review questions Flashcards
Which of the following structures would a deep vein thrombus in the leg reach first?
a. aorta
b. L atrium
c. L ventricle
d. pulmonary arteries
e. pulmonary vein
d. pulmonary arteries
Tracer dye is injected into a patient’s skin. Based on the path of tissue fluid flow from the skin, which of the following would the tracer dye reach last and therefore be least likely to show the tracer dye?
a. arteries
b. heart
c. lymphatic vessels
d. lymph nodes
e. veins
a. arteries
lymph enters lymphatic capillaries in connective tissue —> enters lymph nodes via afferent lymph vessels and exits via efferent lymph vessels —> lymph drains into venous circulation at R/L venous angles (where subclavian and internal jugular veins meet) via right lymphatic duct and thoracic duct —> enters right side of heart and leaves via pulmonary arteries to lungs
in a standard radiograph:
a. blood is more radiolucent than fat
b. cartilage is more radiopaque than blood
c. cartilage is more radiopaque than bone
d. enamel is more radiolucent than bone
e. fat is more radiolucent than muscle
e. fat is more radiolucent than muscle
radiopacity —> radiolucency
1. foreign heavy metal
2. enamel
3. bone
4. water density (muscle, cartilage, tendon, bone, nerve, connective)
5. fat
6. air
Faulty neural crest cell migration would result in multiple defects, including defective formation of (2):
a. cardiac septa and cardiac valves
b. the CNS
c. cornea and lens of the eye
d. epithelium of GI and UG systems
e. epithelium of respiratory system
f. ganglia
g. tooth enamel
a. cardiac septa and cardiac valves
AND
f. ganglia
neural crest cells form some connective tissues, nervous tissue, muscle tissues, endocrine tissues, melanocytes, odontoblasts (teeth), and cardiac septa & valves
the cardiovascular system forms from:
a. intermediate mesoderm
b. lateral plate mesoderm, parietal layer
c. lateral plate mesoderm, visceral layer
d. notochord mesoderm
e. paraxial mesoderm
c. lateral plate mesoderm, visceral layer
lateral plate mesoderm (cavity):
1. parietal/somatic mesoderm: deep to ectoderm, forms CT of body walls and parietal serosa lining body cavity
2. visceral/splanchnic mesoderm: superficial to endoderm, forms muscles and CT of internal viscera/organs, forms visceral serosa covering viscera/organs
Obstruction in the LAD would limit blood supply to myocardium of the:
a. anterior 2/3 of the IV septum
b. AV node
c. posterior 1/3 of the IV septum
d. right atrium
e. SA node
a. anterior 2/3 of the IV septum
blood supply to ventricular septum:
anterior 2/3 is LCA (left carotid artery)
posterior 1/3 is RCA
As a result of an endocardial infection, your patient suffers a rupture of the chordae tendineae of the right ventricle. This is likely to result in an alteration of blood flow that will cause a:
a. diastolic murmur that is heard best at the left fifth intercostal space at the sternal border.
b. diastolic murmur that is heard best at the right second intercostal space at the sternal border.
c. systolic murmur that is heard best at the left fifth intercostal space at the midclavicular line.
d. systolic murmur that is heard best at the left second intercostal space at the sternal border.
e. systolic murmur that is heard best at the right fifth intercostal space at the sternal border.
e. systolic murmur that is heard best at the right fifth intercostal space at the sternal border.
Chordae tendinae are associated with AV valves, which on on the R is tricuspid valve. AV valves are OPEN during diastole. Ruptured chordae tendinae would impair the ability of AV valves to CLOSE properly (would allow valves to swing open the other way) and so there would be regurgitation… so murmur would be a systolic one, when AV valve should be closed.
