EMILIO AGUINALDO COLLEGE

SCHOOL OF MEDICINE

Department of Physiology
1st Semester, AY 2017-2018

Small Group Discussion Case Files

Cardiovascular Physiology

Case #1 Hemodynamic Physiology

Objectives:

1. Discuss the components of the vascular system

2. Calculate blood flow, resistance, mean arterial pressure and other cardiovascular calculations
3. Demonstrate knowledge on the different hemodynamic measurements between arteries and veins
4. Define systolic, diastolic and pulse pressures

Case:

A 65-year old man with a history of hypertension and coronary artery disease presents to the ER with complaints
of left-sided facial numbness and weakness, along with slurred speech. His BP is normal, as is his PR, RR and
temperature. On examination, the patient has clear breath sounds and normal cardiac rhythm. Auscultation of the
carotid arteries reveals a whooshing sound (bruit) bilaterally. There is evidence of slurred speech and left-sided facial
droop. The patient is diagnosed with a stroke. A CT scan is performed. The patient is taken immediately to the ICU for
stabilization.

Questions:

1. What is the mechanism of the audible carotid bruit?

2. How does one calculate the velocity of blood flow? Why is velocity of blood flow higher in the arterioles than in
capillaries? Why is this physiologically necessary?
3. What is Reynolds number, and how would it apply to this case?

Case # 2 Cardiac Conduction System

Objectives:

1. Demonstrate knowledge about the normal conduction through the heart

2. Evaluate and explain the mechanisms of cardiac action potential
3. Evaluate and explain the mechanisms of pacemaking
4. Describe regulation by the autonomic nervous system

Case:

A 68-year old woman presents to the ER with shortness of breath, light-headedness, and chest pain described as
being like an elephant sitting on her chest (chest heaviness). She is diagnosed with a myocardial infarction. She is
given oxygen and an Aspirin to chew and is not felt to be a candidate for thrombolytic therapy. Her HR is 40 bpm.
Although there are P waves, they seem to be dissociated from the QRS complexes on the ECG. The patient is diagnosed
with Complete Heart Block, probably as a result of her myocardial infarction. The patient is taken to the ICU for
stabilization, and plans are made for pacemaker insertion.
Questions:

1. Where are the normal pacemaker and the backup pacemakers of the heart located?
2. Why does this patient have bradycardia?
3. What parts of the heart have the fastest and slowest conduction velocities/

Case # 3 Electrocardiography Physiology

Objectives:

1. Demonstrate knowledge about the ECG leads and electrical vectors

2. Evaluate and explain the correspondence of parts of the ECG to the cardiac cycle
3. Demonstrate knowledge on the effects of heart block, hypertrophy, and acute myocardial infarction on the ECG

Case:

A 57-year old man presents to the ER with complaints of chest pain with radiation to the left arm and jaw. He
reports feeling anxious, diaphoretic, and shortness of breath. His past history is significant for type II diabetes mellitus
and hyperlipidemia. On examination, the patient appears to be in moderate distress and anxious. His ECG shows
evidence of acute myocardial injury in the inferior leads. The ER physician suspects that the left anterior descending
artery is involved.

Questions:

1. What would the ST segment of this ECG look like?

2. On which leads would you see this ST segment change?
3. What does the T wave represent?

Case # 4 Physiology of Cardiac Mechanics

Objectives:

1. Demonstrate knowledge about the cardiac cycle

2. Evaluate and explain the cardiac muscle cell structure
3. Describe excitation-contraction of the heart
4. Evaluate and explain the force of myocardial contractions

Case:

A 62-year old woman with a history of atrial fibrillation presents to her primary care physician with worsening
shortness of breath when she lies down flat in the supine position. She often has to sleep with several pillows at night
(orthopnea) and has frequent urination at night (nocturia). She has noticed that her ankles are more swollen that usual
(edema). Of note, she has run out of digoxin, which she takes to control her heart rate. On examination, she is noted to
be slightly hypotensive with a BP of 90/65 mm Hg. Her HR is 120 bpm and is irregularly irregular, consistent with atrial
fibrillation. She has bilateral pulmonary rales and increased jugular venous distention. Her heartbeat is irregularly
irregular without a murmur. No S3 or S4 is noted. She has +3 (out of +4) dependent peripheral edema of the legs. She is
diagnosed with congestive heart failure and admitted to the hospital for further management.
Questions:

1. What is the cause of the 4th heart sound, and why does this patient not have an audible one?
2. What factors affect stroke volume?
3. How does stimulation of muscarinic receptors affect contractility?

Case # 5 Physiology of Venous Return

Objectives:

1. Evaluate and explain the Frank-Starling relationship in terms of venous pressure and cardiac output
2. Draw and label cardiac and vascular function curves
3. Diagram the effects that changes the heart rate, contractility, blood volume, venous unstressed volume, and total
peripheral resistance have on the cardiac and vascular function curbes and the resultant venous pressures and
cardiac outputs

Case:

A 25-year old pregnant woman is in labor at the hospital. She has no medical problems and has had no
complication with this pregnancy. She is in the active phase of labor, feeling intense contractions, and wants pain relief.
The anaesthesiologist is called and administers an epidural nerve block (including sympathetic blockade) for anesthesia.
Shortly after the administration of the epidural, the patient reports feeling light-headed and dizzy. She is noted to be
tachycardic and hypotensive. The anaesthesiologist notices the hypotension and gives an IV fluid bolus and a small
amount of IV ephedrine. These measures resolved the patients symptoms and hypotension.

Questions:

1. Why would epidural analgesia cause these symptoms?

2. How would increasing the blood volume change venous pressure?
3. How would ephedrine counter the hypotension?

Case # 6 Arterial Pressure Physiology

Objectives:

1. Describe the baroreceptor reflex

2. Demonstrate knowledge about the rennin-angiotensin-aldosterone system
3. Describe the effects of aldosterone on renal function and arterial blood pressure

Case:

A 55-year old man with long-standing diabetes mellitus and newly diagnosed hypertension presents to his
cardiologist for follow-up. The patient has been trying to alter his dietary habits and now exercises more frequently, but
the hypertension has persisted. The patient is started on angiotensin-converting enzyme inhibitor (Ace inhibitor) with
good results. He is instructed to continue his medication and follow-up after 3 months.

Questions:

1. What neural and humoral pathways regulate arterial pressure?

2. What are the two (2) effects of angiotensin II?
 3. How would inhibition of angiotensin-converting enzyme decrease blood pressure?

Case # 7 Regional Blood Flow Physiology

Objectives:

1. Demonstrate knowledge on the mechanisms of intrinsic control of regional blood flow

2. Describe the mechanisms of extrinsic control of regional blood flow
3. Demonstrate knowledge about the control of blood flow to the heart, brain, skeletal muscles, and skin
4. Describe the transfer of substrates, metabolites, and volume between capillaries and interstitial fluid

Case:

A 21-year old woman presents to her cardiologist because she want to begin an exercise program for weight loss.
She is concerned because when she exercised in the past, she noticed her heart seemed to beat rapidly. She has no
know medical history and has no family members with medical problems. She denies chest pain. After a thorough
physical examination, everything appears to be normal and the physician reassures the patient that her increased HR is
probably a normal response to exercise.

Questions:

1. In what two (2) ways is blood flow to skeletal muscle controlled?

2. What are some differences between cerebral circulation and skeletal circulation?
3. What are some forms of extrinsic control of blood flow?