause of this pattern of splitting of the Region Pressure % Saturation
second heart sound? (mm Hg) of Hb with
A. Aortic regurgitation oxygen
B. Left bundle branch block Right atrium 5 70
C. Physiologic splitting of S2 Right ventricle 28/6 70
D. Pulmonic stenosis Pulmonary artery 30/15 70
Pulmonary 25 90
68. Normally, which of the following events in the capillary wedge
cardiac cycle occurs at some point between S1 Left ventricle 102/25 88
and the following S2? Aorta 98/56 88
A. Onset of ventricular diastole
B. Atrial systole This data is most consistent with the possibility
C. Rapid ventricular filling of which of the following as the underlying cause
D. The ‘a’ wave of the JVP of breathlessness?
E. The ‘y’ descent in the JVP A. Tricuspid stenosis
B. Pulmonary stenosis
69. Comparing left and right atria, the left atrium C. Mitral regurgitation
normally has a taller v wave than the right atrium D. Aortic stenosis
because
A. left atrial filling pressure is high 73. In postnatal life, steady state outputs of the
B. pulmonary vessels empty into the left atrium right and left ventricle are matched in vivo by:
C. left atrium is more complaint A. the Frank-Starling mechanism
D. right ventricle is more compliant B. sympathetic influences on the SA node
C. vagal influences on the SA node
70. Which of the following is a low pitched sound D. varying the afterload for each ventricle
heard best in the apex just prior to S1 and is E. matching the tension generated by each
associated with effective atrial contractions in the ventricle
setting of diminished ventricular compliance?
A. Pericardial knock 74. While introducing the Swan Ganz catheter, its
B. Opening snap placement in the pulmonary artery (PA) is best
C. S3 inferred from which of the following?
D. S4 A. Diastolic pressure is lower in PA than in right
ventricle
71. In which of the following states is B. Diastolic pressure is higher in PA than right
isovolumetric ventricular relaxation abbreviated, ventricle
assuming that the prevailing heart rate is identical C. PA pressure tracing has dicrotic notch
in each? D. Right ventricular pressure tracing for plateau
A. Aortic regurgitation and sharp drop in early diastole.
B. Mitral regurgitation
C. Mitral stenosis 75. Which of the following statements represent
D. Tricuspid regurgitation the most appropriate interpretation of the ECG
E. Patent ductus arteriosus shown below?
72. Results of cardiac catheterization in a 50-year-
old man who presented with a history of acute
breathlessness since the past 24 hours are as
below. Coronary angiography showed no
evidence of significant narrowing of the right or
left coronary arteries or its branches.
88
E.S.Prakash. Multiple-Choice Questions in Medical Physiology, 2014
 10.399780 B. 50 %
X beat C. 66 %
5.199890
D. 75 %

Volts
ECG

0.000000

81. During exercise, a man consumes 2 liters of

-5.199890 oxygen per minute. His arterial O2 content is 200
128.00000 130.00000
ml/L and the oxygen concentration of mixed
seconds
venous blood is 120 ml/L. His cardiac output is:
A. X beat originated from an atrial focus. A. 16 L/min
B. X beat reset the cardiac rhythm. B. 25 L/min
C. S1 & S2 would have been present at X beat. C. 32 L/min
D. The path of spread of excitation was normal. D. 40 L/min

76. Which of the following need to be recorded in 82. If blood [Hb A] = 15 g/dL and Hb is fully
order to determine systolic time intervals? saturated with oxygen, average stroke volume =
A. ECG, ECHO, and phonocardiogram (PCG) 70 ml, average HR = 72 bpm, calculate whole-
B. ECG, PCG and carotid artery pulse (CAP) body oxygen delivery; i.e., the amount of oxygen
C. ECHO, CAP and PCG delivered to the tissues per minute, assuming Hb
D. ECG, CAP and apexcardiogram is fully saturated with oxygen.
A. 1 L/min
77. Which of the following is not essential to B. 0.5 L/min
determine QS2, left ventricular ejection time C. 2 L/min
(LVET) and pre-ejection period (PEP)? D. 2.5 L/min
A. Pulse transducer
B. Electrocardiograph 83. Which method is dependable for measuring
C. Phonocardiogram cardiac output when cardiac output is low?
D. Swan-Ganz catheter A. Fick’s method (using oxygen uptake)
B. Thermodilution method
78. The dicrotic notch is absent from:
A. radial arterial pulse tracing 84. A dye ABC has been in use for the
B. pulmonary arterial pulse tracing measurement of blood volume and cardiac output.
C. aortic pulse tracing This was rivaled by the introduction of XYZ,
D. none of the above which crossed the capillaries. What difference
would the use of XYZ make in this context?
79. A cardiologist asked his lab technician to A. No change in measured cardiac output &
determine the systolic time intervals of a 60 yr old blood volume
patient with a recent anterior wall infarction. The B. Increase in measured blood volume alone
technician said that the pulse transducer was not C. Increase in measured cardiac output alone
working. Which of the following could he then D. Cause an error in the measurement of both
have not determined?
A. QS2 85. The most recent technique for noninvasive
B. Left ventricular ejection time (LVET) measurement of cardiac output is:
C. Pre-ejection period (PEP) A. pulmonary artery catheterization
D. Both LVET and PEP B. thermodilution
C. echocardiography
80. The cardiac output of a 50 year old man at rest D. impedance cardiography
is 6 L / min; mean HR is 75 BPM. Left ventricular
end-diastolic volume (LVEDV) is 120 ml. What is 86. The best measure of left ventricular preload
the mean ejection fraction? is:
A. 35 % A. left ventricular end-diastolic volume
89
E.S.Prakash. Multiple-Choice Questions in Medical Physiology, 2014
B. left atrial pressure A. aorta
C. pulmonary capillary wedge pressure B. internal jugular v.
D. right atrial pressure C. arterioles
E. central venous pressure D. muscular arteries
F. jugular venous pressure
94. The stopcocks of the circulation are:
87. The most appropriate index of left A. arterioles
ventricular afterload is B. capillaries
A. systolic arterial pressure C. valves
B. mean arterial pressure D. venules
C. systemic vascular resistance
D. aortic valve resistance 95. Across which site in the circulation is the
E. left ventricular systolic pressure pressure drop maximum?
A. Arterioles
88. Right ventricular preload typically exceeds B. Venules
left ventricular preload during: C. Capillaries
A. deep inspiration D. Aortic valve
B. deep expiration
C. Valsalva maneuver (done for 15 seconds) 96. At any time, the greatest fraction of blood
D. quiet standing volume is present in the:
A. heart
89. LV preload is increased by a/an: B. arteries
A. increase in intrapericardial pressure C. veins
B. decrease in left ventricular compliance D. capillaries
C. sympathetic stimulation of veins and the heart
D. inhibition of Na-K ATPase in cardiomyocytes 97. What fraction of total blood volume is present
in the capillaries at any given time?
90. During severe exercise, a well-trained athlete A. 5%
may be able to achieve a cardiac output of: B. 20%
A. 15 liters C. 15%
B. 25 liters D. 1%
C. 35 liters
D. 45 liters 98. The term “capacitance vessels” is applied to:
A. pulmonary capillaries
91. An increase in whole body oxygen demand is B. thoroughfare channels
met chiefly by: C. shunts
A. increasing cardiac output D. veins and venules
B. increasing oxygen content of arterial blood
C. increasing oxygen extraction from arterial 99. Hydraulic conductivity of capillaries is highest
blood in:
D. increasing blood pressure A. glomeruli
B. intestinal villi
92. Maximal oxygen consumption (VO2 max) in C. skin
healthy active men is about: D. brain
A. 10 ml/kg/min
B. 20 ml/kg/min 100. The mean systemic arterial pressure and the
C. 40 ml/kg/min mean pulmonary artery pressure are respectively
D. 80 ml/kg/min 90 and 15 mm Hg. What is the ratio of systemic
and pulmonary vascular resistances?
93. Windkessel vessels are represented by the: A. Data inadequate
90
E.S.Prakash. Multiple-Choice Questions in Medical Physiology, 2014
B. 1 B. Laplace’s law
C. 6 C. Poiseuille Hagen law
D. 10 D. Fahraeus-Lindquist effect