Since defect causes regurgitation, “downstream” of the valve is upstream, so you would listen on the right side of the sternal border, rather than the usual auscultation point on the left
Your patient has suffered a stab wound to the right side of his thorax between the 4th and 5th ribs. Which of the following observations lead you to suspect a tension pneumothorax as opposed to an open pneumothorax?
a. His mediastinum deviates to the right when he exhales.
b. His mediastinum deviates to the right when he inhales.
c. His trachea is deviated to the left and he is cyanotic.
d. His trachea is deviated to the right and he is cyanotic.
c. His trachea is deviated to the left and he is cyanotic.
With TENSION PNEUMOTHORAX mediastinal shifts (including the trachea) are to the opposite side of the injury. In this case as air/tension builds in the right pleural space, there is a mediastinal shift to the left, and inhaled air is unable to escape the shifted trachea.
- A baby is born premature at seven months of gestation with a patent ductus arteriosus. A reason that the incidence of patent ductus arteriosus is higher in pre-term babies than it is in full term babies is that the
a. level of circulating prostaglandin is too low in pre-term babies to allow closure of the ductus.
b. oxygen level in the blood flowing through the ductus arteriosus in pre-term babies is too high to allow closure of the ductus.
c. pressure in the pulmonary circulatory system is too low in pre-term babies to allow closure of the ductus.
d. reversal of the pressure gradient between the right and left sides of the circulatory system does not occur until later in gestation.
e. underdevelopment of the alveoli of the lung in pre-term babies results in inadequate oxygenation of the blood in the pulmonary circuit.
e. underdevelopment of the alveoli of the lung in pre-term babies results in inadequate oxygenation of the blood in the pulmonary circuit.
increased oxygen&bradykinin + decreased prostaglandin causes closure of the ductus arteriosus
An underweight infant has “tet spells” of cyanosis (turning blue) when he cries and the cyanosis resolves when he is placed in a knee-to-chest position. Based on this presentation, Tetralogy of Fallot (TOF) is suspected and confirmed with further evaluation of a boot-shaped heart on radiographic imaging. TOF results from displacement of the embryonic aorticopulmonary septum, which leads to defects of structures derived from the
a. bulbus cordis.
b. primitive atrium.
c. primitive pulmonary vein.
d. sinus horns.
e. sinus venosus.
a. bulbus cordis
What is a tell-tale radiological sign of Tetralogy of Fallot?
boot-shaped heart, due to hypertrophy of the R ventricle
4 defects: pulmonary stenosis, overriding aorta, ventricular septal defect, hypertrophy of R ventricle
A patient has a solid mass located immediately superior to the root of the right lung. Which structure would most likely be compressed by this mass?
arch of the azygos vein - passes superior to the root of the right lung to enter the superior vena cava
what is the sternal angle a landmark for?
sternal angle is landmark for articulation between sternum and costal cartilages of 2nd ribs (anteriorly), T4-T5 (posteriorly), transverse thoracic plane, start/end of the aortic arch, and carina (bifurcation of the trachea)
at what vertebral level are presynaptic sympathetic neurons found?
T1-L2
(presynpatic parasympathetic are S2-S4)
what is found in dorsal vs ventral root of spinal cord?
dorsal root = sensory axons
ventral root = motor axons
merge into mixed spinal nerve, with anterior and posterior ramus (also mixed)
what nerve loops around the aortic arch
left recurrent (read: making a U turn) laryngeal nerve loops around aortic arch to head back up to larynx
where does blood from the right posterior intercostal veins drain into?
azygos vein
what is the septomarginal trabecula and where is it found (specifically)
aka moderator band, found extending from muscular IV septum to anterior papillary muscle in RIGHT ventricle
what artery courses alongside the great cardiac vein?
LAD (left anterior descending) courses along great cardiac vein in anterior IV groove
what is the fossa ovalis a remnant of?
septum primum (the spot where it was not covered by septum secundum)
what embryologic structure are the AV valves and semilunar valves formed from, respectively?
