First Aid Flashcards
1
Q
Where does fetal erythropoiesis occur?
A
Yolk sac | 3-8 wks
Liver | 6 wks - birth
Spleen | 10-28 wks
Bone Marrow | 18 wks to adult
2
Q
What is fetal hemoglobin composed of?
A
α2 γ2
3
Q
What is adult hemoglobin composed of?
A
α2 β2
4
Q
Why does HbF have a higher affinity for oxygen?
A
Less avid binding of 2,3-BPG (left shift)
5
Q
Where in the fetal circulation is there the highest concentration of O2
A
Umbilical vein
6
Q
Starting in the umbilical vein, trace the flow of O2
A
Umbilical vein → Ductus venosus → IVC → RA → foramen ovale → LA → Aorta → Body
7
Q
In the fetal circulation, deoxygenated blood flowing into the SVC goes where?
A
RA→ RV → main PA → patent ductus arteriosus → descending aorta
8
Q
What causes the foramen ovale to close?
A
1st breath → ↓resistance in pulmonary vasculature → LAP>RAP
9
Q
What causes the ductus arteriosus to close?
A
↑O2 (respiration) + ↓ prostaglandins (placental separation)
10
Q
What drug can be used to close a PDA? To keep it open?
A
Indomethacin PGE (E1 and E2)
11
Q
What is the fetal structure that turns into the ligamentum teres hepatis, contained in the falciform ligament
A
Umbilical vein
12
Q
What do the umbilical arteries become?
A
Medial umbilical ligaments
13
Q
What does the notochord become?
A
Nucleus pulposus of intervertebral disc
14
Q
What do the ductus arteriosus and ductus venosus become?
A
Ligamentum arteriosum and venosum
15
Q
What does the foramen ovale become?
A
Fossa ovalis
16
Q
What does the allantois become
A
Urachus-median umbilical ligament
17
Q
What supplies the SA and AV nodes?
A
RCA
18
Q
What determines whether a person has Right or Left dominant circulation? Which is more common?
A
Right-dominant = PDA arises from RCA Left-dominant = PDA arises from LCX 85% = right dominant
19
Q
When does coronary blood flow peak?
A
Early Diastole
20
Q
What symptoms can enlargement of the L atrium cause?
A
Dysphagia - presses on esophagus
Hoarseness - compression of L recurrent laryngeal n. (CNX)
21
Q
How do you compensate CO during early exercise? Late exercise?
A
↑ HR and SV
↑ HR only - SV plateaus
22
Q
Which phase is decreased w/ ↑ HR?
A
Diastole - decreased filling time, ↓ preload
23
Q
What things affect Mean Arterial Pressure (MAP)?
A
CO * TPR
24
Q
What things affect Stroke Volume?
A
SV CAP - SV increases w/
Contractility ↑
Afterload ↓
Preload ↑
25
How do you increase contractility?
↑ intracellular Ca
1. Catecholamines: ↑activity of Ca pump in SR
2. ↓extracellular Na: ↓ activity of Na/Ca exchange
3. Digitalis: blocks Na/K pump directly - indirectly blocks Na/Ca exchange
26
Which way does the Na/Ca pump work?
Ca in efflux (leaving) - mostly
| Uses Na gradient in
27
How do you decrease contractility?
1. β1-blockade (↓cAMP)
2. Non-dihydropyridine Ca channel blockers - diltiazem & verapamil
3. HF w/ systolic dysfunction
4. Acidosis
5. Hypoxia/Hypercapnea
28
What does preload depend on?
Ventricular EDV - venous tone and circulating blood volume
29
What class of drugs will decrease preload?
Venodilators - nitroglycerin
30
What does afterload depend on?
MAP
31
How does the heart respond to ↑MAP?
LV hypertrophy
| Wall tension = (P*r)/(2*wall thickness)
32
What 2 classes of drugs will decrease afterload?
Vasodilators - hydralazine
| ACEi/ARBs - ↓preload & afterload
33
How is ejection fraction calculated? What is a normal EF? When is it decreased?
SV/EDV
Normal ≥ 55%
Systolic HF
34
What does the starling curve show?
LVEDV x SV (or CO)
| That changes in inotropy can cause changes in SV outside of preload
35
What is R directly proportional to? Inversely proportional?
1. Viscosity and vessel length
| 2. r^4
36
What accounts for most of the TPR?