101. In a circuit model of the systemic circulation 106. Select all correct answers. When
of dog, the inflow pressure at Point A is 100 mm determining BP with a sphygmomanometer, a
Hg and the downstream pressure at Point B is 10 spuriously high value (of either SBP or DBP) may
mm Hg. Each of the vascular beds R1 through R5 be recorded when:
offers a resistance of 5 Units. The total flow A. there is an auscultatory gap
through the entire circuit is approximately: B. the cuff is smaller than preferable
C. the person is obese
D. the arm is not placed at the level of the heart

107. If we compared wall tension at the following

sites in a normotensive dog, it would be highest
in:
A. aorta
B. capillaries in the lower limb
C. hepatic sinusoid
A. 5 liters per minute
D. inferior vena cava
B. 3.5 mm Hg / Unit
E. pulmonary arteriole
C. 10 mm Hg / Unit
F. radial artery
D. 90 mm Hg / Unit
108. Which of the following is usually associated
102. What would be the change in blood flow to a
with turbulence in blood flow?
tissue if radius of the arterioles in that tissue is
A. Reynolds number less than 2000
doubled and perfusion pressure is halved?
B. Decrease in blood flow velocity
A. Increase 8 times
C. Decrease in density of blood
B. Increase 16 times
D. Increase in diameter of blood vessel
C. Increase 4 times
D. Decreases 4 times
109. Turbulence is almost always present when
Reynolds number is more than:
103. The pressure in a blood vessel at which flow
A. 2000
ceases is called:
B. 2500
A. mean arterial pressure
C. 3000
B. pulse pressure
C. critical closing pressure
110. The average arm-to-tongue circulation time
D. perfusion pressure
is:
A. 5 seconds
104. Thin walled capillaries do not burst when
B. 10 seconds
intracapillary pressure is increased within
C. 15 seconds
physiologic limits because:
D. 20 seconds
A. they lack smooth muscle cells
B. the blood flow rate is less
111. Bernoulli’s principle could be applied to
C. they have a small radius
explain why:
D. capillary hematocrit is less than whole-body
A. intravesical pressure does not change with
hematocrit.
increase in intravesical volume
B. mean pressure in the femoral artery is greater
105. That capillaries can withstand high internal
than that in the brachial artery
pressures without bursting is explained using:
A. Bernoulli’s principle
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E.S.Prakash. Multiple-Choice Questions in Medical Physiology, 2014
C. coronary blood flow is compromised in aortic A. Adenosine
stenosis B. Potassium ions
D. tissue blood flow ceases below critical closing C. Endothelin-1
pressure D. Hydrogen ions
E. ADP
112. Select all correct answers. Which of the
following statements is/are correct? 119. What is the chemical identity of
A. Pulse pressure is directly proportional to endothelium-derived relaxing factor (EDRF)?
stroke volume. A. Nitrous oxide
B. Pulse pressure is inversely proportional to B. Nitric oxide
compliance of large arteries. C. Potassium
C. Reflected arterial pulse waves normally serve D. Carbon monoxide
to increase coronary perfusion during diastole.
120. Which of the following has a direct
113. Filtration at the arterial end of capillary vasodilator effect on smooth muscle in arterioles
occurs mainly due to: in the presence of endothelial dysfunction?
A. hydrostatic pressure in capillaries A. Acetylcholine
B. hydrostatic pressure in interstitium B. Angiotensin II
C. oncotic pressure in capillaries C. Nitric oxide
D. oncotic pressure in interstitium
D. Norepinephrine
114. Patients with acute cardiac failure may not E. Thromboxane A2
have edema if:
A. oncotic pressure of plasma proteins is high 121. Which of the following does not have
B. renal compensation occurs vasodilator actions?
C. cardiac output is decreased A. NO
D. there is a fall in systemic capillary hydrostatic B. CO
pressure C. Potassium
D. Angiotensin III
115. Venous return is transiently increased during:
A. strain phase of Valsalva maneuver 122. Blood flow to exercising skeletal muscle is
B. positive end-expiratory pressure decreased by:
C. intravenous bolus of frusemide A. accumulation of K+
D. deep inspiration B. norepinephrine
C. ↑ in PCO2 in muscle
116. Which of the following does not occur when D. Adenosine
the body is immersed in water up to the neck? E. products of muscle metabolism
A. Increase in central venous pressure F. activation of beta-adrenergic receptors in
B. Increase in plasma level of renin skeletal muscle
G. activation of sympathetic cholinergic
117. Quantitatively, the most important means of vasodilator system
increasing flow to an actively metabolizing tissue H. nitric oxide
is:
A. increasing cardiac output 123. The most potent vasoconstrictor is:
B. increasing peripheral resistance A. endothelin 1
C. increasing blood pressure B. angiotensin II
D. decreasing local vascular resistance C. norepinephrine
D. vasopressin
118. Which of the following is not a vasodilator
metabolite?
92
E.S.Prakash. Multiple-Choice Questions in Medical Physiology, 2014
124. Check whether the following statements 129. The first reflex response to an increase in
about the arterial baroreflex mechanism are true arterial pressure produced by intravenous
or false. injection of phenylephrine is:
1. Baroreceptors are free nerve endings A. increase in RR interval
responsive to stretch. B. increase in heart rate
2. Herring’s nerve terminates in the nucleus C. decrease in cardiac output
tractus solitarius. D. decrease in total peripheral resistance
3. An increase in discharge rate in afferents from
the arterial baroreceptors reflexly excites 130. Which of the following is most likely to
vagal outflow to the heart and inhibits happen in a normal healthy adult seated in a
sympathetic outflow to resistance vessels. centrifuge and spun at a force equal to 2 times that
4. The effect of a decrease in BP is a decrease in of gravity?
discharge frequency of arterial baroreceptor A. Increase in intracranial tension
afferents. B. Increase in BP
C. Increase in cardiopulmonary blood volume
125. Select all correct answers. On rising from the D. A doubling of pressure in the veins of the foot
supine position:
A. central blood volume increases 131. Loss of 500 ml of blood over 30 minutes will
B. heart rate decreases lead to:
C. central venous pressure decreases A. an increase in HR, fall in BP
D. discharge from arterial baroreceptors B. a fall in BP and HR
decreases C. a prominent increase in HR and BP
E. stroke volume decreases D. a slight increase in HR

