14. Signs And Symtoms

Question 1

What is the key factor in ischaemia that stimulates pain afferents in muscle? How?

Answer 1

pH drop due to lack of O2, then substance P released locally, increases sensitivity of pain afferents in muscle.

Question 2

Why can young people with thyrotoxicosis develop angina or MI?

Answer 2

Increased metabolic rate, increased O2 demand, requires increased blood supply but cannot be supplied leading to ischaemia.

Question 3

Why can cardiac pain be brought on by exercise, stress, emotion, cold weather or a meal?

Answer 3

Adrenaline response.
Vasoconstriction due to breathing in cold air.
Blood diverted to gut.

Question 4

What is the definition of palpitations?

Answer 4

Noticeably rapid, strong, or irregular heartbeat due to agitation, exertion or illness.

Question 5

Give 3 causes of palpitations

Answer 5

Heightened awareness of normal heart beat.
Sinus tachycardia.
Arterial or ventricular ectopic beats.
Atrial tachycardias (eg supraventricular tachycardia/fibrillation).
Ventricular tachycardia/fibrillation.

Question 6

What is orthopnea?

Answer 6

Breathing altered with position

Question 7

What is paroxysmal nocturnal dyspnoea?

Answer 7

Intermittent difficulty breathing lying down

Question 8

What other disease might dyspnoea be confused with?

Answer 8

Asthma

Question 9

What is the cause of collapse/loss of consciousness in low/no output cardiac tachy or brady arrhythmias?

Answer 9

Cerebral hypoperfusion

Question 10

What is required for a patient to be diagnosed with postural hypotension?

Answer 10

Drop in systolic pressure of 20 or more, or diastolic drop of 10 or more from lying to standing.

Question 11

What leads to a strong bounding pulse?

Answer 11

Lowering of diastolic pressure eg bradycardia caused by heart block, or by lowered peripheral resistance eg exercise or pregnancy

Question 12

What type of pulse is particularly seen in aortic regurgitation?

Answer 12

Collapsing or water-hammer pulse

Question 13

What type of pulse is seen in aortic stenosis?

Answer 13

Slow rising pulse

Question 14

What anatomical pulse best represents the nature/quality of the central aortic pulse?

Answer 14

Carotid

Question 15

Why does raising the arm exaggerate a bounding pulse?

Answer 15

Pumping against gravity

Question 16

Why are right-sided murmurs increased during inspiration?

Answer 16

Negative intrathorasic pressure, drawing blood into lungs, higher pressure through vale, louder murmur

Question 17

Why are left-sided murmurs increased during expiration?

Answer 17

Positive intrathorasic pressure, drawing blood to other parts of the body, higher pressure through valve, louder murmur.

Question 18

Why might you want to ask a patient to hold their breath when you are listening for heart murmurs?

Answer 18

So you can’t hear their breathing sounds.

Question 19

Why does the S2 heart sound split on inspiration?

Answer 19

Closure of aortic valve and pulmonary valve not synchronised normally due to changes in pressure on inspiration

Question 20

Where can you listen to the aortic vale and pulmonary valve anatomically in the chest?

Answer 20

Aortic - 2nd-3rd right intercostal space.

Pulmonary - 2nd-3rd left intercostal space.

Question 21

Where can you listen to the tricuspid valve and mitral valve anatomically on the chest?

Answer 21

Tricuspid - left sternal border.

Mitral - apex.

Question 22

In what direction from the source of turbulence are murmurs conducted?

Answer 22

Distally.

Question 23

What is buerger’s test?

Answer 23

Pale foot on elevation, pink foot on dependency, shows ischaemia

Question 24

What is sunset foot?

Answer 24

Foot that is nearly ischaemic - not enough O2, substances released locally, vasodilation, collaterals form, area looks red and feels warm, but is actually becoming ischaemic.

Question 25

Do painkillers help peripheral ischaemic pain?

Answer 25

No

Question 26

Why do you not get oedema in hypertension?

Answer 26

Increase in peripheral resistance due to constriction of arterioles, so decreased hydrostatic pressure in capillaries and no oedema.

Question 27

What is cor pulmonale?

Answer 27

Right sided heart failure due to long-term increased vascular resistance in the lungs.

Question 28

When does right sided heart failure occur without left sided heart failure?

Answer 28

Patient has chronic severe lung disease

Question 29

How does chronic lung disease lead to right ventricular failure?

Answer 29

Alveolar hypoxia results in vasoconstriction of pulmonary vessels, to ensure perfusion matches ventilation. Poorly ventilated alveoli are less well perfused to optimise gas exchange, but this increases vascular resistance in the lungs, increasing pulmonary artery pressure and making it harder for the right ventricle to pump.

Question 30

How does right sided heart failure cause peripheral oedema?

Answer 30

Poor pumping by right ventricle, right ventricular end systolic volume increased, harder to fill right ventricle, increased right atrial and therefore systematic venous pressure, increased hydrostatic pressure in capillaries = oedema.

Question 31

Why do ACE inhibitors work to treat heart failure?

Answer 31

Prevent production of Ang II
- reduced peripheral resistance, so heart has to work less hard as reduced preload, and reduced blood volume moves away from top of Starling curve. Venous pressure reduced so less oedema.