1. ][السنة
Pathophysiology
summary
2nd exam lecture
Done by :abeer dirawi & ahmed alshamary & oday noa'man & hadeel sumrain
samsung
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2. First lecture Summary
Right and left side of the heart are separated from each other by
fibrous tissue .
There are two opening in the heart in the fetal life and should be
closed after birth :
1-foramin ovali.
2-ductus arteriosus.
For your information
ductus arteriosus ,what is it??
In the developing fetus, the ductus arteriosus (DA), is a blood vessel
connecting the pulmonary artery to the aortic arch. Upon closure at birth, it
.becomes the ligamentum arteriosum
The impulse transmit in the heart by the conductive system not
direct between the atrium &ventricle ,except in rare situation
called muscular bridge.
The location of the heart: in the mediastinum between the 2nd -5th
intercostal space.
PMI= point of maximum impulse "where you can feel the
impulse".
Cardiomegaly :enlargement of the heart "the PMI will increase ".
Papillary muscle: it's the muscle attached to the atrioventricular
valves via the chordae tendinae.
Arteriole: control blood pressure.
Vein: blood reservoir .
The heart is self-excited .
The heart work not under the direct control of the Brian ,but it's
affected by the sympathetic and parasympathetic system.
Atrium innervated mainly by parasympathetic system & ventricle
mainly by sympathetic system.
The heart is affected by hormones mainly adrenaline and
noradrenaline which is secreted by adrenal gland, they cause
central vasodilation and peripheral vasoconstriction.
3. Alpha 1 :blood vessel Alpha 2 : heart vasodilatation
vasoconstriction
Beta 1 : increase heart rate & Beta 2 : bronchi dilatation
contractility
The vein affected by the sympathetic system more than any other
blood vessels because they are blood reservoir .
Done by: Hadeel sumrain.
4. Hypertension lec. summary
Hypertension :
It is sustained blood pressure beyond the normal average .
- The normal blood pressure :
- systolic : 120-139 mm
- diastolic : 80-89 mm
- BP = diastolic + 1/3(systolic – diastolic )
Regulation of blood pressure :
A. Short term regulation : moment to moment regulation
controlled by barrow receptors .
B. Long term regulation: the mechanism to maintain blood
volume “there is compensated blood loss” !
Signs & symptoms of hypertension :
“ silent killer “ usually no symptoms but rarely it shows :
- Headache
- Blurry vision
- Chest pain
- Frequent urination at night
Blood pressure measurement :
- Optimal : systolic < 120 & diastolic < 80
- normal : systolic < 130 & diastolic < 85
- high normal : systolic < 130-139 & diastolic < 85 – 89
Causes of hyper tension :
1. Primary hyper tension: which is 90 -95 % of the cases that the
cause of it is unknown.
2. Secondary hypertension , it’s only 5-10% that the cause might be
cardiac , renal or endocrine ( these systems involved in the
maintenance of blood pressure )
5. We can classify the factors which cause hypertension into two
categories:
a) Controllable factors : increased salt intake , obesity , alcohol
, stress, lack of exercise and smoking .
b) Uncontrollable factors : heredity , race and age ( men 35-50
, women after menopause ).
Hypertension may lead to Ischemic heart disease
Myocardial infraction
Stroke
Congestive heart failure
Kidney failure
Heart attack
Heart rhythm problems
Aneurysm (localized, blood-filled
balloon-like bulge .
in the wall of a blood vessel).
Medications :
1. Diuretics – get rid of excess fluids
2. Beta blockers –reduce HR
3. Calcium antagonist – reduce HR & relax BV
4. Angiotensin II receptors blockers
5. Vasodilators
- malignant hypertension if it’s not treated it will be fatal
- resistant doesn’t respond to treatment of three
medications
Done by: Abeer dirawi.
6. Heart Failure lec. summary
Definitions
occur together
Heart Failure Pulmonary Edema
The inability of the
heart to maintain an An abnormal
output adequate to accumulation of
maintain the metabolic fluid in the lungs.
demands of the body.