AV valves form from atrioventricular endocardial cushions
semilunar valves form from conotruncal endocardial cushions
what do the umbilical veins and artery become after birth, respectively
umbilical vein —> ligamentum teres
umbilical artery —> medial umbilical ligaments
where exactly are the following located:
a. SA node
b. AV node
c. AV bundle
d. bundle branches/ Purkinje fibers
a. SA node: junction of SVC and R atrium
b. AV node: interatrial septum
c. AV bundle: membranous part of IV septum (IVS)
d. bundle branches/ Purkinje fibers: subendocardium of ventricular walls
what is carried by the ductus venosus and ductus arteriosus in the fetal heart?
ductus venosus carries IVC blood (more oxygenated because mixes with umbilical artery blood)
ductus arteriosus carries SVC blood to arch of aorta after branch points for cranial arteries (not oxygenated)
CNS develops from ____ while PNS develops from ____
neural tube —> CNS (brain/spinal cord)
neural crest cells —> PNS (spinal nerves, cranial nerves, ganglia)
Explain why it makes sense that ACh signaling (PSNS) slows down HR by causing K+ outflow,
While hyperkalemia causes tachycardia by inducing a more depolarizing state
Keep in mind there is usually more K+ inside cell than out, and the inside of the cell is more negative than out (via Na/K ATPase)
ACh causes K+ outflow —> inside of the cell becomes even more negative compared to out —> harder for depolarization to occur
Hyperkalemia (high K+ in blood) lessens the difference between in/out, so K+ within cells is less likely to leave —> inside of the cell becomes more positive —> depolarizing effect
What part of the ECG does S2 overlay?
S2 = semilunar valve closure
corresponds to T wave (ventricular repolarization)
What part of the ECG does S2 overlay?
S2 = semilunar valve closure
overlays T wave (ventricular repolarization)
Changes in ANS cardiac tone would most profoundly reflect changes in duration of [systole/diastole]
diastole
according to Frank-Starling law, the strength of ventricular contraction is directly proportional to…
end-diastolic volume
more volume in means stronger contraction to send it back out
which of the following is most likely to cause edema?
a. hypotension
b. decreased plasma protein
c. decreased plasma hydrostatic pressure
d. decreased total peripheral resistance
b. decreased plasma protein
aka less albumin in blood, therefore less oncotic pressure to pull fluid back into capillaries on venous end
which of the following most accurately describes CO?
a. stroke volume / TPR
b. heart rate / (EDS - ESV)
c. stroke volume x heart rate
CO = SV x HR
An otherwise healthy patient is experiencing an episode of atrial fibrillation - which of the following is most likely to be measured?
a. abnormally low BP
b. bradycardia
c. reduced ventricular filling
d. impaired CO
e. increased venous return
c. reduced ventricular filling
atrial contraction contributes ~20% of ventricular filling
Damage to the ventral ramus of T1 spinal nerve would affect:
a. somatic fibers and sympathetic fibers
b. parasympathetic motor fibers
c. efferent fibers only
d. afferent fibers only
a. somatic fibers and sympathetic fibers
rami of spinal nerves are mixed, but presynaptic sympathetic are present in T1-L2 while parasympathetic are present in S2-4
Failure of which of the following developmental events would result in cyanosis after birth?
