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Advanced Anatomy & Physiology > Module 16: Heart and Blood Vessels > Flashcards

Module 16: Heart and Blood Vessels Flashcards

1
Q

the heart lies in a cavity called the

A

mediastinum

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2
Q

what is the mediastinum?

A

thoracic cavity minus pleural cavity (lungs and other associated structures)

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3
Q

the mediastinum includes:

A
  • esophagus
  • thymus
  • great vessels of the heart
  • heart
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4
Q

the mediastinum is located

A

posterior to the sternum and anterior to the vertebral columns

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5
Q

membrane that protects the heart is called

A

the pericardium

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6
Q

define echocardiography:

A

ultrasound of the heart and shows both cardiac anatomy and function

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7
Q

TEE

A

transesophageal echocardiography

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8
Q

what is transesophageal cardiography?

A

by placing a transducer in the esophagus, physicians can get a picture of the heart that is unobstructed by tissues that limit conventional echocardiography

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9
Q

function of the pericardium is to

A

surround and protect the heart

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10
Q

the pericardium consists of what 2 layers?

A
  • deeper serous pericardium

- outermost fibrous pericardium

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11
Q

the serous pericardium consists of what 2 layers?

A
  • visceral layer (deeper and synonymous with epicardium)

- parietal layer (fused to fibrous pericardium)

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12
Q

a tough, dense connective tissue that prevents the heart from over expanding and anchors it to the mediastinum.

A

fibrous pericardium

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13
Q

what is pericardial effusion?

A

an accumulation of excess fluid in this space

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14
Q

why would a pericardial effusion occur?

A
  • infections
  • trauma
  • myocardial infarction
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15
Q

when does a pericardial effusion become life threatening and what is it called?

A
  • when the excess fluid creates enough pressure that it prevents the heart from pumping
  • cardiac tamponade
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16
Q

cardiac tamponade is

A

excess pericardial fluid or leaking blood that keeps the heart from pumping blood

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17
Q

where is pericardial fluid found?

A

within the pericardial cavity between the visceral and parietal layers of the serous pericardium

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18
Q

how many chambers are found within the heart?

A

4 consisting of two atria (superior) and two ventricles (inferior)

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19
Q

collective function of atria

A

receiving/holding chambers for blood

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20
Q

collective function of ventricles

A

pumping chambers for blood to the lungs and body

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21
Q

this chamber receives deoxygenated blood from the body

A

right atrium

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22
Q

this chamber receives oxygenated blood from the lungs

A

left atrium

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23
Q

this chamber receives blood from the right atrium. Its job is to pump deoxygenated blood out to the lungs.

A

right ventricle

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24
Q

this chamber receives oxygenated blood from the left atrium. its job is to pump oxygenated blood out to the body

A

left ventricle

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25
Q

how many valves does the heart have and what are they?

A

4

  • tricuspid valve
  • pulmonary valve
  • mitral (bicuspid) valve
  • aortic valve
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26
Q

how do these valves operate?

A

in pairs

  • AV valves (tricuspid and bicuspid) open together
  • outflow valves (pulmonary and aortic) open together
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27
Q

AV stands for

A

atrioventricular

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28
Q

these valves control the flow of blood between the atria and the ventricles

A

atrioventricular valves (AV)

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29
Q

valve found between the right atrium and right ventricle

A

right atrioventricular valve (AV) or tricuspid valve

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30
Q

valve found between the left atrium and left ventricle

A

left atrioventricular valve (AV) bicuspid valve, or mitral valve.

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31
Q

these valves control the flow of blood leaving the heart from the ventricles. these valves are sometimes referred to as ‘‘semilunar’’ due to their shape

A

outflow valves

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32
Q

this valve regulates blood flow from the right ventricle to the pulmonary trunk (out to the pulmonary circulation)

A

pulmonary valve

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33
Q

this valve regulates blood flow from the left ventricles to the aorta (out to the systemic circulation)

A

aortic valve

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34
Q

this great vessel carries deoxygenated blood to the lungs

A

pulmonary trunk

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35
Q

the pulmonary trunk further divides into the

A

right and left pulmonary arteries

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36
Q

they are named arteries because they do what?

A

lead blood away from the heart

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37
Q

this great vessel carries oxygenated blood from the lungs

A

pulmonary vein

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38
Q

they are named veins because they do what?