Arterioles
37
What does viscosity depend on? When might it be elevated?
Hematocrit
| Polycythemia, hyperproteinemic states (multiple myeloma), aHereditary spherocytosis
38
When does S3 occur?
Early in diastole - ↑filling pressure
Mitral regurg, CHF, dilated ventricles
Normal in children and pregnant women
39
When does S4 occur?
End of diastole - atrial kick
| High atrial pressure, ventricular hypertrophy
40
What does the a wave represent?
Atrial contraction
41
What does the c wave represent?
RV contraction - closed tricuspid valve bulges into atrium
42
What does the x descent represent?
Atrial relaxation - absent in tricuspid regurg
43
What does the v wave represent?
↑ RA pressure due to filling against closed TV
44
What does the y descent represent?
Blood flow from RA to RV
45
What is normal splitting?
A2 and P2 get farther apart w/ inspiration
| ↓intrathoracic pressure → ↑RV SV → ↑ RV ejection time → delayed closure of the pulmonic valve
46
When would you hear wide splitting?
Conditions that delay RV emptying
| Pulmonic stenosis, RBB block
47
When would you hear fixed splitting?
ASD: L→R shunt → ↑RA and RV volumes
| Pulmonic closure is delayed regardless of breath
48
When do you hear paradoxical splitting?
Conditions that delay LV emptying
Aortic stenosis, LBB block
P2 gets closer to A2 on inspiration (paradox)
49
What murmurs are heard during systole?
A/P stenosis
M/T regurgitation
VSD
50
What murmurs are heard during diastole?
A/P regurgitation
| M/T stenosis
51
What murmur is holosystolic, high-pitched "blowing"
M/T regurgitation
52
How could you tell the difference between Mitral and Tricuspid Regurgitation?
Where you hear the murmur
Mitral: enhanced w/ squatting/hand grip (↑TPR)
Tricuspid: enhanced w/ inspiration (↑RA return)
53
What murmur is a crescendo-decrescendo systolic ejection murmur?
Aortic Stenosis - syncope, angina, dyspnea on exertion
54
What murmur is a holosystolic, harsh-sounding murmur?
VSD - tricuspid area
| enhanced w/ handgrip
55
What leads show ST elevation in a lateral infarction
I, aVL, V5, V6
56
What leads show ST elevation in a inferior (RCA) infarction
II, III, avF
| Recip: I, aVL
57
What leads show ST elevation in a anterior (LAD) infarction?
V1-V4
58
What does a high pitched "blowing" early diastolic decrescendo murmur indicate? What other symptoms are seen?
Aortic Regurgitation
| Bounding pulses, head bobbing
59
What are causes of aortic regurgitation? (4)
Aortic root dilatation, bicuspid aortic valve, endocarditis, rheumatic fever
60
What does a late systolic crescendo murmur w/ midsystolic click indicate?
Mitral valve prolapse - click due to sudden tensing of chordae tendineae
61
What does a delayed rumbling, late diastolic murmur, following an opening snap indicate?
Mitral Stenosis
62
What does a continuous machine-like murmur, loudest at S2 indicate? What can cause this?
PDA
| Congenital rubella or prematurity
63
ANP
Released from atrial myocytes in response to ↑BV and ↑atrial pressure
Vasodilation, ↓Na reabsorption, promotes diuresis (cGMP)
64
BNP
Released from ventricular myocytes in response to ↑tension
| Used to diagnose HF
65
What baroreceptor responds to both ↑BP and ↓BP?
Carotid sinus (IX) - Aortic arch (X) only responds to ↑BP
66
Which chemoreceptors respond to ↓PO2, ↓pH and ↑PCO2?
Peripheral chemoreceptors - central don't respond to PO2
67
What organ has the largest blood flow?
Lung
68
What organ has the largest share of systemic CO?
Liver
69
What organ has the highest BF/g of tissue?
Kidney
70
What organ has the largest AV O2 difference?
Heart - O2 extraction ~80%
| ↑O2 demand met w/ ↑BF — not ↑ extraction
71
How does the heart autoregulate BF?
Local metabolites (VD) CO2, adenosine, NO
72
How does the brain autoregulate?
Local metabolites (VD) CO2 (pH)
73
How do the kidneys autoregulate BF?
Myogenic and tubuloglomerular feedback
74
How do the lungs autoregulate BF?