Causes of Heart Failure
1-Ischemic Heart Disease
2-Cardiomyopathy
3-Hypertension
Valvular Heart Disease Congenital Heart Disease
Alcohol and Drugs. Arrhythmias
Ventricular Dilatation. Myocyte Hypertrophy.
Salt and Water Retention. Sympathetic Stimulation.
Peripheral Vasoconstriction.
7. When we need more Blood due to the body demand but at that
time we were suffering from HF and low Cardiac Output then the
Heart will do the Following
1-Sympathetic stimulation ( lead to #2)
2-Increase in heart rate , contractility ,cardiac output .
3-Release/formation of Angiotensin II to increase of the volume.
4-Vasoconstriction (Increase in the after load )
5-Increase in the heart size (cardiomegaly )
How can we discover that we have HF
Signs:
Cardiomegaly
Elevated Jugular Venous Pressure
Tachycardia
Hypotension
Bi-basal crackles – in the lungs
Pleural effusion
Ankle Edema
Ascites
Tender hepatomegaly
Classification of heart failure
" Symptoms of HF occur at rest and are exacerbated by any
physical activity."
Category Symptoms
No limitation. heavy exercise
Mild limitation normal physical activity
Marked limitation gentle physical activity
8.
Kussmaul’s sign Seen in Note that !
1-constrictive pericarditis an increase in jugular
2-right heart failure venous pressure and it is
3-right ventricular infarction a sign of Right side heart
4-tricuspid stenosis failure .
5-restrictive cardiomyopathy
6-"VIP" tamponade + degree of constricive pericardiditis
Kussmaul’s sign Not Seen in
1- acute cardiac tamponade
What is PMI and Where ?
is the furthermost point outwards (laterally) and downwards
(inferiorly) from the sternum at which the cardiac impulse can be
felt.
PMI is at left 5th intercostals space, at the point of intersection
with the left midclavicular line.
PMI Abnormalities!
1- Dextrocardia, the apex beat may be felt on the right side.
2-Cardiomegaly , enlargement of the heart (at the 6th or 7th
intercostals space).
Heart Sound
Name Time
S1 Close of AV valve
S2 Close of Semilunar valve
S3 "Pathological after 40" Start of Diastole
S4 "always Pathological " After Aerial Contraction
9. To do Compensatory mechanism
Neurohormonal
Increased HR Dilation Redistribution of
-Sympathetic -Frank Starling Blood to the Brain
-Norepinephrine - Contractility
NOTE THAT!
Vicious cycle will
-Decrease in cardiac output
-The body demand for more
ALSO ,
Increase in the afterlaod TPR +
Increase in the preload COP
lead to more and more
deteriorated of the heart !
ALSO ,
People who developed acute
pulmonary edema , should have
endotracheal, To get rid of
excessive fluid
10. Treatment of HF !
1. Diuretics .
2. Beta blockers . (Decrease CO)
3. ACE inhibitors (both preload and afterload will decrease .)
Digoxin
- increase the force of contraction by increase the Ca concentration in
the myocytes and decrease the HR.
- Digoxin isn’t a safe drug the therapeutic index of it is narrow
- Digoxin toxicity: High amount of the Drug
Leads to
1. Dizziness.
2. Confusion
3. Discoloration, the patient will have yellowish discoloration
4. Loose of consciousness
Note About Viagra
Treatment:
- general vasodilator
-Digoxin immune fab
- Cause Tachycardia
-antidote for Digoxin
- Fatal for Old people
What is Cyanosis!
It is the Blue discoloration of skin and mucus membranes, we can
see it in the patient who has heart failure.
We Can't treat the acute pulmonary edema by chest tube
there is no air or fluid in the pleural cavity(cover the lung)
excessive fluid usually are absorbed.
Done By
Prince
Ahmed Al-Shamary
11. arrhythmia lec. Summary
Arrhythmia :abnormality in the conductive system of the heart.