A

lead back to the heart

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39
Q

this great vessel takes blood away from the heart to body

A

aorta

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40
Q

the aorta consists of what 3 portions?

A
  • ascending
  • arch
  • descending
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41
Q

these great vessels carry blood from body back to the heart

A

venae cavae

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42
Q

the venae cavae consist of

A
  • superior vena cava (for body above heart)

- inferior vena cava (for body below heart)

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43
Q

largest artery of the body

A

aorta

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44
Q

valvular stenosis

A

valves that are too stiff and don’t open properly

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45
Q

valvular incompetence

A

valves that are too floppy and leak

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46
Q

valvular incompetence commonly leads to

A

valvular regurgitation

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47
Q

valvular regurgitation is

A

when ventricular pressure increases, blood leaks in wrong direction out of wrong (closed) valve

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48
Q

most common valvular heart disease

A

mitral valve prolapse

-often genetic and is more common in women than men

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49
Q

imaging studies such as a ______ or an ______ can help diagnose valvular disorders

A

doppler ultrasound, MRI

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50
Q

turbulent blood causes

A

abnormal sounds

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51
Q

vegetations

A

bacterial growth on heart valves

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52
Q

vegetations can lead to

A
  • incompetent valves

- sepsis

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53
Q

vegetations may break off and become

A

emboli (which may lodge in blood vessels restricting blood flow)

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54
Q

cause of vegetations

A

endocarditis

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55
Q

special cells that consist of 1% of the hearts cells

A

autorhythmicity cells

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56
Q

the action potential of a cardiac autorhythmic cell consists of what 3 ions?

A
  • sodium (Na+)
  • potassium (K+)
  • calcium (Ca++)
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57
Q

the autorhythmic cell never rests so it does not have a resting membrane potential

A

FREEBEE ;)

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58
Q

explain the 3 steps of autorhythmicity

A
  1. Na+ channels open causing the membrane to “drift” towards the threshold
  2. After threshold is hit, Ca++ channels open causing depolarization of the cell membrane
    K+ leak channels close
  3. K+ channels open causing depolarization of the cell membrane
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59
Q

an increase in K+ does what to the heart?

A

slows it down

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60
Q

an increase in Na+ does what to the heart?

A

blocks Ca++ from entering the cells, slowing down the heart

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61
Q

moderate increase in Ca++ does what to the heart?

A

speeds it up and strengthens it

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62
Q

the three phases of cardiac muscle cell action potential

A
  1. Depolarization
  2. Plateau
  3. Repolarization
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63
Q

what happens during the depolarization phase of cardiac muscle action potential?

A

-when an action potential is triggered, voltage gated fast Na+ channels open which quickly leads to depolarization of a cell.

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64
Q

what is the resting potential of contractile muscle cells

A

-90mv

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65
Q

what happens during the plateau phase of cardiac muscle action potential?

A
  • voltage gated channels slow ca++ channels in the sarcolemma open
  • Ca++ flows into the cytosol triggering further release of Ca++ from the sarcoplasmic reticulum
  • Ca++ ions bind to troponin allowing actin and myosin to bind, sliding past each other and causing contraction.
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66
Q

what happens during the repolarization phase of cardiac muscle action potential?

A
  • voltage gated K+ channels open causing K+ to rush out of the cell
  • Ca++ channels close at the same time. this restores the negative membrane potential
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67
Q

instead of 3 msec, cardiac muscle cells action potential lasts

A

300 msec

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68
Q

refractory period

A

time during which a second action potential cannot be triggered

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69
Q

EKG lasts how long?

A

about the same time as cardiac muscle action potential at about 300 msec

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70
Q

QRS is

A

rapid depolarization as ventricular muscle cells open Na+ channels

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71
Q

QT interval is

A

the time Ca++ channels are open during the plateau of an action potential and repolarization

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72
Q

T is

A

the depolarization from an influx of K+

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73
Q

when measuring blood pressure the top number in the reading reflects

A

the systolic pressure

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74
Q

what is the systolic pressure?

A

pressure of the left ventricle before and after systole

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75
Q

when measuring blood pressure the bottom number in the reading reflects

A

the diastolic pressure

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76
Q

what is the diastolic pressure?

