Brainscape's Knowledge GenomeTM


Top Flashcards (Certified)
All Flashcards

1 REVISION Bismillah > 7. Cardiac Physiology - Beth Phillips > Flashcards

7. Cardiac Physiology - Beth Phillips Flashcards

1
Q

Right side of the heart

  1. What kind of blood comes in?
  2. Through what?
  3. What valve is between the atrium and ventricle?
  4. What vessel does the blood come out from? Through which valve?
A
  1. Deoxygenated blood
  2. Superior and inferior vena cava
  3. Tricuspid valve
  4. Through the pulmonary valve into the pulmonary artery
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Left side of the heart

  1. What kind of blood comes in?
  2. What valve is between the atrium and ventricle?
  3. What vessel does the blood come out from? Through which valve?
A
  1. Oxygenated blood
  2. Mitral valve AKA bicuspid valve
  3. Aortic valve into aorta
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Coronary circulation

  1. What does the coronary circulation supply?
  2. Explain the 2 things the right coronary artery branches into
  3. Explain the 2 things the left coronary artery branches into
A
  1. Heart
  2. Marginal branch and posterior inter-ventricular branch
  3. Circumflex branch and anterior inter-ventricular branch
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Explain the 5 steps of heart muscle conduction

A 
SA node
AV node
AV bundle (bundle of His)
Right and left bundle branches
Purkinje fibres
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Cardiac muscle

  1. What type of muscle is it?
  2. What is contraction dependent on?
  3. What is a sarcomere?
  4. What is a myofibril?
  5. Explain a H zone, an I band and an A band
  6. What are thick filaments mainly made of? What are thin filaments mainly made of?
A
  1. Striated
  2. Calcium and ATP
  3. Smallest functional unit of any striated muscle
  4. Sarcomeres end to end
  5. H zone = part in middle (only thick band)
    I band = thin filaments connecting on adjoins sarcomeres (no thick)
    A band = whole thick and the thin that it overlaps with
  6. Thick = myosin
    Thin = actin
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Cardiac myocytes

  1. Explain cardiac myocytes in 3 ways. Explain the syncytium aspect.
  2. Define intercalated discs
  3. Define gap junctions
  4. Define connexons
A
  1. Small cell, single nucleus, mitochondria take up 30-40% of cell
    Work as functional syncytium but are not a structural syncytium
  2. Electrical boundaries between cells with leaky gap junctions
  3. Electrical pores made of proteins
  4. Charged aqueous pores
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Action potentials

  1. What is the rating membrane potential of all cells?
  2. Membrane permeability to which ions causes depolarisation?
  3. Membrane permeability to which ions causes repolarisation?
  4. What is the part of an action potential called where the line is going from polarised to reaching the threshold?
A
  1. Electronegative
  2. Sodium and calcium
  3. Potassium
  4. Pacemaker potential
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Autonomic control

  1. Higher brain centres and sensory receptors send input to where?
  2. From there, the output to the heart goes via the SNS or the PNS. What does the SNS release and on which receptor? What does this lead to an increase in?
  3. What does the PNS release and on which receptor? What does this lead to a decrease in?
A
  1. Cardiovascular centre
  2. Nor-adrenaline on beta1-adrenoreceptors
    Leading to an increase in HR, spontaneous depolarisation in SA and AV node, contractility and stroke volume
  3. Acetylcholine on muscarinic receptors
    Leading to a decrease in HR and spontaneous depolarisation in SA and AV node
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What do the following do to the slope of the pacemaker potential:

  1. Sympathetic tone
  2. Parasympathetic tone
A
  1. Increases slope

2. Decreases slope

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q
  1. Define ECG
  2. What kind of recordings are these?
  3. What is a galvanometer?
  4. What is a dipole?
A
  1. Recording of electrical activity of the heart which represents mechanical activity
  2. Extracellular recordings
  3. Detects, measures and determines direction of small electrical currents
  4. Difference in charge between one bit of the membrane and another
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What kind of deflection would happen in the following cases?

