Malignant HTN Roop/Jaffe

Question 1

A 40-year-old-male patient presents to his primary care physician complaining of blurred vision and headaches. He has a six-year history of HTN and hyperlipidemia. The pt. has been non-compliant and so his HTN has been poorly controlled. He works in a manufacturing plant and has smoked 1 pack of cigarettes/dy x 20 years. Vital signs: Temp. = 98.6◦F, Pulse = 68/min, Resp. = 22/min, BP = 210/150 mmHg in all four extremities, BMI = 28. The pt. is anxious and complains of an inability to concentrate because of the headaches. He does not remember urinating during the past day and is unable to provide a urine sample for analysis. A presystolic murmur (fourth heart sound) is heard. What is a fourth heart sound?

Answer 1

-S4, atrial gallop, occurs just before S1 when the atria contracts to force blood into the L ventricle
-If the left ventricle is noncompliant, and atrial contraction forces blood through the atrioventricular valves, a S4 is produced by the blood striking the left ventricle
-Low ventricular sound in late diastole, caused by the atrial kick into a non-compliant ventricle

Question 2

S4 is only heard in….

Answer 2

children, very small adults, or elderly

Can also be seen in pts w/ stiffened L ventricles, resulting from conditions like HTN, aortic stenosis, ischemic/hypertrophic cardiomyopathy, or acute MI

In pts w/ mitral regurgitation, this can be suggestive of acute onset of regurg due to the rupture of the chorda tendinae that anchors the valvular leaflets

Question 3

Non-compliance of ventricle can be caused by overexertion (from HTN) = ?

Answer 3

ventricular hypertrophy

Question 4

S4 heart sound is best heard with the bell of a stethoscope at the _____ of the heart

Answer 4

apex

Question 5

What causes the S1 heart sound?

Answer 5

Closure of the AV valves

Question 6

What causes the S2 heart sound?

Answer 6

Closure of the semilunar valves

Question 7

What does a P wave indicate on EKG?

Answer 7

Atrial depolarization (electrical always precedes mechanical in the heart, so atrial contraction is next!)

Question 8

There are 2 phases of ventricular filling. What are they?

Answer 8

Early and late phases

Early rapid filling is a passive process bc AV valves are open

Once there is depolarization and causes atrial contraction, this is an active process (increase in pressure, ventricles vibrate)

Question 9

A 40-year-old-male patient presents to his primary care physician complaining of blurred vision and headaches. He has a six-year history of HTN and hyperlipidemia. The pt. has been non-compliant and so his HTN has been poorly controlled. He works in a manufacturing plant and has smoked 1 pack of cigarettes/dy x 20 years. Vital signs: Temp. = 98.6◦F, Pulse = 68/min, Resp. = 22/min, BP = 210/150 mmHg in all four extremities, BMI = 28. The pt. is anxious and complains of an inability to concentrate because of the headaches. He does not remember urinating during the past day and is unable to provide a urine sample for analysis. A presystolic murmur (fourth heart sound) is heard. Funduscopic examination demonstrates edema of the optic nerve in both eyes: papilledema. What is papilledema and what is its primary, basic cause?

Answer 9

Something putting pressure (ICP) on optic nerve and blurring the optic disc

On fundoscopic exam → cannot see optic disc anymore (optic disc is bulging)

Question 10

A 40-year-old-male patient presents to his primary care physician complaining of blurred vision and headaches. He has a six-year history of HTN and hyperlipidemia. The pt. has been non-compliant and so his HTN has been poorly controlled. He works in a manufacturing plant and has smoked 1 pack of cigarettes/dy x 20 years. Vital signs: Temp. = 98.6◦F, Pulse = 68/min, Resp. = 22/min, BP = 210/150 mmHg in all four extremities, BMI = 28. The pt. is anxious and complains of an inability to concentrate because of the headaches. He does not remember urinating during the past day and is unable to provide a urine sample for analysis. A presystolic murmur (fourth heart sound) is heard. Funduscopic examination demonstrates edema of the optic nerve in both eyes: papilledema. Lab studies show SMA-12: BUN= 160 mg/dL (very high), Creatinine= 8.2 mg/dL (very high), Blood gas analysis: pO2 = 90 mmHg (normal), pCO2 = 33 mmHg (slightly low), HCO3- = 12 mEq (low), pH = 7.30 (slightly acidic/acidosis), Plasma renin activity= 26 ng/ml/hr (very high), ECG= normal sinus rhythm, left axis deviation, no shift in ST segment, Cardiac enzymes (myosin, CK-MB) = normal. What does a very high BUN/creatinine indicate? What does left axis deviation mean on an ECG?