A

pressure when the left ventricle rests

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77
Q

normal BP

A

120/80

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78
Q

a blood reading of 120/80 reflects

A
  • systolic pressure of 120mmHg

- diastolic pressure of 80mmHg

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79
Q

pulmonary BP is a result of

A

right ventricular function (not easily measured)

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80
Q

heart rate

A
  • beats per minute (bpm)

- number of cardiac cycles per minute

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81
Q

end-diastolic volume

A
  • at diastole, ventricles fill to about 120 ml

- ventricular volume at diastole is the EDV

82
Q

end-systolic volume

A
  • amount remaining in ventricles after contraction

- about 50 ml

83
Q

stroke volume output

A
  • at systole, volume of ventricles decrease by amount pumped out
  • end-diastolic volume - end-systolic volume = about 70 ml
  • this is stroke volume output
84
Q

ejection fraction

A
  • stroke volume output divided by end-diastolic volume
  • percentage of ventricle emptied at systole
  • usually 60% (70ml/120ml)
  • lower ejection fraction means blood is pooling in heart and may clot
  • also, heart isn’t effectively pumping (congestive heart failure)
85
Q

cardiac output

A

-quantity of blood pumped into aorta each minute

86
Q

frank-starling mechanism

A

the more the ventricles fill, the more forcefully they contract

87
Q

maximum heart rate is about

A

220 minus age

88
Q

connect arterial blood flow to venous return

A

capillaries

89
Q

precapillary sphincters are

A

smooth muscle cuffs that regulate blood flow through capillary bed

90
Q

what are the three types of capillaries found in the body?

A
  • continuous
  • fenestrated
  • sinusoids
91
Q

continuous capillaries

A
  • endothelial cells that form a continuous tube, interrupted only by small intercellular clefts
  • passage of substances by pinocytosis
92
Q

fenestrated capillaries

A
  • holes + basement membrane allows passage of substances

- found in the kidneys, villi of the small intestine and endocrine glands

93
Q

sinusoids

A
  • open spaces between cells and in basement membrane
  • substances easily pass into and out of these substances
  • found in the liver and the spleen
94
Q

autoregulation is due to

A

low oxygen in tissues

95
Q

when precapillary sphincters are relaxed….

A

blood flows through capillary bed

96
Q

when precapillary sphincters are contracted…

A

blood bypasses capillary bed and takes thoroughfare channel

97
Q

autoregulation

A

ability of capillaries to regulate blood flow

98
Q

blood flow

A

volume of blood that flows through any tissue in a given time period

99
Q

blood that flows too slowly is prone to

A

clots

100
Q

recall ohm’s law

A

V is voltage, analogous to pressure
I is current, analogous to flow rate
R is resistance

101
Q

if pressure increases, blood flow _________

A

increases

102
Q

if resistance increases, blood blow _________

A

decreases

103
Q

Name the layers of the heart wall from deep to superficial

A

Endocardium
Myocardium
Epicardium
Pericardium

104
Q

Simple squamous epithelium lining the inside of the heart

  • can develop chronic infections
A

Endocardium

105
Q

The heart muscle proper. 95% of the heart and is responsible for the pumping action

A

Myocardium

106
Q

Epithelium lining the outside of heart = visceral labor of serous pericardium (slippery covering)

A

Epicardium

107
Q
  • parietal labor of serous pericardium

- fibrous pericardium

A

Pericardium

108
Q

Cardiac muscle Tissue

A
  • striated
  • shorter, branch, & have 1 or 2 centrally-located nuclei
  • intercalated discs
  • > amt. & larger mitochondria than skeletal muscle (for energy)
109
Q

Function of Intercalated discs

A

For structural strength

110
Q

Function of gap junction

A

To synchronize muscle cell contraction (allow muscle action potentials to travel between fibers)

111
Q

Chordae tendinae

A

Chordlike tendons that are anchored to papillary muscles

112
Q

Function of R ventricle

A

Pumps short distance and against low pressure to lungs

113
Q

Function of L ventricle

A

Pumps long distance and against large pressure to body (very thick compared to Right)

114
Q

Functions of valves

A
  • don’t actively open; they’re pushed open by ⬆️ pressure
  • chordae tendinae help keep valves in place
  • mainly act as “back flow preventers”
115
Q

Pattern of Blood Flow (1-10)