126. Which of the following is a visceral afferent 132. Select all correct answers. Which of the
nucleus? following maneuvers evokes an increase in vagal
A. Rostral ventrolateral medulla discharge to the heart?
B. Pre-Bottzinger complex A. IV infusion of phenylephrine
C. Nucleus tractus solitarius B. Carotid massage
D. Caudal ventrolateral medulla C. Pressure on the eyeball
D. Irrigation of the ear canals
127. Intravenous injection of norepinephrine to a
normotensive healthy adult human leads to: 133. Marey’s law states that:
A. an increase in BP & HR A. when BP increases, HR decreases
B. a decrease in BP & HR B. when BP decreases, HR increases
C. an increase in HR & decrease in BP C. when BP decreases, HR decreases
D. an increase in BP & decrease in HR D. when BP increases, HR increases

128. Select all correct answers. During the strain 134. A healthy 24-year-old male athlete is
phase of the Valsalva maneuver (forced expiration performing symptom limited bicycle ergometry.
with the glottis open and maintaining an During exercise at 60% of maximal oxygen
expiratory pressure of 40 mm Hg for 15 seconds): uptake, which of the following would be least
A. venous return decreases likely? An increase in:
B. cardiac output decreases A. heart rate
C. blood pressure decreases B. stroke volume
D. heart rate increases C. systemic vascular resistance
E. sympathetic outflow to blood vessels ↑ D. mean arterial pressure
F. TPR gradually increases
135. During exercise, an increase in O2 uptake by
exercising muscles does not occur due to:
93
E.S.Prakash. Multiple-Choice Questions in Medical Physiology, 2014
A. shift of the oxyhemoglobin dissociation curve A. Valsalva maneuver
to the left B. positive pressure ventilation
B. decrease in vascular resistance in exercising C. negative ‘g’
skeletal muscle D. head-up tilt
C. ↑ blood flow
143. As part of a space-research program, a
136. Vasomotor ischemia triggers an increase in physiologist was asked to investigate the effect of
sympathetic outflow increasing BP and thereby flight-induced stress on blood pressure.
facilitating restoration of cerebral blood flow. Accordingly, the blood pressures of the
This is called: cosmonauts were to be measured twice: once
A. Bainbridge reflex before take-off and once after the spacecraft
B. the CNS ischemic pressor response entered the designated orbit around the earth. For
C. Head’s paradoxical reflex a proper comparison, the pre-flight blood pressure
D. Marey’s reflex should be recorded in (the):
A. lying down position
137. The mechanism that regulates cerebral blood B. sitting position
flow during cerebral compression is the: C. standing position
A. CNS ischemic response D. any position as long as the post-flight
B. Cushing’s reflex recording is made in the same position.
C. Bezold-Jarisch reflex
D. Bainbridge reflex 144. Which of the following is least likely
following prolonged space missions?
138. The ‘last ditch stand’ in defense of a falling A. Cardiac hypertrophy
blood pressure is the: B. Postural hypotension
A. arterial baroreflex mechanism C. Weight loss
B. arterial chemoreflex mechanism D. Motion sickness
C. CNS ischemic pressor response
D. Bainbridge reflex 145. The acute effect of bilateral clamping of the
carotid arteries proximal to the carotid sinuses is
139. Select only one response. Heart rate is a/an:
slowed by: A. increase in heart rate and mean arterial
A. deep inspiration pressure
B. Bainbridge reflex B. decrease in heart rate and mean arterial
C. increased intracranial tension pressure
D. carotid massage C. decrease in heart rate and an increase in mean
arterial pressure
140. In a healthy normotensive individual at rest, D. increase in heart rate and a decrease in mean
heart rate is typically increased by: arterial pressure
A. deep expiration
B. fear 146. The acute effect of clamping internal carotid
C. anger arteries proximal to the carotid sinuses in a dog is
D. IV infusion of phenylephrine most likely:
A. an increase in discharge rate in afferent fibers
141. Atrial natriuretic peptide is metabolized by: from the carotid sinus
A. dicarboxypeptidase B. a decrease in discharge rate of neurons in the
B. kininase II rostral ventrolateral medulla
C. neutral endopeptidase C. an increase in sympathetic outflow to the heart
D. kininase I and resistance vessels
D. an increase in cardiac vagal outflow
142. Cardiac output increases during:
94
E.S.Prakash. Multiple-Choice Questions in Medical Physiology, 2014
147. In a dog, what would be expected to happen C. 5 ml/100 g/min
to BP upon clamping both internal carotids above D. 7 ml/100 g/min
the carotid sinus as to completely stop flow?
A. No change 153. A 10ºC decrease in body temperature
B. Increase decreases cerebral metabolic rate (i.e., cerebral
C. Decrease consumption of oxygen) by:
A. 10%
148. Two students, AB and CD were asked to B. 30%
demonstrate in dogs the role of sinus nerve in C. 50%
hypovolemic shock. AB severed the sinus nerve D. 70%
when the mean blood pressure was 85 mm Hg and
CD cut the sinus nerve when the mean arterial 154. Which of the following is least likely to
pressure (MAP) was 60 mm Hg. On cutting the aggravate insult in an injured brain?
sinus nerve: A. Hypercapnia
A. AB recorded an ↑ in MAP, CD recorded a ↓ B. Hypoxia
B. AB recorded a ↓ in MAP, CD recorded an ↑ C. Hypotension
C. both recorded an ↑ in MAP D. Hypothermia
D. both recorded a ↓ in MAP
155. Which of the following is not true about
149. In hemorrhaged dogs with marked cerebrospinal fluid?
hypotension (mean arterial pressure < 50 mm Hg), A. Its pH is less than that of arterial plasma
denervation of arterial chemoreceptors would: B. It is formed in arachnoid villi.
A. increase BP since chemoreceptors reduce C. Leakage of CSF during dural tap causes
sympathetic outflow headache.
B. produce no change in BP since
chemoreceptors do not influence sympathetic 156. Select all correct answers. Areas where the
outflow blood-brain barrier is leaky include:
C. result in a further fall in BP since the arterial A. Posterior pituitary
chemoreflex is sympathoexcitatory B. Median eminence
D. depend on whether arterial baroreceptors are C. Subfornical organ
reset or not D. Organum vasculosum of lamina terminalis
E. Area postrema
150. Normally, in an adult at rest, total blood flow F. Subcommissural organ
to the brain is about: G. Pineal
A. 250 ml/min
B. 500 ml/min 157. The blood-brain barrier is formed by:
C. 750 ml/min A. tight junctions between vascular endothelial
D. 1200 ml/min cells in the cerebral capillaries
B. choroidal epithelial cells
151. Normally, the brain is perfused with what C. ependymal cells