a. ductus arteriosus closure
b. septum primum fusion with septum secundum
c. membraneous interventricular septum fusion with the muscular interventricular septum
d. aorticopulmonary septum formation
e. septum primum fusion with the endocardial cushion tissue
d. aorticopulmonary septum formation — failure causes mixture of blood from RV and LV —> cyanosis
Rupture of the chordae tendinae of the right ventricle would most likely result in:
a. systolic murmur that is heard best at the left second intercostal space at the sternal border
b. systolic murmur that is heard best at the left fifth intercostal space at the midclavicular line
c. systolic murmur that is heard best at the right fifth intercostal space at the sternal border
d. diastolic murmur that is heard best at the right fifth intercostal space at the sternal border
e. diastolic murmur that is heard best at the left second intercostal space at the sternal border
c. systolic murmur that is heard best at the right fifth intercostal space at the sternal border
ruptured chordae tendinae —> prolapsed tricuspid valve —> systolic (AV valve should be closed here) murmur at right 5th intercostal space at sternal border (this is regurgitation - downstream of murmur is retrograde)
Pt is a 47yo F presenting with a Pancoast tumor which is obstructing their SVC, causing edema in their extremities and…
a. increased blood flow to the right atrium
b. pleural effusion
c. jugular venous distention
c. JVD - tributary to SVC, therefore would have high pressure if SVC is obstructed
Pancoast tumors are lung carcinomas that can compress nearby structures, including the recurrent laryngeal nerve, sympathetic stellate ganglion, SVC, brachiocephalic vein, brachial plexus, and phrenic nerve. Which of these would least likely be found in a patient with a Pancoast tumor?
a. mediastinal shift
b. JVD
c. hoarseness of voice
d. sensorimotor deficits in the upper limb
e. hemi-diaphragm paralysis
f. Horner’s syndrome
a. mediastinal shift
JVD —> due to SVC compression
voice hoarseness —> due to recurrent laryngeal nerve compression
sensorimotor deficits —> due to compression of brachial plexus
hemi-diaphragm paralysis —> due to phrenic nerve compression
Horner’s syndrome —> due to compression of stellate ganglion of sympathetic chain
which of these conducts blood with the lowest O2 saturation in the fetus?
a. umbilical vein
b. ductus venosus
c. ductus arteriosus
d. umbilical arteries
c. ductus arteriosus
deoxygenated blood from SVC passes through RA—>RV—>pulmonary artery—> ductus arteriosus —> arch of aorta
Pt is a 64yo F presenting with a diastolic heart murmur best heard at the L 5th intercostal space at the sternal border.
The most likely cause is:
a. incompetent tricuspid valve
b. incompetent mitral valve
c. incompetent pulmonic valve
d. stenotic mitral valve
e. stenotic aortic valve
c. incompetent pulmonic valve
incompetent valve causes regurgitation… working backwards from pulmonic valve, “downstream” would be L 5th intercostal space at the sternal border (where tricuspid is normally auscultated)
Which of the following embryological events accounts for the location of the SA node in the adult heart?
a. replacement of the ostium primum by the ostium secundum
b. neural crest cell migration into the atrioventricular endocardial cushion tissue
c. incorporation of the sinus venosus into the right atrial posterior wall
d. neural crest cell migration into the conotruncal cushion tissue
c. incorporation of the sinus venosus into the right atrial posterior wall
heart tube folds via cardiac looping to result in placement of sinus venosus (with nearby SA node) into atria superior to ventricles - on the R side of heart, some of sinus venosus with SA node incorporates into posterior R atrium near the location of the SVC, while on the L side of the heart, the left horn of the sinus venosus incorporates into the heart to form the coronary sinus
A patient presents with stenosis of the LAD. Their heart is right dominant. Which of the following arteries would there most likely be retrograde blood flow?
a. right coronary artery proximal to the origin of the right marginal artery
b. posterior interventricular (descending) artery proximal to the apex of the heart
c. anterior interventricular (left anterior descending) artery distal to the stenosis
d. right marginal artery
c. anterior interventricular (left anterior descending) artery distal to the stenosis
in R coronary artery dominant heart, the posterior descending artery is a branch of the right coronary artery - in this case blood would flow anterograde in the posterior descending artery to reach the LAD where the 2 arteries anastomose - because pressure is lower in LAD distal to stenosis (due to limited blood flow), blood would flow retrograde
Drug X confers inactive conformation of Na+ channels within type A-delta afferents, allowing only sub-threshold levels of Na+ influx. What kind of drug is this?