  1. Depolarisation moving towards unipolar electrode (or towards + pole of bipolar lead)?
  2. Depolarisation moving away from unipolar electrode (or away from + pole of bipolar lead)?
  3. What is the case for repolarisation?
A
  1. Positive upward deflection
  2. Negative downward deflection
  3. Opposite for repolarisation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Explain the places where the 10 electrodes are placed, naming each electrode (point out which one is the neutral electrode)

A 
R wrist / L wrist
R ankle (neutral) / L ankle
V1 = 4ICS R sternum
V2 = 4ICS L sternum
V3 = between V2 and V4
V4 = 5ICS L mid-clavicle
V5 = 5ICS L axilla start
V6 = 5ICS L mid-axilla
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Which leads are bipolar? Which leads are unipolar?

A

Bipolar leads = leads 1, 2 and 3

Unipolar leads = leads aVR, aVL, aVF

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Einthoven’s triangle - limb electrodes

  1. What is each corner?
  2. What is lead 1? What is lead 2? What is lead 3?
  3. What are the labels inside the triangle? How do they work?
  4. Where are the other 6 leads from? What are they called?
A
  1. Right arm / left arm / left leg
  2. Lead 1 = LA to RA
    Lead 2= LL to RA
    Lead 3 = LL to LA
  3. aVR (right arm) / aVL (left arm) / aVF (left foot)
    They compare their own spot with the average of the other 2
    Eg. aVF compares LL to average of LA and RA
  4. 6 chest leads (V1-V6)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q 
ECG and heart regions 
Describe what part of the heart each of these sections represents:
V5, V6
aVL
1
aVF
2 
3
V2, V3, V4
V1
A 
V5, V6 = left side of the heart - lateral leads
aVL = upper left side of heart
1 = second high lateral lead
aVF = inferior wall of heart
2 = second inferior lead
3 = third inferior lead
V2, V3, V4 = anterior face of heart 
V1 = septal leads (with V2)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

ECG recording

  1. What 2 things do you need to be careful of when placing electrodes?
  2. What 3 things should the patient be doing?
  3. What else do you need to keep in mind when using an ECG machine?
A
  1. Accurate placing (no crossed cables)
    Contact with skin (may require shaving)
  2. Patient relaxed (pain free), not moving and not talking
  3. Electrical interference
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

P wave

  1. What does it show?
  2. Which atrial activation starts first?
  3. Size of muscle? Amplitude?
A
  1. Atrial depolarisation
  2. Right
  3. Small hence small
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

PR interval

  1. What does it show?
  2. It is measured from the start of the P wave up until when?
  3. Normal duration?
A
  1. Conduction through AV node, Bundle of His and Purkinje fibres
  2. First deflection of QRS complex
  3. 0.12-0.20 secs
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

QRS complex

  1. What does it show?
  2. Large muscle mass of what? Results in what?
  3. Normal duration?
A
  1. Ventricular depolarisation
  2. Left ventricle
    QRS predominantly representing LV
  3. Less than 120 ms
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Q wave

  1. What is it?
  2. Normal depth? Normal duration?
A
  1. Any initial negative deflection
  2. Less than 2mm
    Less than 40 ms
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

ST segment

  1. What does it show?
  2. What is the muscles status at this point?
  3. Usual depth?
A
  1. End of ventricular depolarisation to beginning of repolarisation
  2. Muscle is depolarised and contracting
  3. Level or +- 1mm from baseline
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

QT interval

1. What does this show?

A
  1. Total time for depolarisation and repolarisation of the ventricles
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

T and U wave

  1. What does the T wave show?
  2. Rarely exceeds what depth?
  3. What is the U wave? Do many ECGs have a discernible U wave?
A
  1. Ventricular repolarisation
  2. 10mm
  3. Small deflection after T wave
    No
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

What 2 types of cells does the heart contain and which one is 99% of them? What does each one do?