Hypoxia ➞ Vasoconstriction
75
How does skeletal muscle autoregulate BF?
Local metabolites: lactate, adenosine, K, H, CO2
76
How does skin autoregulate?
Sympathetic stimulation is most important mechanism—temperature control
77
What are the 5 congenital R→L shunts?
1. Persistant truncus arteriosus
2. D-transposition of great vessels
3. Tricuspid atresia
4. Tetralogy of Fallot
5. Total anomalous pulmonary venous return
78
What two congenital heart defects are more commonly seen with DiGeorge?
1. Persistant Truncus Arteriosus
| 2. Tetralogy of Fallot
79
Most persistant truncus atertiosus (PTA) patients have what accompanying defect?
VSD
80
What do D-transposition of great vessels patients need in order to be compatible with life?
VSD, PDA, or patent foramen ovale
81
What do patients with tricuspid atresia require?
ASD and VSD
82
What 4 things make up the Tetralogy of Fallot?
1. VSD
2. Overriding aorta
3. Pulmonary infundibular stenosis - prognostic
4. RVH
83
What other cardiac anomaly is associated w/ TAPVR?
ASD or PDA
84
What are the congenital L→R shunts?
1. VSD
2. ASD
3. PDA
85
What is the most common congenital cardiac defect?
VSD - asymptomatic → present weeks after birth
86
Where do ASDs most commonly occur?
90% Septum secundum
| Septum primum = Down syndrome
87
How does a PDA present?
Late cyanosis in lower extremities
88
Eisenmenger Syndrome
Uncorrected L→R shunts will ↑pulmonary BF
- Pulmonary HTN
- RVH
Shunt becomes R→L
Cyanosis, clubbing, polycythemia
89
Infantile coarctation of the aorta present with lower extremity cyanosis and is associated w/ what disease?
Turner Syndrome - Maintain PDA w/ IGE
90
Adult type coarctation of the aorta results in what symptoms?
HTN in upper extremities
Delayed pulses in lower extremities
Notching of ribs - collateral circulation
91
What cardiac defects can Down Syndrome cause?
ASD, VSD, AV septal defect - endocardial cushion
92
What cardiac defects can congenital rubella cause?
Septal defects, PDA, pulmonary artery stenosis
93
What cardiac defects can Turner syndrome cause?
Bicuspid aortic valve
| Coarctation of the aorta (preductal)
94
What cardiac defects can Marfan syndrome cause?
MVP, thoracic aortic aneurysm/dissection, aortic regurgitation
95
90% of HTN is primary and related to what?
↑CO or ↑TPR
96
What are risk factors for HTN?
Age, obesity, diabetes, smoking, genetics,
| Black > white > asian
97
Hypertensive Emergency
≥180/120
98
What are causes of 2˚ HTN?
1. Renal disease
| 2. Fibromuscular dysplasia
99
What are 3 signs of hyperlipidemia?
1. Xanthomas - lipid laden histiocytes in skin (eyelids)
2. Tendinous xanthoma - achilles
3. Corneal arcus
100
Hyaline arteriolosclerosis is to _________________ as a hyperplastic arteriolosclerosis is to _________________.
```
Hyaline = essential HTN or diabetes (thickening)
Hyperplastic = Severe HTN (onion-skinning)
```
101
Monckeberg (medial calcific sclerosis)
```
Calcification of the media of arteries (radial/ulnar)
Pipestem arteries (X-ray)
```
102
Atherosclerosis
Disease of large and medium-sized muscular arteries
103
What are modifiable risk factors for atherosclerosis?
Smoking, HTN, hyperlipidemia, diabetes
104
What 3 things can trigger variant angina (prinzmetal)? How do you treat?
Cocaine, tobacco, triptans
| Ca channel blockers, nitrates, smoking cessation
105
What three things lead to sudden cardiac death?
Causes lethal arrhythmia i.e. v. fib - w/i 1 hr. of symptoms
1. CAD | 70%
2. CM
3. Hereditary ion channelopathies
106
What are the most commonly occluded coronary arteries?
LAD>RCA>Circumflex
107
When is the greatest risk of developing a fatal arrhythmia post MI?
0-24 hrs
108
When is the greatest risk of developing fibrinous pericarditis post MI?
1-3 days
109
When is the greatest risk of developing rupture problems post MI?