The SA node is the pacemaker of the heart where the impulse should be
initiated ,but some time the impulse could be initiated elsewhere in the heart
this is called "ectopic beat ".
Refractory period : the period of time come after each AP and the heart
muscle can't be excited through it because of the inactivation of fast Na
channel.
Herat block :
o 1-Block at the level of AV node :
a- first degree heart block (PR > 0.22 sec.)
b- second degree heart block(some P wave conduct ).
C-third degree heart block(complete heart block).
o 2- block below the AV node:
a- block at bundle of his.
b- block at the branches.
Causes :acute MI, calcify aortic stenosis ,cardiomyopathy, drug,ischemia.
Tachycardia : the HR more than 100/min (in ECG short PR interval)
Bradycardia : the HR is less than 60/min( in ECG prolonged PR interval).
The main cause of fibrillation are:
o Strong electrical shock.
o Sever ischemic heart disease.
The main cause of AP re-entry :
o Long pathway around the circle.
o Decrees velocity of conduction .
o Shortened refractory period of the muscle .
Premature beat:
o Premature atrial contraction:- the P wave occur too soon
o Premature ventricular contraction:- the QRS complex prolonged .
Ventricular tachy-arrhymia :
Decrees in the COP , the ECG is odd shape.
Anti-arrhythmic drug:
B blockers & Ca or Na channels blockers & digoxin.
Done by : Hadeel sumrain.
12. The kidney lec. summary
Review of kidney structure and function
Functions of the kidneys :
excretion metabolic waste products ( Urea , Uric acid ,
Creatinine and Bilirubin )
e xcretion foreign chemicals ( Food additives , toxins ,
pesticides , drugs )
secretion , metabolism & excretion of hormones ( Renal
erythropoietic factor, Renin and 1,25 dihydroxycholecalciferol )
Regulation of erythrocytes production
Regulation of vitamin D activity (Vitamin D3 is important in
calcium and phosphate metabolism )
Gluconeogenesis ( synthesis of Glucose )
Regulation of acid-base balance
Regulation of arterial pressure ( Endocrine Organ and Control
of Extracellular Fluid Volume. )
Regulation of water and electrolytes balances:
And these functions are acomplished by a sereis of processes like
Filtration , reabsorption , Secretion and Excertion of urine
Very Important note :
13. Urine Formation by the Kidneys:
Glomerular Filtration
Renal Blood Flow,
The functional unit of the kidney is the Nephron
the reabsorption and the secretion happened between the pretubular
capillaries and the tubules
Filtration occurs between the glomerulus and Bowman's capsule
Filtration: not selective (except for proteins), averages 20% of
renal plasma flow
Excretion = filtration – reabsorption + secretion
Reabsorption: highly variable and selective
We have 3 layers glomerulus ( a network of capillaries ) :
1-Epithelium of the glomerulus
2-Basement membrane
3-Endothelium Wall of bowman's capsule ( consists of non-dividing
epithelial cells ( podocytes ) )
Pathophysiology of the renal system
1-Disorders of urine volume ( Anuria , Oliguria and polyria )
2-Disorders in urine composition
Hematuria ( blood od RBC’s in urine )
Proteinuria ( presence of abnormal concentration of proteins in
urine )
14. Hematuria Proteinuria
1-Glomerular bleeding suggests 1-Normally low molecular
fracture in the GBM. weight proteins are filtered at
the glomeruli.
2-Glomerular bleeding may
develop after strenuous exercise. 2-Normally albumin ( has a
high M.W ) is not filtered at
3-Recurrent episodes of gross glomeruli
hematuria associated with 3-Minor leakage of albumin
respiratory tract infection into glomerular filtrate may
indicates IgA nephropathy . occur temporarily after
vigorous exercise fever and
4-Glomerulonephritis with heart disease.
deposition of IgA in mesangial
cell. 4-Albuminuria is seen in early
stages of glomerular disease of
5-Red urine due to haematuria diabetes mellitus "diabetic
must be differentiated from other nephropathy " also in
causes of red or black. hypertension.