A 
Contractile cells (99%)
Mechanical work

Autorhythmic cells
Initiate and conduct action potentials for contractile cells

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q
  1. Where is the SA node?
  2. Where is the AV node?
  3. Explain the travel of the Bundle of His (AV bundle)
  4. Where are the Purkinje fibres?
  5. Which valves are open during ventricular diastole?
  6. Which valves are open during ventricular systole?
A
  1. Right atrial wall near opening of superior vena cava
  2. Base of right atrium, near septum
  3. AV node to IV septum-divides into right and left bundle branches- curve around ventricle walls back towards atria
  4. Bundle of His and spread throughout ventricular myocardium
  5. Bicuspid and tricuspid
  6. Pulmonary and aortic
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Wall of ventricle

  1. What are the 2 sections either side of the mid-wall called? Which direction do the fibres run in and towards what?
  2. Which cells are activated slightly quicker?
A
  1. Subendocardial section
    Fibres run away from mid-wall towards subendocardial surface

Subepicardial section
Fibres run away from mid-wall towards epicardium surface

  1. Endo cells
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

3 distinct layers of heart: epicardium, myocardium and endocardium

  1. Describe the epicardium
  2. What is the myocardium composed of?
  3. Describe the endocardium. What type of tissue is it made of?
A
  1. Thin external membrane that covers the heart
  2. Cardiac muscle
  3. Thin inner layer made of endothelium
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Phases of the cardiac cycle

  1. Because there are 2 sides of the heart, what does that make the cardiac cycle?
  2. Which side has more pressure?
  3. Define stroke volume
  4. Define ejection fraction
A
  1. A tandem
  2. Left side
  3. Stroke volume = amount of blood ejected by the left ventricle in 1 contraction
  4. Ejection fraction = fraction of outbound blood pumped from the heart with each heartbeat
29
Q

Phases of the cardiac cycle
1. Name the 3 phases in order
Name the 7 sub phases within it

A 
1. Diastole
Atrial systole
2. Systole
Isovolumetric contraction
Rapid ejection
Reduced ejection
3. Diastole
Isovolumetric relaxation
Rapid ventricular filling 
Reduced ventricular filling
30
Q

Phases of the cardiac cycle

  1. Which stage is the first heart sound heard? Which valves are closing? This also causes what?
  2. Which stage is the second heart sound heard? Which valves are closing
A 
1. Stage 2 = isovolumetric contraction
AV valves 
Associated blood turbulence 
2. Stage 5 = isovolumetric relaxation 
Semi lunar valves
31
Q

Common valvular problems

  1. What is mitral stenosis? This leads to a back up of blood where? What else does this mean?
  2. What is aortic stenosis? What does this lead to?
  3. What 2 things can cause mitral regurgitation?
A
  1. Incomplete opening of mitral valve = back up of blood in left atrium and inadequate ventricle filling
  2. Incomplete opening of aortic valve = inadequate ventricle emptying
  3. Mitral valve closes but can’t fully prevent back flow of blood during contraction
    Or
    Mitral valve doesn’t close properly
32
Q
  1. Define arterial BP
  2. What are the 2 reasons for having this pressurised system?
  3. Aortic pressure rises to a peak pressure of what during LV contraction?
  4. Aortic pressure falls to a minimum pressure of what during LV relaxation?
  5. What is the small blip in the pressure profile called when the aortic valve closes?
A
  1. Hydrostatic pressure generated on arterial wall by hearts pumping action
  2. Blood can flow around body and also blood can flow against gravity
  3. 120 mmHg
  4. 80 mmHg
  5. Dichroic notch
33
Q

Mean arterial BP

  1. What is the equation for pulse pressure?
  2. What is the equation for mean arterial blood pressure?
  3. Define MABP
A
  1. PP = systolic BP - diastolic BP
  2. MABP = diastolic BP + 1/3 pulse pressure
  3. Average pressure exerted by the blood on the walls of the major arteries
34
Q