fraction of resting cardiac output? D. foot processes of oligodendroglia
A. 5%
B. 10% 158. The plasma/CSF ratio of proteins is:
C. 15% A. 3
D. 20% B. 10
C. 20
152. Normally, cerebral metabolic rate for oxygen D. 300
(CMRO2) is about:
A. 2 ml/100 g/min 159. The arteriovenous O2 concentration
B. 3.5 ml/100 g/min difference is highest across the:
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E.S.Prakash. Multiple-Choice Questions in Medical Physiology, 2014
A. brain C. axon reflex
B. heart D. decreased absorption of fluid
C. kidneys
D. liver 166. Which of the following physiologic
responses has a neural basis?
160. Stimulation of sympathetic nerves to which A. Red reaction
of the following tissues invariably reduces blood B. White reaction
flow to that vascular bed? C. Flare
A. Skin D. Reactive hyperemia
B. Heart
C. Brain 167. In which of the following organs is the flow
least under sympathetic control?
161. An increase in discharge of noradrenergic A. Brain
nerves to the heart causes / has: B. Heart
A. coronary vasoconstriction C. Viscera
B. coronary vasodilation D. Skin
C. no effect on blood flow
168. Orthopnea in heart failure occurs when the
162. If the noradrenergic nerves to the heart are reservoir function of which of the following is
stimulated after giving a β-blocker, then what overwhelmed?
would be the effect on coronary blood flow? A. Pulmonary veins
A. Coronary vasodilation B. Pulmonary arteries
B. Coronary vasoconstriction C. Right atrium
C. No change D. Systemic veins
D. Unpredictable
169. Palpable enlargement of the liver in an
163. Normally, in postnatal life, the left ventricle individual with heart failure is most closely
is more vulnerable to ischemia and infarction related to:
compared to the right ventricle because: A. a decrease in pulmonary venous pressure
A. diastolic pressure is comparable in both B. an increase in left ventricular compliance
ventricles C. an increase in mean arterial pressure
B. pulmonary vascular resistance is greater than D. an increase in mean right atrial pressure
systemic vascular resistance E. an increase in systemic vascular resistance
C. the left ventricle pumps much more blood than
the right ventricle 170. Plasma level of brain natriuretic peptide is
D. left ventricular subendocardial perfusion is least likely to be elevated in:
limited to ventricular diastole A. acute mitral regurgitation
E. flow through the right ventricle is largely B. cardiac tamponade due to chest trauma
passive C. heart failure due to dilated cardiomyopathy
D. heart failure due to acute aortic regurgitation
164. Capillaries empty when mechanically E. heart failure post myocardial infarction
stimulated. This is called the:
A. axon reflex Answers:
B. white reaction 1B 2D 3C 4B 5B
C. flare response 6C 7C 8A-F 9A 10B
D. red reaction 11B 12C 13A 14D 15A
16all 17C 18ABD 19B 20all
165. The wheal in the triple response is due to: 21B 22A 23B 24C 25C
A. contraction of precapillary sphincters 26A 27AC 28A 29A 30C
B. increased capillary permeability 31B 32D 33A 34AD 35A
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E.S.Prakash. Multiple-Choice Questions in Medical Physiology, 2014
36A 37A 38C 39A 40F 10. Vitamin K dependent clotting factors are
41C 42A 43A 44A 45C factors II, VII, IX and X and Protein C and
46D 47CD 48B 49D 50C Protein S. Protein C and protein S inhibit clotting.
51C 52A 53A 54B 55D
56A 57B 58C 59D 60B 11. The extrinsic pathway is called so because it is
61A 62C 63B 64all 65D triggered by a factor extrinsic to plasma (tissue
66B 67C 68A 69A 70D thromboplastin). Simply, it is triggered by “tissue
71A 72C 73A 74C 75C injury”. The extrinsic pathway is also the fastest
76B 77D 78D 79D 80C limb of the clotting cascade. Normally, PT = 12 –
81B 82A 83A 84D 85D 14 seconds.
86A 87E 88A 89C 90C
91A 92C 93A 94A 95A 13.
Test Screening Clotting factors
96C 97A 98D 99A 100C
screened
101D 102A 103C 104C 105B Prothrombin Extrinsic VII, X,
106all 107A 108D 109C 110C time pathway & Prothrombin,
111C 112all 113A 114D 115D common Fibrinogen
116B 117D 118C 119B 120C pathway
121D 122B 123A 124allT 125CDE Activated Intrinsic VIII, IX, X, XI,
126C 127D 128allT 129A 130D partial pathway & XII
131D 132all 133AB 134C 135A thromboplastin common
time pathway
136B 137AB 138C 139D 140C
141C 142C 143A 144A 145A
14. The conversion of plasminogen to plasmin
146C 147? 148A 149C 150C
requires tissue plasminogen activator (TPA). The
151C 152B 153D 154D 155B
conversion of Fibrin to fibrin degradation
156all 157A 158D 159B 160C products is catalyzed by plasmin (fibrinolysin).
161B 162B 163D 164B 165B
166C 167A 168A 169D 170B 16. Loss-of-function mutations in protein C,
protein S, antithrombin III and mutations in factor
Explanations: V resulting in resistance to inactivation to protein
6. MCHC is the most reliable index because it C have all been implicated in hypercoagulable
does not depend on the RBC count. This is states.
because the estimation of RBC count is more error
prone than the estimation of Hb or PCV. 17. Factor V Leiden, a mutated form of Factor V,
resists inactivation by protein C.
8. Fibrinogen is essential for platelet aggregation.
Also fibrinogen is a clotting factor. Von 20. If red cell antigens are also present in exocrine
Willebrand’s factor mediates the attachment of secretions, such individuals are called secretors. In
platelets to subendothelial collagen. Also vWD some, they are not secreted. The significance of
binds factor VIII and prolongs its half-life in the this is unknown.
circulation. When there is a deficiency of vWF,
more factor VIII spills over into the urine. Thus, 21. H substance is absent in persons with the
bleeding time and clotting time are both increased Bombay phenotype. Normally, if an individual
in hypofibrinogenemia and VWD. Thrombin is a has H substance (but lacks the A and B genes),
potent stimulator of platelet aggregation. At least, her blood group would be O. An individual
theoretically, prothrombin deficiency would be lacking H substance will have anti H antibodies in
expected to delay platelet aggregation. plasma and can receive transfusions only from a
Prostacyclin inhibits platelet aggregation. Aspirin person with the Bombay blood group.
therapy lowers TXA2/PGI2.

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E.S.Prakash. Multiple-Choice Questions in Medical Physiology, 2014
22. 70% of iron in the body is present in Hb. 35. Albumin is a ‘negative’ acute phase reactant;
Under abnormal circumstances, a large amount of i.e., its synthesis is reduced during the acute phase
iron may be present in hemosiderin. response.

