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1

fetal erythropoiesis

Young Liver Synthesizes Blood: Yolk sac (3-8wks), Liver (6wks-birth), Spleen (10-28wks), Bone marrow (18wks-adult)

2

allantois ->

urachus -> median umbilical ligament. urachus = part of allantoic duct between bladder and umbilicus

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ductus arteriosus ->

ligamentum arteriosum

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ductus venosus ->

ligamentum venosum

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foramen ovale ->

fossa ovale

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notochord ->

nucleus pulposus

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umbilical arteries ->

medial umbilical ligaments

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umbilical vein ->

ligamentum teres hepatis (contained in falciform ligament)

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SA and AV nodes supplied by

RCA (usually)

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LCX supplies

posterolateral LV, anterolateral papillary muscle

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LAD supplies

anterior 2/3 of interventricular septum, anterolateral papillary muscle, anterior LV

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PDA supplies

posterior 1/3 of interventricular septum, posterior walls of ventricles, posteromedial papillary muscle

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right marginal artery supplies

RV

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in 85%, PDA arises from

RCA

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inc. pulse pressure in

hyperthyroid, AR, aortic stiffening, OSA, exercise

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dec. pulse pressure in

AS, cardiogenic shock, cardiac tamponade, advanced HF

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normal splitting

inspiration -> dec. intrathoracic P -> inc. venous return -> inc. RV filling -> inc. RV stroke volume -> inc. RV ejection time -> delayed pulmonic closure. pulm circulation also has inc. capacity during inspiration.

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wide splitting

in conditions that delay RV emptying: PS, RBBB. = exaggeration of normal splitting

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fixed splitting

in ASD! -> L-R shunt -> inc. RA + RV volumes -> inc. flow through pulmonic valve so that closure is always greatly delayed, regardless of breath

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paradoxical splitting

in conditions that delay aortic valve closure: AS, LBBB. normal order is reversed, P2 sound is before A2, so when P2 is pushed back by inspiration, split is eliminated.

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murmurs: inspiration

inc. venous return to RA -> louder R heart sounds

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murmurs: hand grip

inc. afterload -> louder MR, AR, VSD; quieter hypertrophic cardiomyopathy murmur; later click in MVP.

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murmurs: valsalva, standing up

dec. preload. most murmurs, including AS, get quieter. hypertrophic cardiomyopathy murmur gets louder. earlier click in MVP.

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murmurs: rapid squatting

inc. venous return, inc. preload -> quieter hypertrophic cardiomyopathy murmur, louder AS murmur, later click in MVP

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phase 0 - myocardial AP

rapid upstroke and depolarization - V-gated Na channels open

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phase 1 - myocardial AP

initial repolarization - inactivation of V-gated Na channels. V-gated K channels start opening.

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phase 2 - myocardial AP

plateau - Ca influx through V-gated Ca channels balances K efflux. Ca influx triggers Ca release from SR and myocyte contraction

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phase 3 - myocardial AP

rapid repolarization - massive K efflux due to opening of V-gated slow K channels and closure of V-gated Ca channels

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phase 4 - myocardial AP

resting potential - high K permeability through K channels

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myocardial AP differences from skeletal AP

has a plateau, contraction is due to Ca-induced Ca release from SR.

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funny current

responsible for automaticity. slow, mixed Na-K inward current

32

phase 0 - pacemaker AP

upstroke - opening of V-gated Ca channels. fast B-gated Na channels are permanently inactivated b/c of less neg resting V of these cells -> slow conduction v that is used by AV node to prolong transmission from atria to ventricles

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phase 1, 2 - pacemaker AP

absent

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phase 3 - pacemaker AP

inactivation of Ca channels and inc. activation of K channels -> K efflux

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phase 4 - pacemaker AP

slow spontaneous diastolic depolarization as Na conductance increases (Ifunny). the slope of phase 4 determines HR. ACh/adenosine dec. diastolic depolarization rate and HR, catecholamines inc. depolarization and HR. sympathetic stimulation increases Ifunny.

36

J point

junction between end of QRS complex and start of ST seg

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U wave

caused by hypokalemia, bradycardia.

38

drug-induced long QT mnemonic

ABCDE: antiArrhythmics (class IA, III), antiBiotics (e.g. macrolides), anti"C"ychotics (e.g. haldol), antiDepressants (e.g. TCAs), antiEmetics (e.g. ondansetron)

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torsades de pointes

causes: long WT, drugs, dec. K, dec. Mg. Tx: mag sulfate

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romano-ward syndrome

AD cause of congenital long QT. pure cardiac phenotype (no deafness)

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jervell, lange-nielsen syndromes

AR causes of congenital long QT, sensorineural deafness

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brugada syndrome

AD, often asian males. peudo-RBBB, ST elevations in V1-V3. inc. risk of V tach + SCD. Tx: ICD

43

WPW

most common type of ventricular pre-excitation. abnormal fast accessory pathway (bundle of Kent) bypasses rate-slowing AV node -> early depolarization -> delta wave, widened QRS, short PR interval. can -> SVT (reentry circuit)

44

ANP

released from atrial myocytes in response to inc. blood V and atrial P. acts via cGMP -> vasodilation and dec. NA reabsorption at renal collecting tubule. dilates afferent renal arterioles, constricts efferent arterioles -> diuresis. part of aldosterone escape mechanism.