3-14 days - Mφ
110
When is the greatest risk of developing Dressler syndrome post MI?
Several weeks after - autoimmune fibrinous pericarditis
111
Which infarct is most likely to result in mitral regurgitation?
Posterior Descending Artery (RCA) - Inferior
112
What are the causes of Dilated CM?
```
ABCCCD
Alcohol abuse
Wet Beriberi (B1)
Coxsackie B virus myocarditis
Cocaine use
Chagas disease
Doxorubicin toxicity
```
113
What are findings of DCM?
S3, systolic dysfunction
Dilated heart on ECHO
Balloon appearance of heart on CXR
114
What are findings of HCM?
S4, diastolic dysfunction
| Obstructive: dyspnea, possible syncope
115
What two CM can hemochromatosis cause?
Dilated and Restrictive
116
What is the mutation involved in HCM? How is it inherited?
β-myosin heavy-chain | AD
117
What are the major causes of Restrictive CM?
Sarcoidosis, amyloidosis, postradiation fibrosis, endocardial fibroelastosis, Loffler Syndrome (eosinophils), hemochromatosis
118
What two CM result in diastolic dysfunction?
Restrictive and Hypertrophic
119
What are 3 key symptoms of left HF?
1. Pulmonary edema
2. Orthopnea
3. Paroxysmal nocturnal dyspnea
120
What are 3 key symptoms of right HF?
1. Hepatomegaly - nutmeg liver
2. Peripheral edema
3. JVD
121
What drugs are shown to ↓ mortality in CHF?
ACE Inhibitors, β-blockers, ARBs, Spironolactone
122
What is associated w/ Aschoff bodies (granuloma w/ giant cells) containing Anitschkow cells (enlarged Mφ w/ caterpillar nucleus)?
Rheumatic Fever
123
What are the most likely causes of Culture negative bacterial endocarditis?
Coxiella burnetti and Bartonella spp.
124
How would acute pericarditis present?
Sharp pain worse w/ inspiration better when sitting up/leaning forward
Friction rub
Widespread ST elevation and/or PR depression
125
Dressler syndrome, uremia and radiation will cause what type of pericarditis?
Fibrinous - loud friction rub
126
Viral pericarditis and non-infectious inflammatory disease (SLE/RA) will cause what type of acute pericarditis?
Serous
127
Bacterial infections (pneumococcus and streptococcus) will cause what type of pericarditis?
Suppurative/purulent
128
The triad of hypotension, distended neck veins and distant heart sounds is known as the Beck Triad and is commonly seen in what?
Cardiac tamponade
↑HR, pulsus paradoxus, Kussmaul sign
Low voltage QRS
129
What other diseases will have pulsus paradoxus?
≥10 mmHg drop systolic during inspiration
| Cardiac tamponade, asthma, OSA, pericarditis, croup
130
Tree bark appearance of the aorta is synonymous with what disease?
Syphilitic heart disease - vasa vasorum
Ascending Aorta Aneurysm
Aortic Arch Aneurysm
Aortic insufficiency
131
What is the most common heart tumor?
Mets - melanoma, lymphoma
132
What is the most common 1˚ cardiac tumor in adults?
Myxoma - 90% in atria
| "ball valve" obstruction
133
What is the most frequent 1˚ cardiac tumor in kids, what is it associated with?
Rhabdomyoma - tuberous sclerosis
134
Kussmaul sign is an ↑ in JVP on inspiration (instead of a normal ↓) - what diseases is this seen in?
Neg. pressure not transmitted to heart
1. Constrictive pericarditis
2. Restrictive CM
3. RA or RV tumors
135
Raynaud disease (1˚) and Raynaud syndrome both involve a arteriolar vasospasm in response to cold temperatures - in what diseases is this found?
1. SLE
2. CREST
3. Mixed CT disease
136
Strawberry hemangioma
Benign capillary hemangioma of infancy
- grows rapidly
- regresses at 5-8 yrs
137
Cherry hemangioma
Benign hemangioma of the elderly - does NOT regress
138
Pyogenic granuloma
Polypoid capillary hemangioma that can ulcerate/bleed -associated w/ trauma and pregnancy
139
Cystic hygroma is a cavernous lymphangioma of the neck, what is it associated with?
Turner Syndrome
140
Glomus tumor is a benign, painful red-blue tumor under fingernails that arises from what structures?