23. Sensitization of the mother’s immune system 36. ESR in anemia is high because PCV is low;
with fetal Rh antigens results in the production of secondly, viscosity is low as well and it reduces
anti-Rh immunoglobulin. First, IgM is formed but resistance to sedimentation of cells. By the same
this is too large to cross the placental barrier. reasoning, ESR is reduced in polycythemia since
PCV as well as viscosity are elevated. However,
The major antibody in the primary immune for a given PCV, if blood is more viscous because
response is IgM. However, over a time period that of an increase in plasma levels of globulins and
varies from individual to individual, IgG is also fibrinogen, its effect is to enhance sedimentation
produced as part of this response, although the since these proteins facilitate rouleaux formation.
titer of IgG is usually not sufficient to evoke
significant hemolysis in the first pregnancy. On 39. Hb F binds 2,3 BPG less avidly compared to
the other hand, in a woman who has been Hb A and therefore has a greater affinity for
previously sensitized with Rh antigen and anti D oxygen relative to Hb A. This is one reason why it
IgG titers were significant, significant hemolysis is able to draw O2 from Hb A.
could occur even during the first pregnancy.
40. The viscosity of blood varies with flow rate,
27. Osmotic fragility increases when the RBC and it increases at very low flow rates such as in
cytoskeleton is abnormal, as in hereditary postcapillary venules due to aggregation of RBCs.
spherocytosis. Normal range: 0.5 - 0.3% NaCl This is why blood is considered a non-Newtonian
Osmotic fragility is increased in hereditary fluid.
spherocytosis. Sickle cells and microcytes show
greater resistance to osmotic lysis by virtue of 41. Automaticity is attributed to the presence of
their smaller size and normal cytoskeleton. pacemaker cells that demonstrate spontaneous
depolarization in the absence of extrinsic
28. Hereditary spherocytosis occurs due to innervation.
mutations in cytoskeletal proteins spectrin,
ankyrin, Band 3. Defects in ankyrin are reported 43. Normally, it is the impulse that originates in
to be commoner. the SA node that excites the ventricular
myocardium. Such a rhythm is called sinus
30. Heme oxygenase activity is highest in the rhythm.
spleen. Second, the spleen is much more sensitive
to red cell injury. (Wintrobe’s Clinical 44. There are two regions in the heart where the
Hematology, Lee GR et al, 10th ed, Lippincott inhibitory effect of vagal stimulation on
Williams and Wilkins, volume 1, p 280.) conduction speed is profound. These are the SA
and AV nodes. The conduction speed in the SA
31. Haptoglobin binds extracorpuscular and AV nodes is about 0.05 m/s. (Ganong, 2012;
hemoglobin. Hemopexin binds heme. Haptoglobin p. 524, Table 29-1). Conduction speed is about 4
binds extracorpuscular hemoglobin and prevents it m/s in the Purkinje system, about 80 times faster
from being filtered and excreted by the kidney. than in the SA and AV nodes.
Serum haptoglobin levels are reduced in
hemolytic anemias. 45. Stimulation of the right vagus nerve, which
predominantly innervates the SA node, decreases
32. Fibrinogen is consumed when blood clots the firing rate of the SA node. The effect of
leaving very little of it in serum if at all. acetylcholine on pacemaker cells in the SA node
is to activate a hyperpolarizing potassium current.

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E.S.Prakash. Multiple-Choice Questions in Medical Physiology, 2014
46. Beta-adrenergic receptor activation in the SA
node increases the slope of phase 4 depolarization 50. The AV node, like the SA node, exhibits
in SA nodal cells, thereby increasing SA nodal prepotentials but its rate of discharge is much less
firing rate. Conduction speed through AV node compared to the SA node.
increases. Calcium influx (ICa) and calcium
induced calcium release are facilitated. 52. Depolarization and repolarization are
Sequestration of Ca in the SR is enhanced; this is electrically opposite processes. Normally,
how it accelerates myocardial relaxation. ventricular depolarization occurs from
Remember, an increase in HR entails an endocardium to epicardium, and repolarization
acceleration of the rate of contraction as well as occurs from epicardium to endocardium. This is
relaxation. The rate of pressure increase during why the T wave is upright, i.e. in the same
isovolumetric ventricular contraction is increased direction as QRS. An inverted T wave indicates
because of enhanced calcium influx and an that the direction of ventricular repolarization is
increase in sensitivity of contractile proteins to reversed, i.e. occuring from endocardium to
calcium (positive inotropic effect). epicardium.

47. Note that the terms prepotential, pacemaker 56-57. His Bundle Electrogram:
potential and spontaneous diastolic depolarization PA interval (approximately 30 ms) reflects the
are often used interchangeably. They all mean the time taken for conduction across the atrial
same. Normally prepotentials are present only in pathways to the AV node. PR segment is a
the SA node and AV node which contain combined index of AV nodal delay and
pacemaker cells (P cells). However, in abnormal conduction in infranodal pathways. PR interval is
situations (e.g. hypoxemia) other regions of the a rather poor index of AV nodal delay. AH
heart (e.g. a ventricular focus) exhibit interval, which is obtained by a His bundle
prepotentials. This state is one of “increased electrogram specifically reflects AV nodal
automaticity”, and premature ventricular or atrial conduction time. The AH interval, from the A
depolarizations are manifestations of increased wave to the start of the H spike is normally 60-
automaticity. 125 ms.
Interval Physiologic correlate Time
48. The long duration of action potential (or the (ms)
absolute refractory period) in the heart is due to PA interval Atrial activation time 30
slow repolarization. This is a safety features that
ensures that the ventricles relax to fill with blood AH interval AV nodal delay 60-125
before contracting again.
HV interval His Bundle - 35-50
ventricle
49. Intrinsic heart rate (IHR) is the rate at which Ganong, 2012, p. 528-9.
the heart will beat when completely denervated.
This is determined, in humans, by intravenous 61. Right axis deviation may occur in a healthy
administration of a standard dose of atropine and young adult male during deep inspiration.
atenolol. In healthy humans, IHR is about 100-
110/min. The magnitude of IHR reflects the 64. The mechanisms are incompletely understood
automaticity of the SA node. The fact that resting but this is what has been postulated. First, the
heart rate in healthy humans is around 70 beats infarct is deprived of blood supply. With ATP
per minute indicates that the effects of cardiac depletion, its RMP becomes less negative.
vagal tone at rest are greater than the effect of Remember, the Na-K ATPase is an electrogenic
sympathetic outflow to the heart. Patients with mechanism that contributes a bit to making the
transplanted hearts have higher resting heart rates RMP negative inside (with respect to the exterior).
closer to IHR because of cardiac denervation. The other reason RMP becomes less negative in
Also, because of denervation, they are less able to the infarct zone is potassium (the most abundant
increase their heart rate in response to exercise. intracellular cation) is lost from injured cells.
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E.S.Prakash. Multiple-Choice Questions in Medical Physiology, 2014
 segment elevation does occur in multiple
contiguous leads, the mechanisms are believed to
be those described above.