A

1) blood from superior and inferior vena cava enters R atrium
2) blood flows from R atrium to R ventricle via tricuspid valve tricuspid & mitral valves open
3) blood pumped from R ventricle to pulmonary artery (trunk) via pulmonary valve pulmonary & aortic valves open
4) blood oxygenated in pulmonary capillaries of lungs
5) blood returns to heart via pulmonary veins
6) oxygenated blood from lungs returns to L atrium
7) blood flows through mitral (bicuspid) valves into L ventricle tricuspid & mitral valves open
8) blood is pumped through aortic valve into aorta pulmonary & aortic valves open
9) blood distributed to body through branches off aorta and other vessels into capillaries
10) blood returns to heart via systemic veins and vena cava

116
Q

When cardiac cells can fire regular rate action potentials without nervous stimulation or outside control

A

Autorythmicity

117
Q

Sinoatrial node

A

Heart’s pacemaker(fires action potentials about 100x per minute), cardiomycocytes

Located near Coronary sinus and R atrium

118
Q

A cluster of special heart muscle cells at the base of the heart

A

Cardiomycocytes

119
Q

Atrioventricular node

A

“backup/ectopic pacemaker”

Located near junction of L atrium and R ventricle

120
Q

Atrioventricular bundle of His

A
  • leads from AV Node and through the interventricular septum

- splits into R & L bundle branches

121
Q

Perkins fibers

A

Large caliber, non-contractile cells conduct the electrical impulses to the cardiac muscle cells of the R & L ventricles

122
Q

Where is the cardiovascular center located

A

The medulla

123
Q

What do baroreceptors sense

A

Blood pressure

124
Q

If blood pressure is too high, the ____________________________ responds to ______ the heart rate through the _____________.

A

Parasympathetic nervous system

slow down

Vagus nerve

125
Q

If blood pressure is too low, the _________________________ responds to _________ the rate of the heart through _______________________.

A

Sympathetic nervous system

Speed up

Cardio-accelerator spinal nerves

126
Q

Sympathetic in regard to innervation of the heart

A
  • respond to norepinephrine and epinephrine release
  • ⬆️ heart rate & stroke volume
    • B1-adrenergic receptors
    • B2-adrenergic receptors
127
Q

Parasympathetic in regards to innervation of the heart

A
  • responds to ACh release
  • ⬇️ heart rate
    • muscarinic (M2) receptors
128
Q

P wave =

A

Atrial depolarization

129
Q

P-Q wave =

A

Atrial “kick” fills ventricles

- amt. of time it takes for the atria to depolarize

130
Q

QRS wave =

A
  • ventricles depolarize

- atria repolarize

131
Q

S-T segment =

A

Blood flows out, emptying ventricles

132
Q

T wave =

A

Time from ventricular depolarization to Ventricular repolarization

133
Q

Atrial fibrillation

A

Most common acute EKG abnormality

- almost normal QRS but missing P

134
Q

Ventricular tachycardia

A
  • ventricle depolarizes, but pumping action not effective
135
Q

Ventricular fibrillation

A

disorganized electrical activity

- life threatening (blood not moving to lungs)

136
Q

Systole

A

Contraction

137
Q

Diastole

A

Relaxation

138
Q

Cardiac cycle

A
  1. Diastole (entire heart relaxes, atria fill with blood)
  2. Atrial systole ( atria contract, atrial “kick”)
  3. Ventricular systole (powerful ventricular contraction sends blood from R ventricle to lungs and L ventricle to body)
139
Q

Individual events of the cardiac cycle:

A
  1. Action potential starts at the SA node causing depolarization of atrium producing P wave
  2. (Atrial systole) atria contract
  3. (QRS wave) actions potential pauses at AV node. Then spreads to ventricles = depolarization
  4. contraction of ventricles. Begins shortly after QRS complex appears and continues during S-T segment
  5. (T wave) repolarization of ventricles
  6. Ventricular diastole begins shortly after T wave begins
140
Q

2 loudest heart sounds

A

S1: low pitched “lubb”
• AV valves closing, outflow(semilunar) valves open
S2: higher pitched “dub”
• outflow valves close, AC valves open

141
Q

AV valves

A

Tricuspid & mitral

142
Q

Outflow (Semilunar) valves

A

Pulmonary & aortic

143
Q

Listening to sounds of the heart

A

Auscultation

144
Q

Structure of a Blood Vessel

A

Lumen
Tunica interna
Tunica media
Tunica externa

145
Q

The opening of the vessel

A

Lumen

146
Q

Forms the innermost layer of blood vessel and consists of a simple layer of squamous epithelium connected to a basement membrane