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BNP

released from ventricular myocytes in response to inc. T. similar physiologic action to ANP but longer 1/2 life. can be used to Dx and Tx HF.

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aortic receptors

transmitted via vagus to solitary nucleus of medulla. respond to dec. and inc. in BP

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carotid sinus receptors

trasmitted via glossopharyngeal nerve to solitary nucleus of medulla. respond to dec. and inc. in BP

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carotid massage

inc. P on carotid sinus -> inc. stretch -> inc. afferent baroreceptor firing -> inc. AV node refractory period -> dec. HR

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peripheral chemoreceptors

carotid and aortic bodies = stimulated by dec. PO2 (<60mmHg), inc. PCO2, and dec. blood pH.

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central chemoreceptors

stimulated by changes in pH and PCO2 of brain interstitial fluid (influenced by arterial CO2). not directly related to PO2.

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V1-V3 ST elevations/Q waves

anteroseptal (LAD)

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V3-V4 ST elevations/Q waves

anteroapical (distal LAD)

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V5-V6 ST elevations/Q waves

anterolateral (LAD or LCX)

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I, aVL ST elevations/Q waves

lateral (LCX)

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II, III, aVF ST elevations/Q waves

inferior (RCA) (can -> papillary muscle rupture)

56

myxoma

most common adult primary cardiac tumor. 90% in atria L>R). ball-valve obstruction associated w/syncope. can -> "tumor plop" sound.

57

rhabdomyoma

most common child primary cardiac tumor. associated w/tuberous sclerosis. usually in ventricle.

58

angiosarcoma

rare blood vessel malignancy. head, neck, breast. usually elderly, sun-exposed. radiation and chronic post-mastectomy lymphedema inc. risk. hepatic ones associated w/vinyl chloride (PVC pipe) and arsenic. aggressive

59

bacillary angiomatosis

benign capillary skin papules in AIDS pts. cause by bartonella henselae. looks like kaposi but w/neutrophilic infiltrate

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cherry hemangioma

benign capillary hemangioma of elderly. does not regress. inc. frequency w/age.

61

cystic hygroma

cavernous lymphangioma of neck. associated w/turners

62

glomus tumor

benign, painful, re-blue tumor under fingernails. arises from modified smooth muscle cells of thermoregulatory glomus body

63

kaposi sarcoma

endothelial malignancy most commonly of skin, but can be mouth, GI, respiratory. associated w/HHV-8. looks like bacillary angiomatosis but w/lymphocytic infiltrate.

64

pyogenic granuloma

pollypoid capillary hemangioma that can ulcerate and bleed. associated w/trauma and pregnancy

65

strawberry hemangioma

benign capillary hemangioma of infancy. appears early in life. grows rapidly, regresses spontaneously by 5-8yrs.

66

takayasu arteritis

usually asian females weak UE pulses, fever, night sweats, arthritis, myalgias, skin nodules, ocular disturbances. granulomatous thickening and narrowing of aortic arch and proximal great vessels. Tx: steroids

67

polyarteritis nodosa

young adults. hep B seropositivity in 30%. Sx: fever, wt. loss, malaise, h/a, abd. pain, melena, HTN, neuro Sx, cutaneous eruptions, renal damage. LUNG = SPARED. IC-mediated. fibrinoid necrosis. string-of-pearls. Tx: steroids, cyclophosphamide

68

buerger dz (thromboangiitis obliterans)

heavy smokers. males gangrene, autoamputation of digits, superficial nodular phlebitis. raynauds. segmental thrombosing vasculitis. Tx: smoking cessation.

69

granulomatosis w/polyangiitis

we"c"ener: upper respiratory tract: perf. nasal septum, chronic sinusitis, otitis media, mastoiditis. lower respiratory tract: hemoptysis, cough, dyspnea. renal: hematuria, RBC casts. triad: focal necrotizing vasculitis, necrotizing granulomas in lung/upper airway, necrotizing glomerulonephritis. "c"-ANCA. Tx: "c"yclophosphamide, "c"orticosteroids.

70

microscopic polyangiitis

necrotizing vasculitis involving lung, kidneys, skin. pauci-immune glomerulonephritis and palpable purpura. looks like wegeners but w/o nasopharyngeal involvement. no granulomas, no eosinophilia. p-ANCA. Tx: cyclophosphamide, steroids.

71

churg-strauss

asthma, sinusitis, skin nodules/purpura, neripheral neuropathy (wrist/foot drop). can also involve heart, GI, kidneys (pauci-immune glomerulonephritis), lungs. granulomatous, necrotizing vasculitis w/eosinophilia. p-ANCA, inc. IgE.

72

HSP

most common childhood systemic vasculitis. often follows URI. triad: palpable purpura, arthralgia, abd. pain. 2/2 IgA immune complex deposition. associated w/IgA nephropathy (Berger dz).