68. Ventricular relaxation commences and

ventricular pressure begins to fall before the aortic
valve snaps shut (S2). Options B and D, atrial
systole (a wave) occurs just prior to S1. Rapid
ventricular filling commences after S2. Option E -
the ‘y’ descent of the JVP represents the fall in
Thus, as depicted in the schematic above, atrial pressure during ventricular filling and
extracellularly, the infarct zone, at rest, becomes occurs between S2 and S1.
negative with respect to surrounding normally
polarized tissue. Therefore, during diastole, 72. There is no abnormal pressure gradient across
extracellularly, current flows into the infarct. This the tricuspid valve, pulmonic valve or aortic
is what is called the diastolic current of injury. valve. Pulmonary capillary wedge pressure is
TP segment, the EKG segment corresponding to abnormally high, suggestive of acute left
ventricular diastole, is normally isoelectric ventricular failure. The resulting pulmonary
because normally there is no current flow during venous congestion and pulmonary edema may
diastole. The current flow into the infarct during account for the reduction in percentage saturation
diastole depresses the baseline, i.e., the TP of Hb with oxygen. The data are most consistent
segment is depressed. However, the arrangement with acute mitral regurgitation.
in ECG recorders is such that TP segment
depression is recorded as ST segment elevation. 73. The right and left ventricles are in series and
so they pump the same volume of blood. They, of
Secondly, the infarct depolarizes late with respect course, normally beat at the same rate. Thus, their
to surrounding normal tissue probably due to a stroke volumes are matched over time. This can
decrease in velocity of conduction of impulses in be explained by the Frank-Starling mechanism
the infarcted tissue; the effect of this late which states that stroke volume varies directly
depolarization is to simply delay the QRS with preload (ventricular end-diastolic volume)
complex, causing ST segment elevation. within physiologic limits.

Thirdly, ischemic myocardium repolarizes faster 75. The depolarization at X beat is from a focus in
due to accelerated opening of potassium channels. the ventricle. The beat could not have originated
(One can’t predict this from first principles; it in an atrial focus since it has not reset the sinus
simply, is a property of potassium channels in the rhythm. An atrial premature beat is not usually
myocardium) Normally, ventricular repolarization followed by a compensatory pause; it is conducted
is evident as the T wave. But the effect of early to the SA node and it “resets” sinus rhythm. In
repolarization is also ST segment elevation. contrast, a ventricular premature beat is usually
not conducted retrograde through the AV node to
Thus, myocardial infarction is characterized by the SA node, so it does not reset normal sinus
ST segment elevation in leads facing an acute rhythm.
myocardial infarction (Ganong, 2005, pp. 563-4).
It should be added that the definition of an acute The duration of premature ventricular
myocardial infarction has evolved over the years, depolarization is longer than a normal QRS
and now non-ST segment elevation myocardial complex since it is conducted much slowly
infarction (NSTEMI) is an entity distinguished through the myocardium rather than through the
from ST-segment elevation MI (STEMI). Thus, normal conducting pathway. Thus the resulting
based on recent definitions of MI, not all MIs ventricular contraction is unlikely to have been
cause ST segment elevation. But when ST really “premature”. So enough ventricular filling
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E.S.Prakash. Multiple-Choice Questions in Medical Physiology, 2014
would likely have occurred and the beat must Therefore, average SV = 80 ml.
have been strong enough for the aortic valve to Average LVEDV = 120 ml.
open (and then close). Thus both heart sounds Therefore, ejection fraction = SV/LVEDV = 0.66
would most likely have been present at beat X. = 66%.
The learning point here is that a premature
ventricular depolarization does not always result 81. The Fick’s principle states that the amount of
in a premature beat. a substance (X) consumed by an organ per unit
time (A) = A-V conc. difference of X across that
76-79. Systolic time intervals (STI) organ (circuit) × blood flow through that organ (or
QS2 is the time duration from the beginning of circuit)
the Q wave to the first high frequency component
of the aortic component A2 of the second heart Thus, blood flow (Q) = A / A-V conc. diff
sound. Note that this is an electromechanical In this example, O2 consumption = 2000 ml/min.
interval; QS2 is called electromechanical systole. AV O2 difference = 80 ml/L. Cardiac output =
It is remarkably constant. 2000/80 = 25 L/min.

Left ventricular ejection time (LVET) is the 82. Whole body oxygen delivery = cardiac output
period from the upstroke of the carotid artery × oxygen content of arterial blood.
pulse to the dicrotic notch (an oscillation on the
falling wave of the carotid artery pulse). The Cardiac output = 5 L/min; Blood Hb = 15 g/dL.
dicrotic notch in the carotid artery pulse tracing Oxygen carrying capacity of blood is
represents the closure of the aortic valve. Note approximately 20 ml/dL i.e. 200 ml/L.
that ejection is a part of systole.
Therefore about 1L of oxygen will be delivered to
Pre-ejection period (PEP) is calculated as QS2 – the tissues per minute.
LVET. It denotes the time taken for electrical
excitation of left ventricle, excitation-contraction 83. When cardiac output is low, blood flow
coupling and isovolumetric ventricular velocity is reduced and temperature of injected
contraction. saline is quickly dissipated into tissues thereby
rendering an accurate measurement of cardiac
If the duration of ventricular excitation and output (pulmonary blood flow) by the
excitation-contraction coupling can be assumed to thermodilution difficult.
be constant, then, PEP can be taken to reflect the
duration of isovolumetric ventricular contraction. 84. For correct estimation of blood volume as well
as cardiac output, the dye must remain in the
PEP, which reflects the duration of isovolumetric blood stream.
contraction, is prolonged in heart failure. This is
also associated with a decline in left ventricular 90. Ganong, 2012, p. 546, Table 30-3.
ejection time. Thus, PEP/LVET ratio is a sensitive
index of left ventricular systolic performance. STI 91. At rest, blood flow through the systemic
cannot be used for diagnosis of specific heart circulation (i.e., cardiac output) = 5 L/min
conditions. Of late, STI have been superseded by Assuming that functional Hb A concentration is
echocardiography. 15 g/dL and PaO2 is 100 mm Hg and that Hb is
fully saturated with oxygen,
Without the carotid pulse transducer, LVET Oxygen content of arterial blood = 200 ml/L
cannot be determined. Since PEP = QS2-LVET, Whole body oxygen delivery = 1 L/min
PEP cannot also be determined. Whole body oxygen consumption = 250 ml/min
Whole body oxygen extraction = 0.25
80. Cardiac output = SV × HR This is sometimes called ‘oxygen utilization
HR = 75/min; cardiac output = 6 L/min. coefficient (OUC)’.
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E.S.Prakash. Multiple-Choice Questions in Medical Physiology, 2014
Theoretically, oxygen extraction can increase up 106. When there is an auscultatory gap and the
to 1. Thus, an increase in oxygen extraction is one palpatory method is not used, systolic pressure
mechanism of fulfilling an increase in oxygen will be underestimated. When there is an
demand. However, in trained athletes, cardiac auscultatory gap and you use the palpatory
output can be increased 7 times from its resting method, you will get a correct estimate of systolic
value. pressure (say 210 mm Hg). Sounds will cease at
some point (say 160 mm Hg). However, if the
92. VO2 max is the maximum amount of oxygen cuff is not deflated any further (because sounds
that can be utilized during dynamic exercise; it disappeared at 160), one may not realize that there
can be increased by training. is an auscultatory gap with the result that diastolic
pressure is overestimated. Something like 210/160
97. At any time, 54% of blood volume is mm Hg will be recorded when the actual pressure
contained in the veins and venules & vena cava. is 210/90 mm Hg.