A

Tunica interna

147
Q
  • Muscular tissue & connective tissue

* vasoconstriction and vasodilation in arteries controls blood flow and blood pressure

A

Tunica media

148
Q
  • elastic and collagen fibers

* sympathetic nerves and tiny blood vessels (Vaso vasorum) in larger vessels

A

Tunica externa

149
Q
  • smooth muscle layer thickened

- lumen diameter can change depending on muscle tone

A

Artery

150
Q
  • thin or absent smooth muscle layer
  • lumen diameter does not change
  • valves prevent backflow
A

Veins

151
Q

Elastic arteries

A
  • large diameter
  • thin walls
  • able to withstand high pressure
152
Q

Muscular (distributing) arteries

A
  • medium diameter
  • more smooth muscle
  • fewer elastic fibers
153
Q

Arterioles

A
  • tiny arteries

- these adjust the rate of blood flow to the capillaries

154
Q

Capillaries

A

Site of nutrient and gas exchange

155
Q

Venules

A

Small veins

156
Q
  • valves become incompetent and “floppy”
  • backflow of blood results
  • pooling occurs: venous stasis
  • increase risk of clots forming
A

Varicose veins

157
Q

Capillary exchange

A
  1. Capillaries are specializes for exchange of materials
  2. Filtration: O2, glucose, other nutrients must be delivered to cells
  3. Reabsorption: CO2, acid, urea, other wastes must be carried away to be excreted
158
Q

Starling’s Law of the Capillary

A
  • hydrostatic pressure
  • this is opposed by the concentration force of water trying to dilute out higher concentration of dilutes in blood (interstitial fluid osmotic pressure)
  • Balance between these forces = Starling Forces –> equation is Starling’s Law of the Capillary
  • interstitial fluid osmotic pressure is about the same throughout capillary, but hydrostatic pressure drops
  • capillary delivers nutrients on the Arterioles side, and picks up wasted on the Venule side
159
Q

Hydrostatic pressure

A

Delivery of nutrients to tissue depends on blood pressure at capillary

160
Q

Blood hydrostatic pressure

A

About 33mmHg

161
Q

Where does Interstitial fluid osmotic pressure come from and what does it do

A

The presence of plasma proteins that cannot cross the capillary….it opposes blood hydrostatic pressure but it smaller at 25 mmHg

162
Q

Vasoconstrictors

A 
Norepinephrine
Epinephrine 
ADH
Angiotensin ll
Endothelium-derived factors 
  • released in low blood flow
163
Q

Vasodilator a

A 
Atrial natriuretic peptide
Nitric oxide
Inflammatory mediators
   • histamine (also increases capillary permeability)
   • prostacyclin
   • kinins
Ethanol
   •inhibits ADG & vasomotor center
164
Q

Describe changes in arterial pressure throughout the circulation

A

Blood pressure in highest in the aorta as it leaves the heady. As blood travels through the systemic circulation, it gets farther and farther away from the pump and pressure drops.

165
Q

Describe changes in venous pressure throughout the circulation

A

When blood gets to the venous system, BP in very low. Blood helps muscles act as help

The closing of valves in the veins prevents the blood from running backwards. Changes in pressure during inhalation also draws venous blood back up towards the heart

166
Q

The response to an increase in blood pressure (detected by stretching of baroreceptors):

A
  1. Nerves from the medulla increase parasympathetic stimulation by the vagus nerve and decrease sympathetic stimulation
  2. Rate of impulses on sympathetic neurons to the vessels slow, causing vasodilation

= ⬇️ blood pressure

167
Q

Response when blood pressure is low:

A

Baroreceptors stretch less and send impulses at slower rate

  1. The cardiovascular center decreases parasympathetic stimulation and increases sympathetic stimulation
  2. Adrenal medulla increases secretion of epinephrine and norepinephrine
  3. Blood vessels constrict. Blood pressure increases as a result
168
Q

What do chemoreceptors do

A

Sense the chemical composition of the blood. Detect pH, O2, CO2, & H+ levels

Located: close to baroreceptors of carotid bodies and aorta

169
Q

Carotid artery

A
  • splits into internal carotid (to brain) & external carotid (to face)
  • structure called carotid body at this point
170
Q