73

hydralazine

MoA: inc. cGMP -> smooth muscle relaxation -> arteriolar vasodilation -> dec. afterload. often used w/BB to prevent reflex tachycardia. side effects: tachycardia, fluid retention, h/a, angina, lupus-like syndrome

74

nitroprusside

short acting, inc. cGMP via direct release of NO. can cause cyanide toxicity

75

fenoldopam

DA D1 receptor agonist: coronary, peripheral, renal, and splanchnic vasodilation. dec. BP, inc. natriuresis.

76

nitrates

vasodilate by inc. NO in vascular smooth muscle -> inc. in cGMP -> smooth muscle relaxation. dilate veins >> aterires. dec. preload. toxicity: reflex tachycardia, hypotension, flushing, h/a. "monday dz" in industrial exposure: tolerance during work week, then tachycardia, dizzines, h/a on monday.

77

bile acid resins (e.g. cholestyramine)

dec. LDL, slightly inc. HDL and TGs. MoA: prevent intestinal reabsorption of bila acids; liver must use cholesterol to make more. side effects: GI upset, dec. fat-soluble absorption.

78

ezetimibe

dec. LDL, no effect on HDL, TG. MoA: prevent cholesterol absorption at small intestine brush border. side effects: rare inc. LFTs, diarrhea.

79

fibrates

dec. TGs, slightly dec. LDL, inc. HDL. MoA: upregulate LDL -> inc. TG clearance. activates PPAR-alpha to induce HDL synthesis. side effects: myopathy (inc. risk w/statins), cholesterol gallstones

80

niacin

dec. LDL, inc. HDL, slight dec. TGs. MoA: inhibits lipolysis (hormone-sensitive lipase) in adipose tissue; reduces hepatic VLDL synthesis. side effects: red, flushed face (dec. w/NSAIDs or long-term use). hyderglycemia, hyperuricemia.

81

class IA antiarrhythmics

quinidine, procainamide, disopyramide

82

class IA MoA

inc. AP duration, inc. effective refratory period in ventricular AP, inc. QT interval. dec. slope of phase 0 (Na current)

83

class IA use

both atrial and ventricular arrhythmias, esp. re-entrant and ectopic SVT and VT

84

class IA toxicity

cinchonism (h/a, tinnitis w/quinidine), reversible SLE-like Sx (procainamide), HF (disopyramide), thrombocytopenia, torsades de pointes due to inc. QT

85

class IB antiarrhythmics

lidocaine, mexiletine, (+ phenytoin sortof)

86

class IB MoA

dec. AP duration. preferentially affect ischemic or depolarized purkinje and ventricular tissue. dec. slope of phase 0.

87

class IB use

acute ventricular arrythmias (esp. post-MI). dig-induced arrhythmias

88

class IB toxicity

CNS stimulation/depression, CV depression

89

class IC antiarrhythmics

flecainide, propafenone

90

class IC MoA

sig. prolongs ERP in AV node and accessory bypass tracts. no effect on ERP in purkinje and ventricular tissue. minimal effect on AP duration. dec. slope of phase 0.

91

class IC use

SVTs, inc. a fib. last resort in refractory VT

92

class IC toxicity

proarrhythmic, esp. post-MI.

93

class II antiarrhythmics

beta-blockers!

94

class II MoA

dec. SA and AV node activity by dec. cAMP, dec. Ca currents. suppress abnormal pacemakers by dec. slope of phase 4.

95

class II use

SVT, ventricular rate control for atrial fibrillation and atrial flutter

96

class II toxicity

impotence, exacerbation of COPD/asthma, CV effects *bradycardia, AV block, HF), CNS effects (sedation, sleep alterations). may mask hypoglycemia signs. Tx overdose w/saline, atropine, glucagon.

97

class III antiarrhythmics

K channel blockers: amiodarone, ibutilide, dofetilide, sotalol.

98

class III MoA

inc. AP duration. inc. ERP, inc. QT. markedly prolonged repolarization (K current)

99

class III use

a fib, a flutter, VT (amio, sotalol).

100

class III toxicity

sotalol: torsades, excessive beta-blockade. ibutilide: torsades. amio: pulm. fibrosis, hepatotoxicity, thyroid issues, acts as hapten (deposits in skin/cornea), neuro effects, constipation, CV effects (bradycardia, heart block, HF). amio: check PFTs, LDTs, TFTs. it is also lipophilic and has class I, II, III, and IV effects

101

class IV antiarrhythmics

Ca channel blockers: verapamil, dilt

102

class IV MoA

dec. conduction velocity, inc. ERP, inc. PR interval. slow rise of AP, prolonged repolarization.

103

class IV use

prevention of nodal arrhythmias (e.g. SVT), rate control in a fib

104

class IV toxicity

constipation. flushing, edema, CV effects (HF, AV block, SA node depression.

105

adenosine

inc. K out of cells -> hyperpolarizing the cell and dec. Ca current. drug of choice in Dx/Tx of SVT. very short action (~15sec). effects blunted by theophylline and caffeine (adenosine receptor antagonists). adverse effects: flushing, hypotension, CP, sense of doom, bronchospasm)

106

Mg

effective in torsades and dig. toxicity