6-Red urine can sometimes be 5-Apperes in hypertention and
due to other reasons like food dye diapetus maletuas.
or drugs.
Done by: Oday noa'man.
15. Kind of anemia Cause
1-iron deficiency anemia. Due to deficiency of iron. Either by :
a-loss of iron because of bleeding.
b-inadequate iron intake.
c-malabsorption. D- parasites.
2-megaloblastic anemia. Due to deficiency of vit.B12 and /or folic
acid. By:
a-inadequate intake.
b-IF deficiency(for vit.B12)
c-diseases of terminal ileum(site of vit.B12
absorption) D-parasites.
e-malabsorption (folate is mainly absorbed
in jejunum) f- increase demand for folic
acid.
3-Aplastic anemia.
Due to failure or reduction in the ability of
the bone marrow to produce RBC's. the
cause is either idiopathic, or because of :a-
bone marrow inhibition by drugs. b-
chemical effect.
c-radiation. D- disease ex.viral hepatitis.
4-Anaemia of chronic Associated with chronic diseases due to the
diseases. inhibitory effects of cytokines on iron
metabolism or erythropoiesis process.
5-Haemolytic anemia. Due to excessive destruction of RBC's.
either congenital :a-RBC membrane
abnormalities .
b- haemoglobinopathies.
c-RBC's enzyme defect.
OR..acquired: a- immune disease.
b- non- immune :*mechanical causes .
*infections. *drugs & chemicals.
*malaria.
6-Sickle cell anemia. Inheritance autosomal recessive trait.
7-Anemia due to "G6PD" is important to generate "NADPH".
deficiency of
(G 6 P D).
16. .. ًمقارنة بٌن الصداع العادي ..والصداع النصف
..اوال ..فً سالٌد 7 هً تفسٌر بعض االشٌاء
Has two of the following..
ٌعنً عشان نحكً انه صداع نصفً الزم ٌكون عنا على االقل اثنٌن من هذه
.. االعراض
1-unilateral location..
.بٌكون بجهة واحدة اما بالٌمٌن او الٌسار
2-pulsating quality..
. ًٌعنً االلم زي النبض بٌروح وبٌج
3-severe intensity..
.الم حاد
4-aggravated by activity..
."بٌزٌد مع القٌام بالنشاطات "العمل
migraine Tension headache
Unilateral bilateral
Pulstating quality constant
Severe intensity Not severe
Aggravated by activity Do not Aggravate by activity
Associated with vomiting or Not Associated with vomiting
photophobia/phonophobia or photophobia/phonophobia
. ٌنزعج من الضوءPhotophobia:
ً ٌنزعج من الصوت العالPhonophobia:
17. Test your self
Q)the impulse in the heart conduct directly between the atrium and ventricle, True
or false?
A-false.
Q)in normal person the PMI should be on which intercostal space?
A- on the 5th intercostal space.
Q) what will happen if one of the papillary muscles get ruptured ?
A-the blood will back to the atrium and that will reduce the output of the heart.
Q)The resting coronary blood flow equal ?
A- 225 ml/min
Q) The perfusion occurs during the systole , True or false ?
A- False, during diastole .
Q) if the metabolic regulation increase then the blood flow will………?
A- increase.
Q) sympathetic stimulation increase the heart rate and contractility and decrees the
cardiac output , True or false ?
A- false, "increase the cardiac output" .
Q) when there is a complete occlusion of the coronary artery this will lead to
necrosis . necrosis is less severe than ischemia ,true or false ?
A- 1- True . -2- false.
Q) The location of the obstruction do not affect the quantity of myocardial ischemia,
true or false ?
A- false.
Q) What do we mean by " ectopic beat" ?
A- it's an abnormal case when the impulse of the heart initiated not in the SA node
but elsewhere .
18. Q)regarding Refractory period why the heart muscle can't be excited through it?
A- because of the inactivation of fast Na channel.
Thanx alooot for :Abeer dirawi & Ahmed Al shamary & Oday noa'man ..
the best of luck