a. anti-arrhythmic
b. alpha toxin
c. ACh agonist
d. tetrodotoxin
e. anesthetic
e. anesthetic
Type A-deltas are involved in afferent pain relay
Drug Z acts by prolonging phase 0 of cardiac myocyte AP. Which of the following best describes the mechanism?
a. block Cl- channels
b. activate Ca2+ channels
c. activate K+ channels
d. block Na+ channels
e. up-regulate Na+/K+ ATPase activity
d. block Na+ channels
If left untreated, hyperkalemia can reduce the excitability of muscle cells by which mechanism?
a. lowering the Nernst potential for Na+
b. cell hyperpolarization drives threshold toward 0 mV
c. increased Na+/K+ ATPase activity hyperpolarizes the cells
d. depolarization inactivates voltage-gated Na+ channels
e. raising the electromotive force for K+ efflux from cells
d. depolarization inactivates voltage-gated Na+ channels
if severe enough, hyperkalemia can make RMP less negative (more K+ stays in cell because there is so much of it outside the cell - lessens the concentration gradient) —> initially depolarizing effect (allows activation of voltage-gated Na+ channels), but as membrane potential is clamped at this less negative voltage, Na+ channels begin to inactive due to built-in timer (fail safe) mechanism
A medication working by which of the following mechanisms would most likely reduce a patient’s pulse?
a. inhibition of type 2 cholinergic-muscarinic receptors
b. hyperpolarization of sinoatrial nodal cells
c. inhibition of type alpha 2 adrenoreceptors
d. stimulation of type beta 1 adrenoreceptors
e. inhibition of cardiomyocyte Na+/Ca2+ exchangers
b. hyperpolarization of sinoatrial nodal cells —> RMP made more negative —> increased time required to reach threshold —> lower HR
A drug working by which mechanism would most likely lower a patient’s cardiac sympathetic tone?
a. alpha2 antagonist
b. alpha1 antagonist
c. beta1 antagonist
d. beta2 antagonist
e. cholinomimetic
f. cholinesterase antagonist
g. catecholamine
h. cholinergic-muscarinic agonist
c. beta1 antagonist —> this would block SNS activity
blocking which of the following would reduce contractility of cardiomyocytes?
a. SERCA
b. Na+/K+ ATPase
c. L-type Ca2+ channels
d. Na+/Ca2+ exchanger
e. type 2 cholinergic-muscarinic receptors
c. L-type Ca2+ channels
recall that L channels allow for calcium influx, and inotropic state of myocardium is directly proportional to the level of intracellular calcium
all muscle contractions begin as ______, and only ______ contraction occurs if preload overcomes afterload
all muscle contractions begin as ISOMETRIC, and only ISOTONIC contraction occurs if preload overcomes afterload
Pt is a 73yo F presenting with PE significant for BP of 148/85mmHg, pulse 75/min and regular, RR 15/min. Electrocardiography shows sinus rhythm with QRS duration in lead V1 of 0.14 seconds (ref. 0.06-0.10s) with an R-S-R prime pattern. What is most likely to be seen accompanying these findings?
a. murmur between S2 and S1
b. no discernible P waves
c. complete AV dissociation
d. widened splitting of S2
e. holosystolic murmur best heard at the cardiac apex
findings: prolonged QRS, R-S-R pattern (indicating right bundle branch block)
d. widened splitting of S2
how would MAP, venous pressure, and CO be affected in the first 1-2 seconds following a selective reduction in arterial resistance?
reduce arterial resistance —> lower MAP, higher venous pressure, higher CO
reduced resistance allows for increased flow to venous side (higher pressure) and increased venous return to heart
increased venous return + decreased afterload = increased CO
Which is most likely to result from diastolic heart failure?