99. Ganong, 2012, p. 572, Table 31-10 108. Reynolds number Re = ρDV/η
ρ is the density of the fluid;
100. Since pulmonary and systemic circulations D is the diameter of the vessel;
are in series, the flows are identical V is the blood flow velocity; and
Cardiac output = P / R; η is the viscosity of fluid.
(P is mean arterial pressure and R is vascular Flow is turbulent when Re exceeds 3000.
resistance)
Ps / Pp = Rs/Rp (s and p refer to systemic and 111. Bernoulli’s principle: The greater the
pulmonary vascular beds respectively) velocity of flow in a vessel, the lower the lateral
Ps / Pp = 90 / 15 = 6 pressure distending its walls. Coronary arteries
Ratio of systemic and pulmonary vascular originate virtually at a right angle from the aorta,
resistance = 6 above the aortic valve. Thus, in aortic stenosis, the
Thus, the pulmonary circulation is a low lateral pressure at the level of the origin of
resistance, low pressure system. coronary arteries is reduced, and this in turn
reduces coronary blood flow. However, this is
101. For resistors in series, net resistance is the only one of many mechanisms that contribute to
sum of all resistances. For resistors in parallel, the reduction in coronary blood flow in aortic
1/R = 1/R1 + 1/R2 + 1/R3 + .. + 1/Rn, and the net stenosis.
resistance is R not 1/R.
112. The stiffer the arteries, i.e., the less
Flow = Pressure gradient / Net resistance to flow distensible they are, higher the pulse pressure for
a given stroke volume. This is the basis of higher
102. Tissue blood flow = BP / local vascular systolic pressure in isolated systolic hypertension,
resistance. Blood flow is directly proportional to the commonest type of hypertension in the
the fourth power of radius. elderly.

104. For a cylindrical structure, transmural 113. The major force driving filtration is the
pressure (P) = T/r (Laplace’s law) where T is wall capillary hydrostatic pressure, which is normally
tension and r is radius about 40 mm Hg at the arterial end of the capillary
in a capillary that is at the level of the heart. More
Though capillaries are thin walled, they have a precisely, transcapillary hydrostatic pressure
smaller radius and consequently need to develop gradient is the major factor.
less tension in order to withstand a given
distending (transmural) pressure. 114. In forward heart failure, cardiac output is
low, and as a result, mean arterial pressure may be
low, since MAP = cardiac output times TPR. This
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E.S.Prakash. Multiple-Choice Questions in Medical Physiology, 2014
may cause capilary hydrostatic pressure to be low. maneuver Thus BP = SV × HR × TPR
If edema is not observed in an individual who ‘overshoots’
truly has heart failure, then this is the most likely Response The BP overshoot triggers a
explanation. However, in advanced heart failure, baroreflex mediated lowering of
salt and water retention by the kidneys causes an HR
increase in total body sodium and water and Significance BP maintained
edema ensues.
131. Blood loss occurs over a 30-minute period (a
117. Tissue blood flow = mean arterial pressure / common example is venesection of a healthy adult
blood donor). There occurs only a slight increase
local vascular resistance. A doubling of radius of
in HR because of a reduction in central blood
all arterioles can increase flow to a tissue 16 times
volume. BP is maintained in the steady state, and
assuming all other factors affecting flow remain
one cannot detect the fall in BP by intermittent
the same. Thus, quantitatively, changes in local
sphygmomanometry.
vascular resistance achieved mainly through local
autoregulatory mechanisms contribute the most to
132. Phenylephrine is an alpha adrenergic agonist,
regulating tissue blood flow.
so it raises TPR and BP and elicits a baroreflex
mediated lowering of HR. Carotid massage
125. Central venous pressure decreases upon
mechanically activates the vagus nerve contained
rising due to a decrease in venous return. A
within the carotid sheath increasing cardiac vagal
decrease in arterial pressure, which occurs on
outflow.
rising from the supine position, also decreases the
stretch of arterial baroreceptors (i.e., arterial
133. Marey’s law states that HR (the dependent
baroreceptors are said to be ‘unloaded’) and the
variable) is inversely related to BP (the
firing rate in the carotid sinus nerves decreases.
independent variable) and that the converse is not
This reflexly inhibits vagal outflow to the heart
true. When Marey’s law holds, it is because the
and increases sympathetic outflow from the brain
arterial baroreflex works as a negative feedback
resulting in an increase in heart rate and a rise in
mechanism to maintain BP. However, when the
total peripheral resistance.
arterial baroreflex is reset – for example, during
exercise, HR as well as BP increase.
127. Norepinephrine has a greater affinity for
alpha adrenergic receptors than beta adrenergic
134. Systemic vascular resistance (or total
receptors. So when it is administered
peripheral resistance) would most likely reduce at
intravenously to a healthy individual with normal
such exercise intensity because of accumulation of
BP, it elicits a rise in total peripheral resistance
products of metabolism.
because of alpha adrenergic receptor mediated
vasoconstriction. The rise in BP elicits a
136. Vasomotor ischemia stimulates sympathetic
baroreflex mediated lowering of HR that
outflow. This leads to an increase in BP that in
overwhelms the direct cardioacceleratory effect of
turn serves to restore cerebral blood flow. This is
norepinephrine.
the CNS ischemic pressor response.
128. Valsalva maneuver:
Maneuver Forced expiration against a closed 137. The Cushing’s reflex is a subtype of the CNS
glottis sustained for 15 seconds. ischemic pressor response in which the cause of
Stimulus Decrease in BP due to a decrease in vasomotor ischemia is raised intracranial tension.
venous return and consequently
stroke volume (SV) 138. Arterial BP is affected by numerous neural
Response Immediate increase in HR and a and humoral mechanisms. The arterial baroreflex
more gradual increase in TPR mechanism buffers BP fluctuations when mean
‘Goal’ To maintain BP arterial pressure (MAP) is in the 70-150 mm Hg
Immediately Venous return suddenly increases, range. But when MAP is lower than 70 mm Hg,
after the SV increases, TPR is already high. baroreceptors are maximally deactivated and the
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E.S.Prakash. Multiple-Choice Questions in Medical Physiology, 2014
arterial chemoreflex mechanism assumes greater the load on the heart is reduced. This is because
importance in defending against a further fall in skeletal muscles are not regularly used in
BP. microgravity conditions. Postural hypotension
occurs upon return to earth (where the effects of
In severe hypotension such as when MAP is < 50 earth’s gravity are again fully manifest) because
mm Hg), ischemia of the vasomotor center in the of autonomic as well as physical deconditioning.
medulla triggers a powerful increase in Motion sickness in space occurs due to conflicting
sympathetic outflow. This mechanism, the CNS neural inputs from visual cues and vestibular
ischemic pressor response (called the “last ditch system and diminished input from muscle
stand” in defense of a falling BP), contributes to proprioceptors.
restoring cerebral blood flow.
145-146. This procedure reduces the pressure at
Reflex mechanism MAP (mm the level of the carotid sinuses. The result is
Hg) range in inhibition of arterial baroreceptor discharge and a
which it reflex increase in sympathetic discharge to the
operates heart and blood vessels. This is an instance of
Arterial baroreflex 70–110 neurogenic hypertension. Ganong, 2012, p. 592.
Arterial chemoreflex 40–70
CNS ischemic pressor response < 50 148. When MAP is in the normal range, i.e.,
between 70 and 110 mm Hg, an increase in BP
139. Regarding option C: Raised intracranial results in an increase in discharge rate from the
tension (ICT) is not necessarily associated with carotid sinus. Activity in the buffer nerves inhibits
bradycardia. An individual with raised ICT may tonic vasoconstrictor discharge from the medulla.
be hypotensive due to blood loss. In this instance, Therefore, sectioning of the buffer nerves when
hypotension is usually associated with MAP is normal would result in acute elevation of
tachycardia. Rather, if raised ICT leads to BP. This is called neurogenic hypertension.
hypertension, this usually elicits a baroreflex
mediated lowering of heart rate. A MAP less than 70 mm Hg is a hypotensive
state. When MAP is as low as 60 mm Hg,
142. When intrathoracic pressure is raised as discharge rate in carotid baroreceptors is already
occurs during the Valsalva maneuver, venous at its minimum, and the resulting reflex
return reduces and cardiac output decreases. sympathoexcitation is fully manifest.
Similarly, during positive pressure ventilation, the Thus, sectioning of afferents from arterial
increase in ITP reduces venous return and baroreceptors at a low MAP would not be
decreases cardiac output. During negative ‘g’, i.e. expected to have further sympathoexcitatory
acceleration in the long axis of the body from foot effects.
to head, there is a headward shift of body fluids
and central blood volume, cardiac output and On the other hand, when MAP is as low as 60 mm
blood pressure increase. Passive head-up tilt is Hg, blood flow through the arterial
associated with a decreased cardiac output since chemoreceptors near the carotid sinus would be
venous return is reduced. reduced. A reduction in either PaO2 and or a
decrease in flow through the chemoreceptors lead
143. Tolerance for g forces across the body (chest to a reflex increase (via afferents from carotid
to back) is much better than that acting along the bodies) in sympathetic outflow that serves to
long axis of the body (head to foot). Thus, bring BP back into the normal range. Thus, when
astronauts are positioned to take g forces of space the buffer nerves are sectioned at a time when
flight chest to back. (Ganong, 2005, p. 632). MAP is lower than normal, BP falls further.
(Ganong, 2005, p. 628).
144. Cardiac atrophy rather than hypertrophy
occurs following prolonged space missions since
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E.S.Prakash. Multiple-Choice Questions in Medical Physiology, 2014
Summary: When MAP is reduced below 70 mm ischemia would result with predictable
Hg, arterial baroreceptor discharge is maximally consequences.
inhibited and sympathetic outflow is disinhibited
as a result of this; apart from this, activation of the At rest, oxygen extraction ratio in the heart
arterial chemoreflex contributes significantly to = (A–V O2 difference / arterial O2 content) × 100
“increasing” MAP at such low pressures. = (114 / 200) × 100 = 0.55
This is based on data in Ganong, 2012, Table 33-
149. This is a simpler version of Question 148. 1, p. 602.