Efferent blood vessels

  1. Describe the wall of the artery
  2. Describe the wall of the arteriole
  3. Describe the wall of the capillary
A
  1. Muscular and elastic
  2. Muscular
  3. Thin walled
35
Q
  1. Define cardiac output
  2. What does TPR stand for?
  3. What is the equation for CO?
  4. How can you work out MABP using Ohm’s law?
A
  1. Volume of blood ejected from the heart per minute
  2. Total peripheral resistance
  3. CO= HR x SV
  4. MABP = TPR x (HR x SV)
36
Q
  1. What 4 things affect arterial BP?
  2. What 3 things increase MABP?
  3. What 3 things decrease MABP?
  4. In what 2 ways does the body maintain the correct BP, and what is their time?
A
  1. Circulatory volume/ force of ventricular contraction/ elasticity of arteries/ peripheral resistance
  2. increased HR/ increased fluid retention by kidneys/ polycythaemia
  3. Dilation of blood vessels/ reduced force of ventricular contraction/ dehydration
  4. Baroreceptor reflex (immediate)
    Endocrine system (over days/weeks)
37
Q

Baroreceptors

  1. What kind of receptors are they?
  2. Which 2 places are they found?
  3. Where do they send the information to?
  4. They increase MABP by increasing what 2 things?
  5. How do they increase TPR?
A
  1. Pressure receptors
  2. Wall of arch of aorta / carotid sinus
  3. Central nervous system
  4. HR and SV
  5. Constrict blood vessels
38
Q

What 3 things does angiotensin 2 do to increaseTPR, MABP, CO and circulating blood volume?

A
  1. Constricts blood vessels
  2. Stimulates and promotes ADH release
  3. Stimulates aldosterone release
39
Q

What is the 8 step systematic method of reading an ECG?

A
  1. Any electrical activity?
  2. What is the HR?
  3. QRS rhythm: regular/irregular?
  4. QRS duration: normal/prolonged?
  5. Atrial activity present?
  6. How is atrial activity related to ventricular activity?
  7. ST segment: raised/ depressed
  8. Any Q waves?
40
Q

What are 6 common symptoms associated with arrhythmia presentation?

A 
Palpitations
Dizziness
Chest pain
Dispnea
Syncope
Sudden cardiac events
41
Q

What are the 3 principle methods for arrhythmia formation?

A
  1. Disordered impulse formation
  2. Disordered impulse conduction
  3. Combined disorder
42
Q

Sinus bradycardia

  1. Describe it
  2. Rate?
  3. Patient?
  4. Name 2 causes

(RR intervals constant and regular/ all wave forms present/ one P wave to each QRS complex)

A
  1. Normal sinus rhythm and conduction, but slowed down
  2. Less than 60bpm (not less than 40bpm)
  3. Asymptomatic
  4. Beta blockers or calcium channel blockers
43
Q

Sinus tachycardia

  1. Describe it
  2. Rate?
  3. Patient?
  4. Name 3 causes

(RR intervals constant and regular/ all wave forms present/ one P wave to each QRS complex)

A
  1. Normal sinus rhythm and conduction, faster
  2. More than 100bpm (not more than 130)
  3. Asymptomatic
  4. Stress/ exercise/ hypovolaemia
44
Q

Sinus arrythmia

  1. What kind of sinus rhythm?
  2. How much does the PP interval vary by?
  3. 2 causes?
  4. If respiratory: what will happen to the PP interval with inspiration?
A
  1. Regularly irregular
  2. More than 10%
  3. Naturally occurring/heart damage
  4. Shortens
45
Q

Atrial fibrillation

  1. What kind of rhythm?
  2. Absence of what 2 things?
  3. AV conduction?
  4. 2 causes?
  5. Often associated with which 3 symptoms?
A
  1. Irregularly irregular
  2. No P waves or isolectric baseline
  3. Variable AV conduction
  4. COPD/CHF
  5. Palpitations/ fainting/ chest pain
46
Q

