Understanding symptoms and signs

Question 1

Ichaemic muscle pain

Answer 1

• When muscle is ischaemic the pH drops and this is thought to be a key factor in stimulating pain afferents (nociceptors) in muscles. Substance P. a neuropeptide is released locally which then increases the sensitivity of pain afferents in muscle.
• Ishcaemia means insufficient blood supply to a cell, tissue or organ. It is the lack of oxygen that is particularly damaging.
• It is a relative phenomenon so, it occurs when there is poor blood supply compared to the cell/tissue requirement.

Question 2

Why can a young person get ischaemic pain?

Answer 2

Anaemia, cocaine

Question 3

What words are often used to describe the pain from ischaemic muscle?

Answer 3

• Tight
• Vice-like
• Constriction
• Heavy
• Crushing
• Cramping
• Pressing
• Tearing
• Pressure
• Choking feeling in throat (cardiac)

Question 4

What are some sites of cardiac and referred cardiac pain?

Answer 4

Its about visceral efferents entering at the same level as dermatomes.

Especially in Diabetic and elderly.

Question 5

What can cause angina?

Answer 5

• Cardiac pain bought on by exercise, stress, emotion
• Pain resolves with rest
• Pain relieved by GNT

Question 6

What is unstable angina?

Answer 6

• Angina that occurs at rest, more intense than stable angina, may last longer, does not respond to GTN. ECG may show ST depression or T wave inversion but no ST elevation. Cardiac markers are NOT raised
• UA may be the precursor to MI

Question 7

Myocardiac infarction

Answer 7

Often spontaneous onset of cardiac pain that does not go away with rest, nitrates and is usually worse than angina pain. Often the patient is sweaty, neuseated, dyspnoeic, pale, clammy and fearful for thair life.

This is because the sympathetic nervous system has kicked in.

Nitrates dont work because the vessels are occluded so, no matter how much they dilate them, nothing can get past. Often nitrates are given anyway just incase.

Question 8

Cardiac symptoms

Answer 8

Palpitations - a niticeable rapid, strong or irregular heartbeat due to agitation, exertion or illness.

• Ask about timings of such events. Exercise or emotion related? Only at night? Random? Caffeine? Smoking? Alcohol? Drugs?
• How long do they last?
• Associated with dizzyness or light headedness?
• Ever been associated with collapse / loss of contiousness?
• Ask the patient to “tap the heartbeat out on a table.”

Question 9

What are the causes of palpitations?

Answer 9

• Heightened awareness of normal heart beat
• Sinus tachycardia
• Atrial or ventricular ectopic beats
• Atrial tachycardias (SVT, fibrilation, flutter)
• Ventricular tachycardia (dizzy) / fibrilation (on floor as on cardiac output) - treat now!

Question 10

What can cause Collapse / loss of consciousless?

Answer 10

It is caused by cerebral hypoperfusion. This can result from both tachy and brady arrythmias - VT and VF.

Question 11

What do we need to assess when measure pulse?

Answer 11

• Rate
• Rhythm
• Character / Quality (storng bounding, weak thready)

Question 12

What is the normal range of pulse rate?

Answer 12

60-100

Below = bradycardia

Above = tachycardia

Question 13

What determines the strength of the pulse?

Answer 13

The pulse pressure

Question 14

What can cause a strong bounding pulse?

Answer 14

Bradycardia (As more blood in each beat as heart has more time to fill. This means that there is a larger difference between systolic and diastolic)

AF gets some strong ones if the gap between two beats is longer

Question 15

What are different characters / qualities of pulses?

Answer 15

• Thready pulse
  
  • Shock (Cardiogenic, hypovolaemic, ect…) LV failure
• Bounding pulse
  
  • Conditions associated with low peripheral resistance (Sepsis / Hot bath)
  • Bradycardia
  • A collapsing or water-hammer pulse us a particularly strong type of bounding pulse seen in aortic regurgitation because this decreases peripheral diastolic pressure because, in diastole some blood goes back into the heart so less is leaving.
• Slow rising pulse
  
  • Aortic stenosis - This starts weaker and gets stronger as it takes longer for the blood to get throguh the valve. So, it feels longer and there is a crescendo.

Question 16

What can cause low peripheral resistance?

Answer 16

• Hot bath
• Exercise
• Pregnancy

Question 17

What are the best places to listen to the different valves?

Answer 17

Question 18

What is the classic history of chest pain?

Answer 18

Pain in the foot that comes on when the patient goes to bed and is releved by hanging the foot out of bed.

Worse lying flat as they don’t have the help of gravity to fill the vessels in the food.

Question 19

What is Buerger’s test?

Answer 19

Test for peripheral vascular disease.

Get them to lie down and lift foot up until it goes white. Then, measure angle.

Bigger the angle, the less severe the ischaemia (better vessels) as can maintain flow without help of gravity.

Then, drop foot below the level of the bed and it will go bright red / pink - Vasodilation (vessels fill) - egt reactive hyperaemia.

Question 20

Acute ischaemic progression.

Answer 20

Suddenly - pale, white, ischaemic limb (occlusion)

1 hour later - Moveable mottling (toxins building up causing vasodilation)

6 hours later - Fixed mottling (capillaries rupture, toxins released, need to chop leg off)