Case 4

19 February 2015
15:38

ILO:

1.
2.
3.
-

What is the structure and function of the heart and the major vessels?
How does blood flow through the heart?
What is the control of the conductive system in the heart?
Cardiac excitation begins in the SA node, located in the right atrial wall.
The SA node's prepotential causes action potential to be triggered.
Each action potential triggered by the SA node propagates through the atria via gap
junctions In the intercalated discs of atrial muscle fibers. This causes the atria to
contract
By conducting along the internodal pathways, the action potential reaches the AV
node in the atrial septum near the opening of the coronary sinus.
The impulse slows as it enters the AV node( 100msec delay), as the nodal cells are
smaller than the conducting cells.
The delay is important because it allows the atria to contract before the ventricles do.
Next, the impulse is conducted along the AV bundle and the bundle branches to the
purkinje fibers and papillary muscles.
The purkinje fibers distribute the impulse to the ventricular myocardium, and
ventricular contraction begins.

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4.
-

What is the cardiac cycle and the pressures involved (graph)?

1 - The atria contract, rising atrial pressures push blood into the ventricles through the right and left
AV valves
2 - Atrial systole ejects blood into ventricles, filling the last 30% of volume needed. The other 70%
fills from passive flow from last cycle.
3 - At the end of atrial systole, each ventricle holds the maximum amount of blood that it will hold the end diastolic volume - about 130ml. The left AV valve closes
4 - Now atrial systole has ended, ventricular systole begins. Isovolumetric contraction happens, as
the pressure rises, the ventricles contract and generate tension until the pressure rises enough to
make the semilunar valves open.
5 - Once pressure in the ventricles exceeds the arterial trunks, the semilunar valves open and blood
flows into the pulmonary and aortic trunks. This is ventricular ejection.
During ventricular ejection, each ventricle ejects 70- 80 ml of blood - the stroke volume
6 - As the end of ventricular systole approaches, ventricular pressures fall rapidly. The semilunar
valves close. Pressure in the aorta rises again as the elastic walls recoil, producing a dicrotic notch.
The amount of blood remaining in the ventricle when the semilunar valve closes is the end systolic
volume
7 - All heart valves are closed, ventricular myocardium is relaxing. Isovolumetric relaxation - the
ventricle pressures are dropping, but no more blood is entering them.
8 - When ventricular pressures fall below the atrial pressures, the atrial pressure forces the AV
valves open. This causes passive flow of blood from atria into ventricles, even though both chambers
are in diastole. The ventricle becomes about 70% full before cardiac cycle ends.
End-Diastolic Volume (EDV): The amount of blood in each
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End-Diastolic Volume (EDV): The amount of blood in each

ventricle at the end of ventricular diastole (the start of
ventricular systole).
End-Systolic Volume (ESV): The amount of blood remaining
in each ventricle at the end of ventricular systole (the start
of ventricular diastole).
Stroke Volume (SV): The amount of blood pumped out of
each ventricle during a single beat. It can be expressed as
SV = EDV - ESV.
Ejection Fraction: The percentage of the EDV represented by
the SV.

5.
What is the nerve supply to the heart?
6.
What is rheumatic fever?
a.
Incidence, Prevalence, Epidemiology, pathophysiology, causes, symptoms, diagnosis,
treatments.
7.
What is the role of NHS interpreters?
a.
Number of different languages?
b. Role of families?
c.
Cost?
8.
What is parentalism?
a.
Young interpreters?
b. Accuracy?
9.
What is BNP a test for?
BNP is a
32-amino acid polypeptide secreted by the ventricles of the heart in response to excessive
stretching of heart muscle cells.
- The most commonly used decision threshold for BNP is 100 pg/ml.
- BNP levels of more than 100 pg/ml have a greater than 95% specificity and greater than 98%
sensitivity when comparing patients without congestive heart failure (CHF) to all patients
with CHF
10. Why is Mr Ahmed breathless?
a.
Why is he propped up by pillows?
11. What is heart failure?
a.
Left and right sided heart failure?
12. What are you listening for during an auscultation of the heart?
13. Drugs Class, Side Effects, Mechanism of Action, Uses?
a.
Furosemide.
b. Digoxin.
c.
Beta Blockers.
d. Ace Inhibitors.
e. Ramipril.
f.
Aspirin.
g.
GTN.
h. Carvedilol.
i.
Warfarin.
j.
INR
Prothrombin time is a measure of how fast blood clots via the extrinsic pathway.
INR is

Method: blood is drawn into a test tube containing sodium citrate, which binds the calcium
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Method: blood is drawn into a test tube containing sodium citrate, which binds the calcium
and prevents coagulation.
Plasma is isolated
Calcium is added, then tissue factor is added, and the clotting time is measured.
High INR= risk of bleeding
Low INR= risk of clotting
Warfarin results in low INR.
14. What are the types of mitral valve replacements?
Tilting disc -

Ball and cage:

Bileaflet valve - most common

15. What is an ECG?
- A recording and display of the electrical events in the heart.
- When a portion of the heart has been damaged, an abnormal ECG is present
- The P wave represents he depolarization of the atria
- The QRS complex represents depolarization of the ventricles. It is larger because the
ventricles are bigger than the atria

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ventricles are bigger than the atria

- Extension of the PR interval to more than

200 msec can indicate damage to the conducting
pathways or AV node.

16. What is an echocardiogram?

17. What is Starlings law?
states that the stroke volume of the heart increases in response to an increase in the volume of
blood filling the heart (the end diastolic volume) when all other factors remain constant. The
increased volume of blood stretches the ventricular wall, causing cardiac muscle to contract more
forcefully
Pasted from <http://en.wikipedia.org/wiki/Frank%E2%80%93Starling_law>

18.
19.
20.
21.

What is pulmonary oedema?

What causes heart enlargement?
Why was he given an oxygen mask?
Why does he require antibiotics?

Pasted from <https://outlook.office365.com/owa/#path=/mail>

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