Answer 10

Very high BUN/creatinine indicates kidney problems and not getting rid of toxic wastes

Left axis deviation = left ventricular hypertrophy

Question 11

A 40-year-old-male patient presents to his primary care physician complaining of blurred vision and headaches. He has a six-year history of HTN and hyperlipidemia. The pt. has been non-compliant and so his HTN has been poorly controlled. He works in a manufacturing plant and has smoked 1 pack of cigarettes/dy x 20 years. Vital signs: Temp. = 98.6◦F, Pulse = 68/min, Resp. = 22/min, BP = 210/150 mmHg in all four extremities, BMI = 28. The pt. is anxious and complains of an inability to concentrate because of the headaches. He does not remember urinating during the past day and is unable to provide a urine sample for analysis. A presystolic murmur (fourth heart sound) is heard. Funduscopic examination demonstrates edema of the optic nerve in both eyes: papilledema. Lab studies show SMA-12: BUN= 160 mg/dL (very high), Creatinine= 8.2 mg/dL (very high), Blood gas analysis: pO2 = 90 mmHg (normal), pCO2 = 33 mmHg (slightly low), HCO3- = 12 mEq (low), pH = 7.30 (slightly acidic/acidosis), Plasma renin activity= 26 ng/ml/hr (very high), ECG= normal sinus rhythm, left axis deviation, no shift in ST segment, Cardiac enzymes (myosin, CK-MB) = normal. What is the diagnosis?

Answer 11

Malignant HTN, which is papilledema + HTN in all 4 extremities = medical emergency

Malignant HTN causes microvascular lesions due to high BP and affects the brain, heart, and kidneys (first goal of treating this in hospital is slowly lower BP)

Question 12

What organs are the long-term regulators of BP? How?

Answer 12

Kidneys regulate BP by regulating blood volume

Blood volume is regulated by manipulating water

Water → diuresis (get rid of water when needed)

Salt → natriuresis

Question 13

A 40-year-old-male patient presents to his primary care physician complaining of blurred vision and headaches. He has a six-year history of HTN and hyperlipidemia. The pt. has been non-compliant and so his HTN has been poorly controlled. He works in a manufacturing plant and has smoked 1 pack of cigarettes/dy x 20 years. Vital signs: Temp. = 98.6◦F, Pulse = 68/min, Resp. = 22/min, BP = 210/150 mmHg in all four extremities, BMI = 28. The pt. is anxious and complains of an inability to concentrate because of the headaches. He does not remember urinating during the past day and is unable to provide a urine sample for analysis. A presystolic murmur (fourth heart sound) is heard. Funduscopic examination demonstrates edema of the optic nerve in both eyes: papilledema. Lab studies show SMA-12: BUN= 160 mg/dL (very high), Creatinine= 8.2 mg/dL (very high), Blood gas analysis: pO2 = 90 mmHg (normal), pCO2 = 33 mmHg (slightly low), HCO3- = 12 mEq (low), pH = 7.30 (slightly acidic/acidosis), Plasma renin activity= 26 ng/ml/hr (very high), ECG= normal sinus rhythm, left axis deviation, no shift in ST segment, Cardiac enzymes (myosin, CK-MB) = normal. What is causing the headaches?

Answer 13

Cerebral edema → ICP as a result of HTN

Question 14

Every organ can regulate BP through autoregulation. If the organ cannot autoregulate enough, then this will cause problems. Arterioles will _____________ to decrease blood volume and control how much blood is coming into organ. If the arterioles cannot constrict enough and pressure is way too high, then they will dilate and all the fluid will come through. The fluid will increase filtration pressure due to high BP which causes cerebral edema and the impinging of the optic nerve/bulging optic disc causes the papilledema

Answer 14

vasoconstrict

Question 15

What does sausage string pattern mean?

Answer 15

blood vessels become constricted and damaged from high BP

Question 16

A 40-year-old-male patient presents to his primary care physician complaining of blurred vision and headaches. He has a six-year history of HTN and hyperlipidemia. The pt. has been non-compliant and so his HTN has been poorly controlled. He works in a manufacturing plant and has smoked 1 pack of cigarettes/dy x 20 years. Vital signs: Temp. = 98.6◦F, Pulse = 68/min, Resp. = 22/min, BP = 210/150 mmHg in all four extremities, BMI = 28. The pt. is anxious and complains of an inability to concentrate because of the headaches. He does not remember urinating during the past day and is unable to provide a urine sample for analysis. A presystolic murmur (fourth heart sound) is heard. Funduscopic examination demonstrates edema of the optic nerve in both eyes: papilledema. Lab studies show SMA-12: BUN= 160 mg/dL (very high), Creatinine= 8.2 mg/dL (very high), Blood gas analysis: pO2 = 90 mmHg (normal), pCO2 = 33 mmHg (slightly low), HCO3- = 12 mEq (low), pH = 7.30 (slightly acidic/acidosis), Plasma renin activity= 26 ng/ml/hr (very high), ECG= normal sinus rhythm, left axis deviation, no shift in ST segment, Cardiac enzymes (myosin, CK-MB) = normal. Is the patient in renal failure? Justify the answer w/ his symptoms and lab studies.

Answer 16

YES

BUN + creatinine is very high

Did not urinate for the past 24 hrs

Metabolic acidosis (bicarbonate, pH and hydrogen ions are low)

Question 17

What are acid base disturbances?