1st degree heart block

  1. What is wrong in this case?
  2. Patient?
  3. What should you do if metabolic disturbance is suspected?
  4. Increases risk of what 3 things?
A
  1. PR interval longer than 0.20 seconds
  2. Usually asymptomatic
  3. Check U&Es
  4. AF/ pacemaker use and all-cause mortality
47
Q

Second degree heart block

  1. Mobitz type 1: what is wrong here? What happens next? Where does it occur?
  2. Mobitz type 2: what is wrong here? PR interval? Where does it occur? What can it lead to? What is common treatment?
A
  1. PR interval progressively longer until 1 P wave is blocked
    Cycle begins again after blocked P wave
    Occurs in AV node
2. Some P waves not conducted to the ventricles
PR interval constant
Occurs below Bundle of His
Leads to 3rd degree heart block
Common treatment = external pacing
48
Q

Third degree heart block

  1. What is wrong here?
  2. HR?
  3. PR interval?
  4. P waves and QRS complex?
  5. What does it require?
  6. Common treatment?
A
  1. All impulses from atria are blocked by the AV node
  2. Slow HR
  3. PR interval = random
  4. No relationship between P wave and QRS complex
  5. Requires subsidiary pacemakers in ventricles to act
  6. Common treatment = external pacing
49
Q

Ectopics

  1. What are they?
  2. What are 2 main types and what do they mean?
A
  1. Premature impulses in cardiac cycle
  2. Atrial ectopics (premature atrial contractions)
    Ventricular ectopics (premature ventricular contractions)
50
Q

Starlings forces

  1. What are they also known as?
  2. What do they determine?
A
  1. Passive forces

2. How much fluid leaves plasma and enters interstitial fluid (and vice versa)

51
Q

Diffusion

  1. Definition?
  2. Happens through what 3 things?
  3. Describe oxygen and nutrient movement through diffusion
  4. Describe carbon dioxide movement through diffusion
A
  1. Movement of ions/molecules/particles down a concentration gradient
  2. Intracellular clefts/ fenestrations/ endothelial cells
  3. From blood to interstitial fluid to body cells
  4. From body cells to interstitial fluid to blood
52
Q

Transcytosis

  1. Definition
  2. What 2 ways are used to enter and leave the endothelial cells?
  3. What kind of molecules is transcytosis important for?
A
  1. Transport of large, insoluble molecules by pinocytotic vesicles
  2. Endocytosis and exocytosis
  3. Large lipid-insoluble molecules
53
Q

Define bulk flow

A

Passive movement of a large number of ions, molecules or particles in a fluid moving in the same direction down a pressure gradient

54
Q

Normal Starlings forces

  1. What 2 acronyms are inside the vessel?
  2. What 2 acronyms are outside the vessel?
  3. How often is lymph formed? Where does the lymphatic system drain back into?
  4. Which 2 forces promote fluid filtration?
  5. Which 2 forces promote fluid reabsorption?
A
  1. BCOP + CHP
  2. ICOP + IHP
  3. Lymph formed daily
    Drains back into blood
  4. CHP + ICOP
  5. BCOP + IHP
55
Q

Starlings forces

  1. What does BCOP stand for?
  2. What does CHP stand for?
  3. What does ICOP stand for?
  4. What does IHP stand for?
  5. Which 2 forces promote fluid filtration?
  6. Which 2 forces promote reabsorption?
A
  1. Blood colloidal osmotic pressure
  2. Capillary hydrostatic pressure
  3. Interstitial colloidal osmotic pressure
  4. Interstitial hydrostatic pressure
  5. CHP + ICOP
  6. BCOP + IHP
56
Q