Modified smooth muscle cells of glomus body
141
Bacillary angiomatosis is a benign capillary skin papules found in ______ patients, that is caused by what bug?
AIDS
| Bartonella henselae
142
Angiosarcoma
Rare blood vessel malignancy typically occurring in the head, neck, and breast areas.
Elderly, sun exposed areas
Assoc. w/ radiation therapy and arsenic
Aggressive and difficult to resect
143
What is lymphangiosarcoma, and what is a common circumstance in which it might arise?
Lymphatic Malignancy - associated w/ persistant lymphedema e.g. post radical mastectomy
144
What is kaposi sarcoma, and what bugs is it associated with?
Endothelial malignancy of skin - also mouth, GI tract, respiratory tract
HHV-8 and HIV
145
What two diseases belong to the large vessel-vasculitis category?
1. Temporal (giant cell) arteritis
| 2. Takayasu arteritis
146
What are symptoms of Temporal (giant cell) arteritis, who usually gets it, and what would a biopsy show?
Unilateral headache and jaw claudication
Elderly females
Focal granulomatous inflammation - branch of carotid
147
How do you treat Temporal (giant cell) arteritis?
High-dose corticosteroid prior to temporal artery biopsy
148
Who gets Takayasu Arteritis and what are its symptoms?
Young asian women
| Pulseless disease, neurologic disturbances
149
What is Takayasu Arteritis?
Graunulomatous vasculitis that involves the aortic arch at branch points
150
What 3 diseases are considered medium-vessel vasculitis (muscular arteries)
1. Polyarteritis Nodosa
2. Kawasaki Disease
3. Buerger Disease
151
What is Polyarteritis Nodosa and how does it present in young adults?
Necrotizing vasculitis involving multiple organs NOT lungs
1. HTN (renal artery)
2. abdominal pain w/ melana (mesenteric artery)
3. Neurologic disturbances
4. Skin lesions
* Assoc. w/ serum HBsAg
152
In polyarteritis nodosa early lesions progress from transmural inflammation with fibrinoid necrosis to fibrosis with a ________________ appearance on imaging.
String of pearls
153
How do you treat polyarteritis nodosa?
Corticosteroids and cyclophosphamide
154
Who does Kawasaki Disease develop in and what are the symptoms?
Asian children < 4
Non specific: Fever, conjunctivitis, erythematous rash of soles and palms, "strawberry tongue", and enlarged cervical LN
*viral-like
155
What blood vessel is involved in Kawasaki Disease?
Coronary artery
| -risk for aneurysm, thrombosis, MI, rupture
156
How do you treat Kawasaki Disease?
Aspirin & IVIG
157
What is Buerger disease? Who gets it?
Necrotizing vasculitis involving digits
| Heavy male smokers <40yo
158
What four diseases are considered small-vessel vasculitis?
1. Granulomatosis w/ polyangiitis
2. Microscopic polyangitis
3. Churg-Strauss Syndrome
4. Henoch-Schonlein purpura
159
What is Churg-Strauss syndrome? What are its symptoms
Granulomatous necrotizing vasculitis w/ eosinophilia
| Asthma, sinusitis, palpable purpura, peripheral neuropathy
160
What is the most common childhood systemic vasculitis
Henoch-Schonlein Purpura
161
How does Henoch-Schonlein Purpura present?
Post URI - vasculitis 2˚ to IgA complex deposition
1. Palpable purpura on buttocks/legs
2. Arthralgias
3. Abdominal pain, melana
162
What is the triad seen in Granulomatosis with polyangiitis?
1. Focal necrotizing vasculitis
2. Necrotizing granuloma in lung and upper airway - hemoptysis, cough, chronic sinusitis, otitis media
3. Necrotizing glomerulonephritis - hematuria
163
How do you treat Granulomatosis with polyangiitis?
Cyclophosphamide, corticosteroids
164
What is the difference between Granulomatosis with polyangiitis and Microscopic Polyangiitis?
Microscopic polyangiitis doesn't have nasopharyngeal involvement, no granulomas
MPO-ANCA/p-ANCA (anti-myeloperoxidase)
165
Which 2 small vessel vasculitis have MPO-ANCA/p-ANCA?
1. Microscopic polyangiitis
| 2. Churg Strauss syndrome
166
What antibody does Granulomatosis with polyangiitis have?
PR3-ANCA/c-ANCA (anti-proteinase 3)