a. LV dilation
b. upward shift in cardiac function curve
c. upward shift in diastolic filling curve
d. increased EDV
e. decreased ejection fraction
c. upward shift in diastolic filling curve —> IV pressures abnormally elevated
diastolic heart failure = ventricle is not filling efficiently due to decreased compliance (stiff)
a. LV dilation - seen with systolic HF (reduced contractibility)
b. upward shift in cardiac function curve - would indicate higher contractibility
d. increased EDV - seen with systolic HF because of dilation
e. decreased ejection fraction - seen with systolic HF (reduced contractibility)
systolic vs diastolic heart failure (in basic sense)
systolic HF - ventricle is not ejecting as well: eccentric hypertrophy —> reduced contractibility —> reduced ejection fraction
diastolic HF - ventricle is not filling as well: concentric hypertrophy —> reduced compliance —> reduced end diastolic volume
both result in higher ventricular pressure
A patient with heart failure has reduced SV and increased EDV - how would ejection fraction, ESV, and cardiac SNS tone be affected?
reduced SV + increased EDV = systolic heart failure (eccentric hypertrophy, reduced contractibility)
ejection fraction is reduced
end systolic fraction is increased
cardiac SNS tone is increased (attempt to compensate)
An ECG shows positive QRS in lead I, negative QRS in lead aVF, and positive QRS in lead aVL. What is the best interpretation of these findings?
a. MI
b. LV hypertrophy
c. RAD
d. aortic valve stenosis
e. A fib
b. LV hypertrophy - leads are indicated LAD (left axis deviation)
how would the LV PV loop be shifted from a healthy patient to a patient with poorly managed HTN?
LV PV loop = left ventricle pressure volume loop
HTN would shift plot up (higher pressure due to increased afterload) and right (higher end systolic volume)
what kind of drug is Enalapril?
ACE inhibitor —> induces vasodilation by inhibiting RAAS system
A patient is prescribed an antiarrhythmic drug to manage their paroxysmal atrial fibrillation. On follow-up, their ECG shows regular rhythm with prolonged QT intervals. What is the most likely mechanism of this electrophysiology anomaly?
a. decreased expression of voltage-gated Na+ channels
b. decreased duration of If (funny current)
c. impeding the activation of potassium current
d. hypercalcemia
e. formation of a reentrant loop
c. impeding the activation of potassium current - by impeding repolarizing K+ currents, duration of AP is prolonged
Pt is a 75yo M presenting with chest and jaw pain for 2 days duration. Nitroglycerine provides some relief. PE shows BP is 140/85mmHg and pulse is 88/min and regular. Which of the following ECG findings would corroborate his signs and symptoms?
a. fibrillatory waves in lead I
b. prolonged PR interval in leads II and III
c. inverted P waves in several precordial leads
d. QRS negative in lead I, positive in lead aVF
e. ST elevation in leads V3 and V4
e. ST elevation in leads V3 and V4
signs/symptoms indicate myocardial infarction (MI) - ST elevation is key finding
a patient presents with severe hyperkalemia - which of these ECG findings is likely?
a. V fib
b. prominent Q waves
c. PR shortening
d. tented T waves
e. inverted P waves
d. tented T waves
remember that imbalances of K+ will cause issues with repolarization, while imbalances of Ca2+ will cause issues with depolarization (QRS)
how will 30 minutes of exercise cause a shift in the LV PV loop?
LV PV loop = left ventricle pressure volume loop
exercise will cause shift up (higher BP —> higher afterload —> higher LV pressure) and left (higher contractibility —> higher SV —> lower ESV)
when do AV valves close
S1 sound, at the time of isovolumetric contraction (~middle of QRS wave)
what ECG would you suspect to accompany a patient with junctional escape and retrograde atrial conduction, in leads II and aVF?
inverted P waves (should be positive in leads II and aVF) —> retrograde conduction is causing depolarization to move away from the leads
3 ways to increase preload on the heart
- add volume
- slow heart rate (more time for filling)
- constrict veins (more venous return)*
*this is why the response to blood loss is venous constriction (veins hold a large blood volume)