Response to conditions of hypoxia, acidosis, or hypercaonia

A

An increase in sympathetic stimulation to Arterioles and veins causing vasoconstriction and increasing blood pressure

171
Q

About ____ % of blood is in the venous system

A

60%

172
Q

Function of venous reserve

A

If massive blood loss occurs, baroreceptors of carotid sinus signal emergency

•nervous system can mobilize about 1 L blood from organs with venous reserves
- blood reservoirs
{systemic veins and venules}
{e.g. Spleen and liver}

173
Q

Most of the blood draining from the head pass through what three pairs of veins

A

Internal jugular
External jugular
Vertebral veins

174
Q

The right and left ______ pass inferiorly on either side of the neck, then join with the subclavian veins to form the right and left _______________.

A

Internal jugular, brachiocephalic veins

175
Q

________________ are superficial veins that run down the lateral sides of the head. They empty into the subclavian veins.

A

External jugular veins

176
Q

_____________ originate in the occipital area of the brain. They descend through the foramina of the cervical vertebrae amp tying into the brachiocephalic veins of the neck. The brachiocephalic veins empty into the __________________

A

Vertebral veins

Superior vena cava

177
Q

Most common site of venipuncture

A

Right median cubitak veins

178
Q

Cephalic V.

A

Lateral

179
Q

Basilic V.

A

Medial

180
Q

The paired brachial veins drain:

A

Forearms
Elbow joint
Arms
Humerus

…pass superiorly and join with the basilica veins to join the axillary veins

181
Q

The _________ and __________ veins are the principle veins draining blood from the upper limbs

A

Basilic

Cephalic

182
Q

Cephalic veins

A

Run superficial and on let weak sides of limbs

183
Q

Basilic veins

A

Deep, running in medial sides of limbs

184
Q

Anterior to he elbow, the basilic veins drains into the ___________________ which drains the forearms. (these are preferred veins for a venipuncture)

A

Median cubital veins

185
Q

The cubital veins drain into the ___________ which in turn empty into the __________.

A

Axillary veins

Subclavian veins

186
Q

The internal and external iliac veins join together to form the ____________, which drains the pelvis, external genitals, and lower limbs.

A

Common iliac vein

187
Q

The paired common Iliad veins empty into the __________

A

Inferior vena cava

188
Q

Veins draining the digestive organs lead to the _____________ which supplies the live with blood to be filtered

A

Hepatic portal veins

189
Q

The ___________ also join the inferior vena cava brining filtered blood back to the systemic circulation

A

Renal veins

190
Q

The _______________ are the longest veins in the body traveling from the foot to the groin

A

Great saphenous veins s

191
Q

The ____________ drain the knee joint joints

A

Popliteal veins drain the knee joints

192
Q

The ___________ are continuous if the popliteal veins

A

Femoral veins

193
Q

Systemic circulation

A

oxygenated blood in L atrium enters the L ventricle through the L AV valve ➡️ L ventricle sends oxygenated blood out through the aorta and to the body ➡️ at the capillaries oxygen diffuses to the cells and CO2 diffuses to the blood ➡️ blood returns to R atrium of the heart through the inferior and superior vena cava

194
Q

Pulmonary circuit

A

Carries deoxygenated blood from the R ventricle to the alveoli within the lungs and returns oxygenated blood from the alveoli to the L atrium ➡️ blood leaves the R ventricle through the pulmonary trunk ➡️ branches into the R and L pulmonary arteries ➡️ oxygenated blood from lungs return through pulmonary veins to L atrium

195
Q

Lymphatic drainage

A

Lymphatic capillaries are filtered through lymph nodes into lymphatic vessels ➡️ all lymphatic vessels eventually anastomose into lymphatic duct ➡️ lymphatic duct drains into venous circulation at subclavian V.

196
Q

Look at Ohm’s Law on page 774 because im lazy

A

FREEBEE

197
Q

N=

A

blood viscosity

198
Q

L=

A

length of all blood vessels in the body

199
Q

Prehypertension

A

at risk of developing hypertension
systolic pressure = 121-39
diastolic pressure = 81-89

200
Q

Hypotension

A

low blood pressure that is too low to adequately deliver O2 and nutrients to vital organs.

201
Q

atherosclerosis leads to hypertension in two ways

A
  • decrease in elasticity of arteries

- decrease in diameter of arteries

Advanced Anatomy & Physiology (10 decks)

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