Answer 17

Question 18

A 40-year-old-male patient presents to his primary care physician complaining of blurred vision and headaches. He has a six-year history of HTN and hyperlipidemia. The pt. has been non-compliant and so his HTN has been poorly controlled. He works in a manufacturing plant and has smoked 1 pack of cigarettes/dy x 20 years. Vital signs: Temp. = 98.6◦F, Pulse = 68/min, Resp. = 22/min, BP = 210/150 mmHg in all four extremities, BMI = 28. The pt. is anxious and complains of an inability to concentrate because of the headaches. He does not remember urinating during the past day and is unable to provide a urine sample for analysis. A presystolic murmur (fourth heart sound) is heard. Funduscopic examination demonstrates edema of the optic nerve in both eyes: papilledema. Lab studies show SMA-12: BUN= 160 mg/dL (very high), Creatinine= 8.2 mg/dL (very high), Blood gas analysis: pO2 = 90 mmHg (normal), pCO2 = 33 mmHg (slightly low), HCO3- = 12 mEq (low), pH = 7.30 (slightly acidic/acidosis), Plasma renin activity= 26 ng/ml/hr (very high), ECG= normal sinus rhythm, left axis deviation, no shift in ST segment, Cardiac enzymes (myosin, CK-MB) = normal. Has the patient’s myocardium been damaged?

Answer 18

NO, or not yet

Cardiac enzymes were normal

No shift in ST segment (damage to heart (ie. ischemia or infarction) = changes/ shift in ST segment)

Left axis deviation

Question 19

renal arteries branch into segmental arteries → ____________ arteries→ arcuate arteries→ interlobular/____________ arteries

How does the arterial blood supply of kidneys differ from venous?

Answer 19

interlobar, cortical radiate

Venous: segmental veins are missing

Question 20

Compromised blood flow to the kidney = ?

Answer 20

vasoconstriction

Question 21

HTN damages small blood vessels resulting in fibrinoid necrosis. Autoregulation results in vasoconstriction of the __________ arterioles, until autoregulatory mechanisms fail. Vasoconstriction of the afferent arterioles increases resistance and decreases renal blood flow, capillary BP, and GFR. Decrease in GFR will go all the way to PCT, loop of henle and then DCT. _____________ will sense GFR changes in the DCT. DCT is lined w/ simple __________ cells, but when these cells come closely packed together and tall, then this is the macula densa cells. Macula densa cells will send the info about decreased GFR to the JG cells. The JG cells are in the afferent arteriole which is composed of smooth muscle. Any part of tunica media is smooth muscle. When the smooth muscle cells are specialized here, they contain secretory granules which secrete/release ______ (JG cells do this). This case study pt had high renin in his blood tests. Increased BP results in pressure natriuresis. All these mechanisms result in low GFR, which activates the macula densa/JG apparatus, thereby producing renin. The macula densa cells sense distal tubule flow and release paracrines that affect afferent arteriole diameter. Granular cells secrete renin, an enzyme involved in salt and water balance

Answer 21

afferent, Macula densa, cuboidal, renin

Question 22

Renin is converted into ________________.

Answer 22

angiotensinogen

Question 23

Angiotensinogen is a precursor to ______________

Answer 23

angiotensin 1

Question 24

Renin converts angiotensinogen to to _______

Answer 24

Ang 1

Question 25

Where is angiotensinogen made?

Answer 25

Made in the liver, it’s a plasma protein

Question 26

What converts Ang 1 to Ang 2?

Answer 26

ACE

Question 27

Ang 2 = potent ______________

Answer 27

vasoconstrictor

Question 28

A 40-year-old-male patient presents to his primary care physician complaining of blurred vision and headaches. He has a six-year history of HTN and hyperlipidemia. The pt. has been non-compliant and so his HTN has been poorly controlled. He works in a manufacturing plant and has smoked 1 pack of cigarettes/dy x 20 years. Vital signs: Temp. = 98.6◦F, Pulse = 68/min, Resp. = 22/min, BP = 210/150 mmHg in all four extremities, BMI = 28. The pt. is anxious and complains of an inability to concentrate because of the headaches. He does not remember urinating during the past day and is unable to provide a urine sample for analysis. A presystolic murmur (fourth heart sound) is heard. Funduscopic examination demonstrates edema of the optic nerve in both eyes: papilledema. Lab studies show SMA-12: BUN= 160 mg/dL (very high), Creatinine= 8.2 mg/dL (very high), Blood gas analysis: pO2 = 90 mmHg (normal), pCO2 = 33 mmHg (slightly low), HCO3- = 12 mEq (low), pH = 7.30 (slightly acidic/acidosis), Plasma renin activity= 26 ng/ml/hr (very high), ECG= normal sinus rhythm, left axis deviation, no shift in ST segment, Cardiac enzymes (myosin, CK-MB) = normal. This patient was diagnosed with malignant HTN. What is the treatment?

Answer 28

Admit to hospital

Sodium nitroprusside (vasodilator, through an IV) to gradually/slowly lower BP (once GFR increases again, he can urinate)

Continuous cardiac, neurologic, and urine output status checks

Question 29

What does mal mean?

Answer 29

bad

Question 30

What are some S&S of malignant HTN?

Answer 30

Paralysis, unconsciousness, blindness, and nephropathy

Brain swells and has multiple areas of hemorrhage

The vasculature of the kidney is dramatically constricted and the urine output is reduced

The heart is dilated (enlarged) and in cardiac failure

Question 31

What anatomical structure is known as the blind spot?

Answer 31

optic disc

Question 32

What blood vessels have 3 tunicas (tunica interna, tunica media, tunica externa)?

Answer 32

arteries and veins

Question 33

What is the difference between arteries and veins in terms of their tunica media?

Answer 33

arteries have a thicker tunica media (smooth muscle), while veins have a thinner tunica media

Question 34

What is the difference between arteries and veins in terms of the lumen?

Answer 34

arteries have a narrow lumen, while veins have a wide lumen

Question 35

Peripheral veins have a valve (projection of tunic interna) that ensures there is….

Answer 35

only one way flow of blood

Question 36

Arteries transport blood at ________ pressure

Answer 36

high

Question 37

veins transport blood at ______ pressure

Answer 37

low

Question 38

Arteries carry _____________ blood from _______ to ________

Answer 38

oxygenated, heart, organs

Question 39

Veins carry deoxygenated blood from system to heart. What are the exceptions?

Answer 39

pulmonary artery carries blood from the R ventricle to the lungs

pulmonary vein carries oxygenated blood from lungs to the left atrium

Question 40

Capillaries have a single tunica ________ layer

Answer 40

interna

Question 41

What type of vessels are the capillaries?

Answer 41

primary exchange vessels

Question 42

What is the smallest type of blood vessel?

Answer 42

capillaries

Question 43

Do capillaries have valves?

Answer 43

no, they have sphincters to help control blood flow

Question 44

What are the 3 types of capillaries?

Answer 44

1) continuous (most common)
2) fenestrated
3) sinusoidal

Question 45

Where can you find fenestrated capillaries?

Answer 45

kidney, specifically the glomerulus, intestines, etc.

Question 46

Where can you find sinusoidal capillaries?

Answer 46

liver (glycogen), BM, spleen, etc

Question 47

What are the primary circuits of the body?

Answer 47

systemic and pulmonary circulation

Question 48

Pulmonary veins return ____________ blood into the L atrium of the heart

Answer 48

oxygenated

Question 49

Systemic circulation begins at the ________ arteries and goes to muscular arteries, then the arterioles, metarterioles, capillary bed, postcapillary venule, ___________ venule, collecting venule, and then the veins

Answer 49

elastic, muscular

Question 50

The primary arteries of the body starts at the L ventricle and goes through the aortic valve (semilunar), through the ascending aorta and then the ________ _______. Next is the brachiocephalic (median) artery which splits into R/L. On the right side, it goes to the ___________ a., axillary a., vertebral a., common carotid a., and then the internal and external carotid arteries. The left common carotid artery goes to the internal and external carotid arteries. When brachiocephalic a. splits to the left/lateral subclavian a. then it goes to axillary a., brachial a. at the cubital fossa and splits into radial and ulnar arteries. There is also deep brachial arteries.

Answer 50

aortic arch, subclavian

Question 51

From the thoracic aorta, blood goes to the intercostal arteries, ___________ arteries, celiac trunk, superior mesenteric a., renal arteries, inferior mesenteric a., and then the….

Answer 51

suprarenal, gonadal arteries

Question 52

From the abdominal aorta, blood travels through the common iliac arteries, external iliac arteries, __________ artery, deep femoral a., popliteal a., anterior tibial a., dorsalis pedis a., posterior tibial a., and then the….

Answer 52

femoral, fibular a.

Question 53

What are the palpable arteries?

Answer 53

-dorsalis pedis a.
-external carotid
-popliteal
-posterior tibialis
-radial
-superficial temporal

Question 54

The SVC drains blood above the….

Answer 54

diaphragm

Question 55

The SVC is formed by R/L ________________ veins joining between C2/C3

Answer 55

brachiocephalic

Question 56

The anterior facial vein goes to the internal jugular vein to the ______________ vein and then the SVC

Answer 56

brachiocephalic

Question 57

The external jugular vein goes to the subclavian vein to the _____________ vein and then the SVC

Answer 57

brachiocephalic

Question 58

The superficial medial cubital vein goes to the superficial basilic vein to the __________ vein to the brachiocephalic vein and then the SVC

Answer 58

axillary

Question 59

Where does the IVC drain?

Answer 59

lower limbs, pelvis, perineum, and the abdomen

Question 60

The IVC is formed by R/L _______________ veins at L5

Answer 60

common iliac

Question 61

The deep popliteal vein goes to the deep femoral vein to the external iliac, ______________ vein, and then the IVC

Answer 61

common iliac

Question 62

The superficial great saphenous vein goes to the….

Answer 62

deep femoral vein

Question 63

the superficial small saphenous vein does to the….

Answer 63

deep popliteal vein

Question 64

The deep posterior tibial vein goes to the….

Answer 64

deep popliteal vein

Question 65

The deep anterior tibial vein goes to the….

Answer 65

deep popliteal vein

Question 66

What are the main tributaries of the IVC?

Answer 66

-R gonadal vein
-renal veins
-R suprarenal vein
-inferior phrenic veins
-hepatic veins

Question 67

The IVC passes through the diaphragm at….

Answer 67

T8

Question 68

superficial and deep veins communicate/connect via….

Answer 68

perforating veins

Question 69

What is an arterial anastomosis?

Answer 69

connecting arteries that improve circulation

Question 70

What is the arterial anastomosis of the brain?

Answer 70

circle of Willis

Question 71

What is the arterial anastomosis of the heart?

Answer 71

coronary arteries

Question 72

What is a portal system?

Answer 72

capillaries connected by a portal vein

Heart, artery, arteriole, capillary bed 1, portal vein, capillary bed 2, venule, vein, heart

Question 73

What is the portal system in the abdomen called?

Answer 73

hepatic portal system

Question 74

What is the hypothalamo hypophyseal portal system?

Answer 74

connects the brain to the anterior pituitary

Question 75

What bones form the eye orbit?

Hint: theres 7

Answer 75

-Frontal bone
-Lacrimal bone
-Ethmoid bone
-Sphenoid bone
-Zygomatic bone
-Maxilla
-Palatine bone

Question 76

What foramen is in the frontal bone?

Answer 76

supraorbital foramen

Question 77

What does the supraorbital foramen of the frontal bone house?

Answer 77

supraorbital n. (branch of CN V1 (trigeminal) ophthalmic branch)) and the supraorbital a.

Question 78

What skull bone contains the optic canal?

Answer 78

sphenoid bone

Question 79

What does the optic canal house?

Answer 79

-optic n.
-ophthalmic a. and v.
-retinal a. and v.
-oculomotor n (CN3)
-trochlear n (CN4)
-trigeminal n (CN5, specifically V1 ophthalmic division)

Question 80

What foramen is in the maxilla?

Answer 80

infraorbital foramen

Question 81

What is housed in the infraorbital foramen of the maxilla?

Answer 81

infraorbital n. (branch of CN V2 (trigeminal) maxillary branch) and infraorbital a.

Question 82

The superior orbital fissure separates what?

Answer 82

greater and lesser wings

Question 83

The inferior orbital fissure separates what?

Answer 83

sphenoid bone and maxilla

Question 84

What structures make up the lacrimal apparatus?

Answer 84

-lacrimal glands
-lacrimal canaliculi
-lacrimal sac
-nasolacrimal duct.

Question 85

What nerve makes you cry?

Answer 85

greater petrosal nerve (branch of facial nerve, CN VII)

Question 86

The lacrimal gland is in the superolateral wall of the orbit in the _________ fossa

Answer 86

lacrimal

Question 87

The lacrimal gland is innervated by the ________________ nerve which is a branch of the facial n. (CN VII). This nerve makes you cry by having the tears flow across eyeball and is collected by the lacrimal puncta and then goes to the lacrimal canaliculus (small tube) and into lacrimal sac

Answer 87

greater petrosal

Question 88

The nasolacrimal duct communicates w/ the the nasal cavity through the _________ _________. This connection is the reason your nose may run when you cry

Answer 88

inferior meatus

Question 89

The lacrimal sac drains into the ______________ duct which communicates with the nasal cavity through inferior meatus

Answer 89

nasolacrimal

Question 90

The lacrimal sac lies in the sulcus that is formed by the ___________ bone and ___________

Answer 90

lacrimal, maxilla

Question 91

What skeletal muscles move the eyeball? Which nerves move them?

Answer 91

Extraocular muscles [LR6)(SO4)]3

Superior oblique = depresses + abducts with CN4

Superior rectus= elevates + adducts with CN3

Medial rectus= adducts w/ CN3

Lateral rectus= abducts w/ CN6

Inferior rectus= depresses + adduction w/ CN3

Inferior oblique= elevates + abducts w/ CN3

Question 92

The corneoscleral tunic is the outer layer of the eye and is made up of __________ tissue. This includes the sclera and cornea

Answer 92

fibrous

Question 93

The uveal tunic is the middle layer of the eye and is made up of _________ tissue. This includes the choroid, stoma of cillary body, and stroma of iris

Answer 93

vascular

Question 94

The retinal tunic is the inner layer of the eye and is made up of ___________ tissue. This includes the pigment epithelium, neural retina (the center back of retina is the macula lutea where the cones are highly concentrated and looks yellow, the fovea centralis is the depression in the center of the macula lutea that contains _______ but no ________), epithelium of the cillary body and iris, and photoreceptor cells (more rods than cones)

Answer 94

nervous, cones, rods

Question 95

Rods= ?, Cones = ?

Answer 95

rods= black and white, cones = color

Question 96

What are the cavities of the internal eye and what separates them?

Answer 96

Anterior and posterior cavities

Posterior cavity is larger, anterior cavity is smaller

Cavities are separated by the lens

Posterior cavity = filled w/ vitreous humor (embryologically made gel, not continuously made)

Anterior cavity= filled w/ aqueous humor (continuously made by ciliary processes)

Anterior cavity can be separated into chambers of the eye- anterior and posterior chambers

Pupil separates anterior chamber from posterior chamber

Cornea is epithelial, so it is avascular (a part of anterior chamber of anterior cavity, internal fluid and lacrimal fluid keeps cornea alive)

Canal of schlemm (also called scleral venous sinus, sucks aqueous humor back into venous flow)

Suspensory ligaments allow for near and far distance focussing of the lens

Question 97

What structures can be seen using the ophthalmoscope?

Answer 97

Retina

Optic disc (optic nerve penetrates at optic disc, no photoreceptors here)

Macula lutea (lutea- color, which is yellowish)

Depression = fovea centralis → where cones are housed

Rods are peripheral

Question 98

What is the innermost eye layer?

Answer 98

retina

Question 99

The retina is divided into 2 areas. What are they?

Answer 99

1) pars optica (posterior 2/3, light sensitive)
2) pars ciliaris and pars iridis (anterior 1/3, light insensitive)

Question 100

Pars ciliaris and pars iridis is seperated by….

Answer 100

ora serrata

Question 101

Pars optica has 10 histological layers:
Outer coat of eye wall= (fibrous coat) sclera
1) Vascular coat (chormid)
2) Retinal pigmented epithelium layer (gathers stray light)
3) ?
4) Outer nuclear layer
5) Outer plexiform layer
6) Inner nuclear layer
7) Inner plexiform layer
8) Ganglion cell layer (axons form optic n.)
9) Nerve fiber layer
10) Inner limiting membrane

Answer 101

Layer of rods and cones

Question 102

What are the 12 cranial nerves and their function?

Answer 102

Question 103

What cranial nerves have somatic function?

Answer 103

3,4,6, and 9

Question 104

What cranial nerves have parasympathetic function?

Answer 104

3,7,9, and 10

Question 105

What cranial nerves have sympathetic function?

Answer 105

1,2,4,5,6,8,11, and 12

Question 106

What is the primary blood supply to the brain?

Answer 106

circle of wilis (its an arterial anastomosis)

Question 107

The circle of wilis provides for __________ circulation if a vessel becomes occluded

Answer 107

collateral

Question 108

The posterior communicating artery connects the internal carotid system to the….

Answer 108

vertebral/basilar system

Question 109

What artery is blocked that causes 40% of strokes?

Answer 109

middle cerebral artery (MCA, known as an end artery because it terminates into brain tissue)

Question 110

What are the largest arteries of the circle of wilis?

Answer 110

internal carotid arteries

Question 111

Mediastinum is the region that separates….

Answer 111

pleural cavities

Question 112

The heart lies centrally within the….

Answer 112

middle inferior mediastinum

Question 113

The mediastinum is divided into superior and inferior. Inferior mediastinum can be further divided into….

Answer 113

anterior, middle and posterior

Question 114

The superior and inferior mediastinum is separated by….

Answer 114

sternal angle (T4/T5 intervertebral disc)

Question 115

What does the middle inferior mediastinum contain?

Answer 115

-pericardium
-heart
-roots of the great vessels entering and leaving heart (IVC, SVC, pulmonary arteries/veins, and root of the aorta)

Question 116

Using bony landmarks identify where the apex and base of the heart are located

Answer 116

apex= primarily made up of left ventricle, found at the inferior border and left 5th intercostal space

base= primarily made up of the left atrium, found at the superior border and left 2nd/3rd costal cartilage

Question 117

Name the cavity and serous membranes associated w/ the heart

Answer 117

fibrous pericardium is the outer layer (inner surface is covered with parietal serous pericardium)

serous pericardium= inner visceral layer

pericardial cavity= potential space that occurs between the 2 serous layers and contains serous fluid

Question 118

Name the layers that make up the walls of the heart superficial to deep

Answer 118

epicardium (visceral pericardium), myocardium (widest), and endocardium (composed of endothelium/purkinje fiber cells)

Folds in the endocardium of the ventricles is called the chordae tendineae (prevent injury when expanding)

Question 119

Name the chambers of the heart

Answer 119

R atrium, R ventricle (2nd largest), L atrium, L ventricle (largest)

Question 120

Is the heart symmetrical?

Answer 120

no

Question 121

Coronary sinus empties into the….

Answer 121

R atrium

Question 122

Chordae tendineae is fibrous cords connecting the valve leaflets of the _________ and _________ valves to papillary muscles

Answer 122

tricuspid, mitral

Question 123

Name the valves of the heart. Using surface bony landmarks, where would you auscultate each of those valves?

Answer 123

1) Aortic valve (semilunar) is found at the R 2nd intercostal space between the L ventricle and aorta
2) Pulmonic valve (semilunar) is found at the left 2nd intercostal space between the R ventricle and pulmonary a.
3) Tricuspid valve (AV) is found at the left 4th intercostal space between the L atrium and L ventricle
4) Mitral (bicuspid) valve (AV) is found at the left midclavicular line 5th intercostal space between the L atrium and L ventricle

Question 124

Components of EKG= atrial _________ → atrial diastole → ventricular systole → ventricular diastole

Answer 124

systole

Question 125

Trace the blood flow into, through, and out of the heart

Answer 125

SVC/IVC goes into R atrium through tricuspid valve into R ventricle through pulmonary semilunar valve into pulmonary trunk which divides into R/L (near the angle of Louis), goes to lungs and comes back

2 pulmonary arteries go out, 4 pulmonary veins come back to heart at L atrium through bicuspid/mitral valve into L ventricle through aortic semilunar valve into ascending aorta and aortic arch

Question 126

The heart receives blood from the _____________ arteries

Answer 126

R/L coronary

Question 127

The coronary arteries arise from….

Answer 127

the aortic sinuses in the ascending aorta

Question 128

As oxygenated blood leaves the left ventricle to the aorta, a small portion goes back to the heart via….

Answer 128

coronary arteries

Question 129

The R coronary artery begins at the right aortic sinus and goes to the right coronary sulcus and then posterior surface of the heart. What are the major branches here?

Answer 129

SA nodal, right marginal, AV nodal, and posterior IV arteries

Question 130

The L coronary artery begins at the left aortic sinus between the pulmonary trunk and left auricle and bifurcates into the _________ artery and goes to posterior surface of the heart

Answer 130

circumflex

Question 131

Anterior IV branch gives rise to the…..

Answer 131

L marginal branch

Question 132

The posterior and anterior IV arteries anastomose where?

Answer 132

at the apex of the heart

Question 133

The heart is drained by a series of cardiac veins. What are they?

Answer 133

Great cardiac vein runs with the anterior IV artery

Middle cardiac vein runs with the posterior IV artery

Small cardiac artery runs with the right marginal artery (arises from R ventricular wall and bypasses the coronary sinus and drains directly into the anterior wall of the R atrium)

Question 134

Cardiac veins drain into the coronary sinus and returns blood to the….

Answer 134

R atrium

Question 135

Identify the fetal bypass structures and what the become once you are born

Answer 135

Foramen oval and ductus arteriosus

They become the ligamentum arteriosum and fossa ovalis once born

Question 136

Where are the kidneys located in relation to the peritoneum?

Answer 136

Retroperitoneal

deep renal fascia keeps the kidneys held up against the posterior abdominal wall

each kidney is surrounded by perineal fat capsule and renal fascia

the fibrous capsule lies deep to the perineal fat (superficial fibrous capsule goes to perirenal fat, then renal fascia, and then pararenal fat)

Question 137

Where are both kidneys positioned in relation to bony landmarks?

Answer 137

between T11/T12-L3

R kidney is lower (inferior) to the liver

Left kidney is higher because the liver forces the right side to be lower (by a half vertebral space)

Question 138

What structures hold the kidney to the back body wall?

Answer 138

Kidney is held to back body wall by deep renal fascia

Question 139

List the regions of the kidney

Answer 139

Outer cortex
-lighter cortex
-contains tubes, capillaries, and renal corpuscles
-between renal pyramids =renal columns
» renal pyramid + renal cortex = renal lobe (nephrons contained within lobes)

Inner medulla
-darker medulla
-renal pyramids and columns alternate here as well
»apex of pyramid= renal papilla
-composed of 12 pyramids = cone shaped structure that contains urine collecting ducts

Collecting system (renal pelvis)
-collecting ducts, minor and major calyces and renal pelvis
-urine drains from the renal pyramids into the minor calyces

Question 140

Describe the internal structures of the kidneys and components of a nephron

Answer 140

nephron = functional unit of kidney

Part of each nephron lies within renal medulla and part within adjacent renal cortex (most in cortex above renal pyramid)

Tubular components
-Renal corpuscle
»Glomerular (Bowman’s) capsule = surrounds renal glomerulus and is double layered (podocytes)
-Proximal convoluted tubule (where most absorption occurs)
-Proximal straight tubule
-Loop of henle (descending thin limb, ascending thin limb, and distal straight tubule)
-Distal convoluted tubule
-Collecting duct (ADH acts on collecting duct aquaporins to conserve water)

Vascular components
-2 capillary beds
»Glomerulus = capillaries within renal glomerulus
(continuous and fenestrated capillaries without diaphragms)
»>Afferent and efferent arteriole
»Peritubular capillary = around renal tubule
»»Small vessel leads from peritubular capillary to renal vein

Question 141

Describe the components of the filtration membrane

Answer 141

Glomerular capillary endothelium= continuously fenestrated (stops blood cells)

Glomerular basement membrane (stops plasma proteins)

podocytes (slit diaphragms between podocytes, only fluid and solutes move through (positive charge moves through))

Question 142

Discuss the macula densa and juxtaglomerular apparatus

Answer 142

Macula densa
-lines DST
-monitors changes in sodium levels and stimulates release of renin from JG cells when BP is low

JG apparatus
-JG complex = specialized structure where DST of nephron contacts glomerulus (where afferent meets efferent) and regulates BP through secretion of renin (RAAS)
-JG cells are located in the tunica media of afferent arterioles and early portion of efferent arteriole which monitors BP and secretes renin (JG cells are innervated by the postganglionic sympathetic nerves

Question 143

Aldosterone is secreted by the…

Answer 143

renal cortex

Question 144

Aldosterone stimulates reabsorption of sodium and water and secretion of….

Answer 144

potassium

Question 145

Angiotensin 2 is a potent vasoconstrictor produced by the liver and decreases …..

Answer 145

GFR

Question 146

ADH is produced by the hypothalamus and reabsorbs….

Answer 146

water and sodium

Question 147

ANP is produced by the cardiac cells. ANP dilates afferent and constricts efferent, which decreases ______.

Answer 147

GFR

Question 148

What are the BP guidelines?

Answer 148

Question 149

A 43-year-old man has a bp of 138/88 taken during his annual examination. He has no other health problems and his blood lab results are in the normal range. He is slightly overweight and has a family hx of cardiovascular disease. What, if any, treatment would you recommend?

Answer 149

This man is at stage 1 HTN, has no ASCVD (no high cardiovascular disease risks)

Start w/ nonpharmacological therapy

Dietary changes
-DASH diet = Dietary approaches to stop HTN
-low sodium, decrease fats

Exercise

Question 150

A 43-year-old man has a bp of 138/88 taken during his annual examination. He has no other health problems and his blood lab results are in the normal range. He is slightly overweight and has a family hx of cardiovascular disease. This pt is at stage 1 HTN with no ASCVD (no cardiovascular disease risks). His treatment started off w/ nonpharmacological therapy, such as exercise and dietary changes (low sodium/fat). One year later at his regular check-up, the patient’s bp is 142/91. What would your treatment be at this stage?

Answer 150

Time for meds, he’s now at stage 2 HTN

Give pt anti-HTN meds

Question 151

How do you choose an appropriate anti-HTN med for a pt?

Answer 151

Must benefit the pt

Any other diseases present?

Be aware of adverse effects of the med

Cost

National guidelines recommend diuretics as initial therapy for patients with uncomplicated HTN who have not responded to lifestyle changes

Question 152

What are the 3 types/groups of diuretics?

Answer 152

Thiazides
-Ex: hydrochlorothiazide
-Works in DCT
-Blocks NaCl cotransporter
-Normally reabsorbs 5% of Na+
-Proximal tubule reabsorbs most of sodium (67%), which is why you don’t use drugs that work here unless it is VERY SEVERE HTN

Loop diuretics
-Ex: Furosemide (lasix)
-work at the ascending loop of Henle
-Block NKCC2 transporter from cycling (not moving them into your cells)
-Releasing 25% of Na+ (ascending loop of Henle normally reabsorbs 25% of Na+), followed by water

K+ sparing
-Ex: Spironolactone → aldosterone antagonist, while the others bind to Na+ receptors
-Inhibit Na+ reabsorption at the P (principal) cells of the distal nephron
-Distal nephron reabsorbs 3% of Na+
-Aldosterone works here in the nucleus of P cells to help make new channels to reabsorb sodium

Question 153

A 68-year-old woman is being treated with 25 mg of hydrochlorothiazide. During her checkup last week, her bp was 161/93 and she was also diagnosed with type 2 DM. What changes would you make to her treatment?

Answer 153

Try to protect the heart and keep BP low

Diabetes affects every single organ
-Options: change to a loop diuretic, could add another diuretic or increase dosage
-Lifestyle changes + pharmacological intervention
-ACE inhibitors seem to be the best option for DM w/ HTN

Question 154

ACE inhibitors are the first-line drugs for diabetics with HTN as they slow the development and progression of _________ ______________ (anything that ends with “-pril”, most common one is lisinopril). ACE inhibitors will prevent body from producing Ang 2

Answer 154

diabetic glomerulopathy

Question 155

A 68-year-old woman is being treated with 25 mg of hydrochlorothiazide. During her checkup last week, her bp was 161/93 and she was also diagnosed with type 2 DM. How would you treat this pt if only her BP increased and she was not diagnosed with anything else?

Answer 155

Change diuretics, or can increase dosage and monitor pt

Question 156

A 68-year-old woman is being treated with 25 mg of hydrochlorothiazide. During her checkup last week, her bp was 161/93 and she was also diagnosed with type 2 DM. The patient is prescribed enalapril (Vasotec) in addition to the hydrochlorothiazide. What are the possible side effects?

Answer 156

Hypotension, therefore always begin with the lowest dose and titrate up. Advise your patients to look for signs & symptoms of hypotension.

ACE inhibitors also block the degradation of bradykinin and substance P. In 5-20% of patients, this results in a dry cough, and in 0.5% of patients there is angioedema.

If angioedema occurs, discontinue the drug and substitute with an AngII receptor antagonist.

Question 157

3 HTN drugs: diuretics, ACE inhibitors, and…..

Answer 157

ang II receptor antagonist

Question 158

NSAIDs reduce effectiveness of antihypertensive drugs, especially those blocking ______. All thiazide drugs cross the placenta but have not shown to affect fetus. ACE inhibitors and AT1 receptor antagonist are teratogenic- can cause mental retardation and physical deformities in fetuses. ____________ is a good alternative for pregnant women bc it is a sympatholytic/vasodilator = decreases BP.

Answer 158

RAAS, Methyldopa

Question 159

Which of the following antihypertensive medications is considered a safe alternative in pregnancy?
A) methyldopa
B) lisinopril
C) spironolactone
D) hydrochlorothiazide

Answer 159

A) methyldopa

Question 160

It is the layer of the retina just deep to the rods and cones:

Answer 160

pigmented layer

Question 161

Which of the following is false about the S4 heart sound?
A) it is a sound in systole
B) it is a sound in diastole
C) it is associated with decreased compliance of the left ventricle
D) the sound is a low pitch or frequency

Answer 161

A) it is a sound in systole

Question 162

The macula densa is not associated with which of the following structures?
A) DCT
B) PCT
C) afferent arteriole
D) efferent arteriole

Answer 162

B) PCT

Question 163

The first line of therapy for patients with uncomplicated hypertension who have not responded to lifestyle changes is….

Answer 163

diuretics

(ACE inhibitors would be used on pts with DM + HTN)

Question 164

A diagnosis of malignant hypertension must include the following:

Answer 164

papilledema and extreme BP elevation

Question 165

The blood vessels composed of 3 tunics is/are….

Answer 165

arteries and veins

Question 166

It is not a part of the circle of willis arterial anastomosis:
A) anterior cerebral artery
B) posterior communicating artery
C) external carotid artery
D) posterior cerebral artery
E) all of the answers are a part of the circle of willis

Answer 166

C) external carotid artery

Question 167

Thiazide diuretics…
A) inhibit the NKCC2 transporter
B) work at the ascending loop on henle
C) cross the placenta
D) all of the above

Answer 167

C) cross the placenta

Question 168

It is the artery most commonly used to obtain standard blood pressure readings

Answer 168

brachial artery