151. In a young healthy adult at rest, cardiac 162. Activity in the noradrenergic nerves to the
output = 5 L/min. Cerebral blood flow = 750 heart increases myocardial oxygen demand since
ml/min (this is 15% of cardiac output) it would increase the force as well as rate of
cardiac contraction. However, this normally
152. Mass of the brain = 1400 g results in coronary vasodilation caused by
Cerebral oxygen consumption per minute = 50 ml products of metabolism. The pressor effect of
CMRO2 (i.e. oxygen consumption per minute per norepinephrine on alpha-adrenergic receptors in
100 g of brain tissue) = 3.5 ml/100 g/min the coronary arteries is not manifest therefore.
However, the direct effect of norepinephrine on
153. A 1ºC decrease in temperature reduces segments of isolated coronary arteries is
cerebral metabolic rate for oxygen by 7%. vasoconstriction. On the other hand, the increase
in myocardial oxygen demand (and consumption)
154. This is because induced hypothermia reduces during exercise is attenuated in individuals taking
cerebral demand for oxygen. beta-blockers because the norepinephrine
mediated rise in heart rate and contractility are
157. While foot processes of astrocytes end on also diminished, and consequently their ability to
cerebral capillaries and induce the formation of exercise is diminished. The learning point here is
tight junctions, the actual anatomic basis of the that the coronary circulation is capable of
blood brain barrier is the tight junctions between excellent autoregulation.
endothelial cells in cerebral capillaries. In the
circumventricular organs such as area postrema, 163. The right ventricle is perfused throughout the
subfornical organ, this barrier is absent. cardiac cycle and the work done by the right
ventricle is 6-7 times lower than that done by the
158. Plasma protein concentration = 6000 mg/dL left ventricle since pulmonary vascular resistance
CSF protein concentration = 20 mg/dL. Since is that much lower compared to systemic vascular
CSF protein concentration is extremely low, resistance.
protons in brain interstitial fluid readily stimulate
breathing. 164-166.The triple response:
Response Mechanism
159. If the arteriovenous concentration difference Wheal production Increased capillary
of a substance (example, oxygen) across a and venular
vascular bed is high, it means that the vascular permeability
bed extracts a large fraction of this substance. Red reaction Venodilation
Flare Axon reflex
Oxygen extraction ratio across the heart is 0.5-0.7 The white reaction is the response to a benign
at baseline, much higher compared to other stimulus. It occurs due to contraction of
tissues. Cardiac venous oxygen tension is low and precapillary sphincters. The triple response is
little additional oxygen can be extracted from the evoked by a noxious stimulus. With the exception
blood in the coronaries, so increases in myocardial of the flare which is mediated by an axon reflex,
oxygen consumption require increases in coronary the triple response, indeed, is an example of
blood flow. If that cannot happen, myocardial autoregulation.
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E.S.Prakash. Multiple-Choice Questions in Medical Physiology, 2014
167. All organs are capable of autoregulating their
blood flows. Although cerebral vessels have
noradrenergic innervation, cerebral blood flow
itself is not chronically under neural control.
Cerebral blood flow is excellently autoregulated
in the steady state when mean arterial pressure is
between 65 and 140 mm Hg.

Although the heart is also capable of excellent

autoregulation, under certain circumstances,
neural regulatory mechanisms override local
regulatory mechanisms. For example, sudden
excessive discharge in the sympathetic fibers to
the heart can cause severe coronary vasospasm
and a severe reduction in coronary blood flow.

Cutaneous blood flow is most often varied in

response to neural signals from the hypothalamus.
It is the vascular bed that is most consistently
under neural control.

170. BNP is released in response to abnormal

stretch (increased passive tension) of ventricular
myocytes such as in heart failure. In tamponade,
the increase in ventricular diastolic pressure is
because of compression by high intrapericardial
pressure rather than increased stretch of
ventricular myocytes.

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E.S.Prakash. Multiple-Choice Questions in Medical Physiology, 2014