Net filtration pressure

  1. Definition
  2. Equation?
  3. What 2 places do you calculate it at?
A
  1. Balance of starlings forces
  2. NFP= fluid filtration - reabsorption
  3. Arterial end and venous end
57
Q
  1. What also effects NFP?
  2. What is it numerically?
  3. How do we add it to the NFP equation?
  4. What does this give us?
A
  1. Changes in capillary permeability
  2. K(small)f = capillary filtration coefficient
  3. NFP = (filtration - reabsorption) X Kf
  4. True net filtration pressure
58
Q

What are the 3 types of capillaries? Describe them briefly

A
  1. Continuous: endothelial cell membranes formed from a continuous tube
  2. Fenestrated: with fenestrations/pores
  3. Sinusoids: wider and more winding, usually with larger fenestrations
59
Q

Oedema

  1. Define oedema
  2. Which 3 places is it most commonly seen?
  3. What is it called in the pleural cavity?
  4. What is it called in the peritoneal cavity?
  5. Give 2 characteristics of localised oedema
  6. Give 2 characteristics of diffuse oedema
A
  1. When net fluid movement exceeds lymphatic drainage
  2. Subcutaneous tissue, lungs and brain
  3. Hydrothorax
  4. Ascites
  5. Influenced by gravity/ dependent
  6. Severe/ non-dependent
60
Q

Etiology of extracellular oedema

Name the 2 possible reasons for extracellular oedema and give 2 causes for each

A
  1. Lymphatic failure
    Obstruction by cancer / surgery
  2. Abnormal fluid leakage across capillary wall
    Infection / tissue injury
61
Q

Etiology of Intracellular oedema

  1. What is the cause? What does this lead to?
  2. What will this then stimulate?
  3. Name 4 consequences as a result of this
A
  1. Cellular pathological consequence
    Leads to cellular damage
  2. Stimulates the inflammatory response
  3. Impaired function of plasma membrane ATP dependent sodium pump
    Increased sodium and calcium influx and increased potassium efflux
    Increased water influx
    Cellular swelling and membrane blebs
62
Q

What 2 things can prevent oedema formation?

A
  1. Pressure changes in the interstitial fluid

2. Reactive lymph flow

63
Q

Promoting oedema formation in ECF

  1. Increase in which 3 things of starlings forces?
  2. decrease in which 3 things of starlings forces?
A
  1. Kf / CHP / ICOP (the filtration aspect)

2. Lymphatic drainage / BCOP / IHP (the reabsorption aspect)

64
Q

Causes of oedema - increased hydrostatic pressure

Give 3 methods and 1 cause for each one

A
  1. Excessive renal retention of salt and water
    (Excessive salt intake)
  2. Impaired venous return
    (Venous obstruction)
  3. Arteriolar dilation
    (Heat)
65
Q

Causes of oedema - decreased plasma proteins

Give 3 methods of this and give a cause for each one

A
  1. Loss of proteins in the urine
    (Nephrotic syndrome)
  2. Loss of protein from denuded skin
    (Burns)
  3. Failure to produce proteins
    (Liver disease)
66
Q

Causes of oedema - lymphatic blockage

Give 3 ways this can happen

A
  1. Inflammatory infections
  2. Neoplastic masses
  3. Treatments
67
Q

Causes of oedema - increased capillary permeability

Name 3 ways in which this can happen

A

Immune reactions
Toxins
Bacterial infections

68
Q

Left hand side heart failure

  1. If the LHS is weakened, it is difficult to pump blood to which circulation?
  2. There is back up behind which part of the heart?
  3. Where does fluid accumulate because of this?
  4. Which pressure rises?
  5. What does this cause?
A
  1. Systemic circulation
  2. Left ventricle
  3. Lungs
  4. Pulmonary vascular pressure
  5. Pulmonary oedema
69
Q

Right hand side heart failure

  1. If the RHS is weakened, pumping of blood to what is weakened?
  2. What kind of congestion does this cause?
  3. What does this result in? What is this also known as?
A
  1. To the lungs
  2. Venous congestion
  3. Peripheral oedema AKA pitting oedema

1 REVISION Bismillah (13 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions