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Malignant HTN Roop/Jaffe Flashcards

1
Q

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?

A

-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

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2
Q

S4 is only heard in….

A

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

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3
Q

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

A

ventricular hypertrophy

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4
Q

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

A

apex

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5
Q

What causes the S1 heart sound?

A

Closure of the AV valves

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6
Q

What causes the S2 heart sound?

A

Closure of the semilunar valves

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7
Q

What does a P wave indicate on EKG?

A

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

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8
Q

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

A

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)

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9
Q

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?

A

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

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

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10
Q

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?

A

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

Left axis deviation = left ventricular hypertrophy

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11
Q

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?

A

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)

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12
Q

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

A

Kidneys regulate BP by regulating blood volume

Blood volume is regulated by manipulating water

Water → diuresis (get rid of water when needed)

Salt → natriuresis

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13
Q

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?

A

Cerebral edema → ICP as a result of HTN

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14
Q

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

A

vasoconstrict

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15
Q

What does sausage string pattern mean?

A

blood vessels become constricted and damaged from high BP

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16
Q

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.

A

YES

BUN + creatinine is very high

Did not urinate for the past 24 hrs

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

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17
Q

What are acid base disturbances?

A
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18
Q

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?

A

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

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19
Q

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

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

A

interlobar, cortical radiate

Venous: segmental veins are missing

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20
Q

Compromised blood flow to the kidney = ?

A

vasoconstriction

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21
Q

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

A

afferent, Macula densa, cuboidal, renin

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22
Q

Renin is converted into ________________.

A

angiotensinogen

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23
Q

Angiotensinogen is a precursor to ______________

A

angiotensin 1

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24
Q

Renin converts angiotensinogen to to _______

A

Ang 1

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25
Where is angiotensinogen made?
Made in the liver, it's a plasma protein
26
What converts Ang 1 to Ang 2?
ACE
27
Ang 2 = potent ______________
vasoconstrictor
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?
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
29
What does mal mean?
bad
30
What are some S&S of malignant HTN?
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
31
What anatomical structure is known as the blind spot?
optic disc
32
What blood vessels have 3 tunicas (tunica interna, tunica media, tunica externa)?
arteries and veins
33
What is the difference between arteries and veins in terms of their tunica media?
arteries have a thicker tunica media (smooth muscle), while veins have a thinner tunica media
34
What is the difference between arteries and veins in terms of the lumen?
arteries have a narrow lumen, while veins have a wide lumen
35
Peripheral veins have a valve (projection of tunic interna) that ensures there is....
only one way flow of blood
36
Arteries transport blood at ________ pressure
high
37
veins transport blood at ______ pressure
low
38
Arteries carry _____________ blood from _______ to ________
oxygenated, heart, organs
39
Veins carry deoxygenated blood from system to heart. What are the exceptions?
pulmonary artery carries blood from the R ventricle to the lungs pulmonary vein carries oxygenated blood from lungs to the left atrium
40
Capillaries have a single tunica ________ layer
interna
41
What type of vessels are the capillaries?
primary exchange vessels
42
What is the smallest type of blood vessel?
capillaries
43
Do capillaries have valves?
no, they have sphincters to help control blood flow
44
What are the 3 types of capillaries?
1) continuous (most common) 2) fenestrated 3) sinusoidal
45
Where can you find fenestrated capillaries?
kidney, specifically the glomerulus, intestines, etc.
46
Where can you find sinusoidal capillaries?
liver (glycogen), BM, spleen, etc
47
What are the primary circuits of the body?
systemic and pulmonary circulation
48
Pulmonary veins return ____________ blood into the L atrium of the heart
oxygenated
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
elastic, muscular
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.
aortic arch, subclavian
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....
suprarenal, gonadal arteries
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....
femoral, fibular a.
53
What are the palpable arteries?
-dorsalis pedis a. -external carotid -popliteal -posterior tibialis -radial -superficial temporal
54
The SVC drains blood above the....
diaphragm
55
The SVC is formed by R/L ________________ veins joining between C2/C3
brachiocephalic
56
The anterior facial vein goes to the internal jugular vein to the ______________ vein and then the SVC
brachiocephalic
57
The external jugular vein goes to the subclavian vein to the _____________ vein and then the SVC
brachiocephalic
58
The superficial medial cubital vein goes to the superficial basilic vein to the __________ vein to the brachiocephalic vein and then the SVC
axillary
59
Where does the IVC drain?
lower limbs, pelvis, perineum, and the abdomen
60
The IVC is formed by R/L _______________ veins at L5
common iliac
61
The deep popliteal vein goes to the deep femoral vein to the external iliac, ______________ vein, and then the IVC
common iliac
62
The superficial great saphenous vein goes to the....
deep femoral vein
63
the superficial small saphenous vein does to the....
deep popliteal vein
64
The deep posterior tibial vein goes to the....
deep popliteal vein
65
The deep anterior tibial vein goes to the....
deep popliteal vein
66
What are the main tributaries of the IVC?
-R gonadal vein -renal veins -R suprarenal vein -inferior phrenic veins -hepatic veins
67
The IVC passes through the diaphragm at....
T8
68
superficial and deep veins communicate/connect via....
perforating veins
69
What is an arterial anastomosis?
connecting arteries that improve circulation
70
What is the arterial anastomosis of the brain?
circle of Willis
71
What is the arterial anastomosis of the heart?
coronary arteries
72
What is a portal system?
capillaries connected by a portal vein Heart, artery, arteriole, capillary bed 1, portal vein, capillary bed 2, venule, vein, heart
73
What is the portal system in the abdomen called?
hepatic portal system
74
What is the hypothalamo hypophyseal portal system?
connects the brain to the anterior pituitary
75
What bones form the eye orbit? Hint: theres 7
-Frontal bone -Lacrimal bone -Ethmoid bone -Sphenoid bone -Zygomatic bone -Maxilla -Palatine bone
76
What foramen is in the frontal bone?
supraorbital foramen
77
What does the supraorbital foramen of the frontal bone house?
supraorbital n. (branch of CN V1 (trigeminal) ophthalmic branch)) and the supraorbital a.
78
What skull bone contains the optic canal?
sphenoid bone
79
What does the optic canal house?
-optic n. -ophthalmic a. and v. -retinal a. and v. -oculomotor n (CN3) -trochlear n (CN4) -trigeminal n (CN5, specifically V1 ophthalmic division)
80
What foramen is in the maxilla?
infraorbital foramen
81
What is housed in the infraorbital foramen of the maxilla?
infraorbital n. (branch of CN V2 (trigeminal) maxillary branch) and infraorbital a.
82
The superior orbital fissure separates what?
greater and lesser wings
83
The inferior orbital fissure separates what?
sphenoid bone and maxilla
84
What structures make up the lacrimal apparatus?
-lacrimal glands -lacrimal canaliculi -lacrimal sac -nasolacrimal duct.
85
What nerve makes you cry?
greater petrosal nerve (branch of facial nerve, CN VII)
86
The lacrimal gland is in the superolateral wall of the orbit in the _________ fossa
lacrimal
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
greater petrosal
88
The nasolacrimal duct communicates w/ the the nasal cavity through the _________ _________. This connection is the reason your nose may run when you cry
inferior meatus
89
The lacrimal sac drains into the ______________ duct which communicates with the nasal cavity through inferior meatus
nasolacrimal
90
The lacrimal sac lies in the sulcus that is formed by the ___________ bone and ___________
lacrimal, maxilla
91
What skeletal muscles move the eyeball? Which nerves move them?
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
92
The corneoscleral tunic is the outer layer of the eye and is made up of __________ tissue. This includes the sclera and cornea
fibrous
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
vascular
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)
nervous, cones, rods
95
Rods= ?, Cones = ?
rods= black and white, cones = color
96
What are the cavities of the internal eye and what separates them?
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
97
What structures can be seen using the ophthalmoscope?
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
98
What is the innermost eye layer?
retina
99
The retina is divided into 2 areas. What are they?
1) pars optica (posterior 2/3, light sensitive) 2) pars ciliaris and pars iridis (anterior 1/3, light insensitive)
100
Pars ciliaris and pars iridis is seperated by....
ora serrata
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
Layer of rods and cones
102
What are the 12 cranial nerves and their function?
103
What cranial nerves have somatic function?
3,4,6, and 9
104
What cranial nerves have parasympathetic function?
3,7,9, and 10
105
What cranial nerves have sympathetic function?
1,2,4,5,6,8,11, and 12
106
What is the primary blood supply to the brain?
circle of wilis (its an arterial anastomosis)
107
The circle of wilis provides for __________ circulation if a vessel becomes occluded
collateral
108
The posterior communicating artery connects the internal carotid system to the....
vertebral/basilar system
109
What artery is blocked that causes 40% of strokes?
middle cerebral artery (MCA, known as an end artery because it terminates into brain tissue)
110
What are the largest arteries of the circle of wilis?
internal carotid arteries
111
Mediastinum is the region that separates....
pleural cavities
112
The heart lies centrally within the....
middle inferior mediastinum
113
The mediastinum is divided into superior and inferior. Inferior mediastinum can be further divided into....
anterior, middle and posterior
114
The superior and inferior mediastinum is separated by....
sternal angle (T4/T5 intervertebral disc)
115
What does the middle inferior mediastinum contain?
-pericardium -heart -roots of the great vessels entering and leaving heart (IVC, SVC, pulmonary arteries/veins, and root of the aorta)
116
Using bony landmarks identify where the apex and base of the heart are located
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
117
Name the cavity and serous membranes associated w/ the heart
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
118
Name the layers that make up the walls of the heart superficial to deep
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)
119
Name the chambers of the heart
R atrium, R ventricle (2nd largest), L atrium, L ventricle (largest)
120
Is the heart symmetrical?
no
121
Coronary sinus empties into the....
R atrium
122
Chordae tendineae is fibrous cords connecting the valve leaflets of the _________ and _________ valves to papillary muscles
tricuspid, mitral
123
Name the valves of the heart. Using surface bony landmarks, where would you auscultate each of those valves?
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
124
Components of EKG= atrial _________ → atrial diastole → ventricular systole → ventricular diastole
systole
125
Trace the blood flow into, through, and out of the heart
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
126
The heart receives blood from the _____________ arteries
R/L coronary
127
The coronary arteries arise from....
the aortic sinuses in the ascending aorta
128
As oxygenated blood leaves the left ventricle to the aorta, a small portion goes back to the heart via....
coronary arteries
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?
SA nodal, right marginal, AV nodal, and posterior IV arteries
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
circumflex
131
Anterior IV branch gives rise to the.....
L marginal branch
132
The posterior and anterior IV arteries anastomose where?
at the apex of the heart
133
The heart is drained by a series of cardiac veins. What are they?
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)
134
Cardiac veins drain into the coronary sinus and returns blood to the....
R atrium
135
Identify the fetal bypass structures and what the become once you are born
Foramen oval and ductus arteriosus They become the ligamentum arteriosum and fossa ovalis once born
136
Where are the kidneys located in relation to the peritoneum?
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)
137
Where are both kidneys positioned in relation to bony landmarks?
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)
138
What structures hold the kidney to the back body wall?
Kidney is held to back body wall by deep renal fascia
139
List the regions of the kidney
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
140
Describe the internal structures of the kidneys and components of a nephron
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
141
Describe the components of the filtration membrane
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))
142
Discuss the macula densa and juxtaglomerular apparatus
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
143
Aldosterone is secreted by the...
renal cortex
144
Aldosterone stimulates reabsorption of sodium and water and secretion of....
potassium
145
Angiotensin 2 is a potent vasoconstrictor produced by the liver and decreases .....
GFR
146
ADH is produced by the hypothalamus and reabsorbs....
water and sodium
147
ANP is produced by the cardiac cells. ANP dilates afferent and constricts efferent, which decreases ______.
GFR
148
What are the BP guidelines?
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?
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
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?
Time for meds, he’s now at stage 2 HTN Give pt anti-HTN meds
151
How do you choose an appropriate anti-HTN med for a pt?
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
152
What are the 3 types/groups of diuretics?
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
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?
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
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
diabetic glomerulopathy
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?
Change diuretics, or can increase dosage and monitor pt
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?
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.
157
3 HTN drugs: diuretics, ACE inhibitors, and.....
ang II receptor antagonist
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.
RAAS, Methyldopa
159
Which of the following antihypertensive medications is considered a safe alternative in pregnancy? A) methyldopa B) lisinopril C) spironolactone D) hydrochlorothiazide
A) methyldopa
160
It is the layer of the retina just deep to the rods and cones:
pigmented layer
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
A) it is a sound in systole
162
The macula densa is not associated with which of the following structures? A) DCT B) PCT C) afferent arteriole D) efferent arteriole
B) PCT
163
The first line of therapy for patients with uncomplicated hypertension who have not responded to lifestyle changes is....
diuretics (ACE inhibitors would be used on pts with DM + HTN)
164
A diagnosis of malignant hypertension must include the following:
papilledema and extreme BP elevation
165
The blood vessels composed of 3 tunics is/are....
arteries and veins
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
C) external carotid artery
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
C) cross the placenta
168
It is the artery most commonly used to obtain standard blood pressure readings
brachial artery

Health Studies (14 decks)

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