Everything You Need to Know (at least) for

NAME YEAR MATRIC NO ACADEMIC SESSION

ONN0809

EDITORIAL
Apabila Ia mengkehendaki sesuatu urusan Ia katakana kepadanya: Jadilah, maka jadilah ia (Al-Baqarah:117)

Dengan nama ALLAH yang MAHA PEMURAH lagi MAHA PENYAYANG I know what I should love to do--to build a study; to write, and to think of nothing else. I want to bury myself in a den of books. I want to saturate myself with the elements of which they are made, and breathe their atmosphere until I am of it. Not a bookworm, being which is to give off no utterances; but a man in the world of writing--one with a pen that shall stop men to listen to it, whether they wish to or not. Dont give up, there is still time to study for the exam, GOOD LUCK!

Onn Azli Puade Medic 2 2008/2009

I studied the lives of great men and famous women; and I found that the men and women who got to the top were those who did the jobs they had in hand, with everything they had of energy and enthusiasm and hard work. (Harry S Truman quotes-1884-1972)

ONN0809

SYMPTOMS CHEST PAIN Definition Is a feeling of uncomfortable or pain at the chest area Causes Cardiovascular Myocardial infarction Acute aortic dissection Pericarditis Musculoskeletal Persistent cough Chest wall injuries Costochondritis Rib tumour, fracture Herpes Zoster Gastrointestinal Gastro-esophageal reflux Peptic ulcer disease Gastritis Oesophageal spasm Pulmonary Pneumonia Pulmonary embolisme Pneumothorax Central bronchial carcinoma Inhaled foreign body

Further history regarding Chest Pain 1. Location of the pain Retrosternally and radiates to jaw and left arm cardiac chest pain and oesophageal reflux Centrally located and radiates to shoulder pericarditis Radiates to back aortic dissection 2. Precipitating factor Effort, cold, food and emotion cardiac chest pain Inspiration (due to movement of thorax) pleuritic chest pain Posture gastro-oesophageal reflux 3. Relieving factor GTN oesophageal spasm and acute coronary syndrome Antacid gastro-esophageal reflux Aspirin pleuritic chest pain 4. Family and social history Any history of diabetes, hypercholesterolemia, smoking and dietary intake that mght become a risk factor for the cardiovascular disease 5. Associated symptom Dyspnoea, orthopnoea and easy fatigue all points towards cardiovascular disease
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Pathogenesis and pathophysiology

Atherosclerotic plaque obstructing coronary artery Reduce or diminished blood supply to region supply by the arteries distal to the obstruction Ischaemia of the myocardial cell Release substance to elicit vasodilation as a compensatory mechanism Still cannot receive adequate blood supply Production of more chemical mediator by ischaemic myocardial cell Histamine, serotonin and bradykinin released and entering vein of the hearts The mediators accepted by chemoreceptor located at the pericardial layer Sending Action Potential towards the lateral spinothalamic tract The signal is either converged or facilitated at the spinal cord (referred pain1 theory) RADIATING CHEST PAIN

Investigation 1. ECG To view the electrical profile of this patient heart. Elevated ST segment elevation seen in myocardial ischaemic, symmetrical T wave inversion in myocardial injury and abnormal Q wave in myocardial infarction. It can also detect Pulmonary embolisme 2. Cardiac Enzymes Look out for Troponin T presence, creatinine kinase and CK-MB enzyme elevation 3. Chest X-ray Observe heart as well as lung field to exclude any heart enlargement and disease that can cause pleuritic chest pain. Also to rule out the pain due to fracture or osteosarcoma 4. Blood cholesterol The number one factor contributes to ACS which is hyperlipidaemia. Poor diet habit also can cause elevation of total lipid in the blood

Referred pain also known as synalgia is pain felt in a part of the body other than where it might be expected due to sensory nerves from different parts of the body share common pathways when they reach spinal cord. For diagram, see Guyton pg 605 ONN0809

DYSPNOEA, ORTHOPNOEA2, PAROXYSMAL NOCTURNAL DYSPNOEA3 Definition Dyspnoea - Is an uncomfortable awareness of breathing or can be described as breathlessness Causes Cardiac failure left heart failure or congestive cardiac failure Arrhythmia Valvular Heart Disease Pulmonary Hypertension Further history regarding these symptoms 1. History or family history of hypertension? Systemic hypertension can leads to congestive cardiac failure but it occurs more likely to the left heart before affecting right heart 2. Surgical history History of chest surgery as well as tooth debridement and any invasive procedure will increase tendency of getting systemic infection which likely to be affecting heart valve 3. Associated signs and symptoms Cyanosis indicating heart failure Cough with pink frothy sputum indicating pulmonary oedema, secondary to pulmonary hypertension Fever indicating infective endocardiis 4. Drug used Certain drugs can cause arrhythmia such as beta blockers 5. Medical history Any pulmonary disease such as obstructive, fibrosis and vascular disease can cause pulmonary hypertension and in long standing case, it can leads to congestive cardiac failure

Orthopnoea is breathlessness the prevents the patient from lying down so that the patient has to sleep propped up in bed (by pillows) or sitting on the chair
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Paroxysmal Nocturnal Dyspnoea is severe dyspnoea that wakes the patient from sleep that the patient is to forced to get up gasping for breath ONN0809

Pathogenesis and pathophysiology

Recumbent position Increase venous return to the right heart Increase afterload of the right heart Pulmonary congestion Pulmonary hypertension Exudation of fluid to the alveolar space (pulmonary oedema) Lung is ventilated but not perfuse V/Q mismatch Respiratory acidosis Increase carbon dioxide (indirectly) and reduce oxygen (directly) level below 30 mmHg Stimulate the chemoreceptor mainly the aortic and carotid body Ascend via vagus and glossopharyngeal nerve Terminates at the nucleus of the tractus sollitarius Stimulate the medullary respiratory area In recumbent position ORTHOPNOEA Increase the respiratory effort as a compensatory mechanism of respiratory acidosis DYSPNOEA PAROXYSMAL NOCTURNAL DYSPNOEA Further investigation regarding dyspnoea 1. Arterial Blood Gas To recognize the respiratory failure and the metabolic profile of the patient 2. Peak expiratory flow rate Reduce in peak flow may indicates asthma or chronic airflow limitation 3. ECG Eliminates probability of cardiac disease related to the symptoms. Look out for axis deviation to rule out left or right ventricular enlargement 4. FBC To rule out any pulmonary infection as well as anemia When sleeping Woke up and gasping for air

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ANKLE SWELLING Definition Swelling of the lower limb may be unilateral or bilateral. Causes Local Swelling Acute swelling Trauma DVT4 Cellulitis Allergy Rheumatoid arthritis Chronic swelling Varicose vein Obstruction to venous return Lymphoedema Caongenital malformations Paralysis Dependency General Swelling Congestive cardiac failure Hypoproteinaemia Renal failure Fluid overload Myxoedema

Further history regarding ankle swelling 1. Swelling location Bilateral swelling cardiac, renal and hepatic failure Unilateral swelling trauma, venous disease, lymphatic disease 2. Associated and signs symptoms Pain trauma, DVT, infection or complication of varicose veins Red, swollen, hot and tender cellulitis Wasting neurological damage Frozen pelvis varicose vein, pelvic tumour Dyspnoea, orthopnoea, PND, ankle oedema cardiac failure Weight loss, diarrhea, steatorrhoea malabsorption 3. Past medical history Trauma to the limb, recent pregnancy (DVT), abdominal or pelvic malignancy

DVT or deep vein thrombosis is an obstruction of a vein by a clot within the deep veins of the calf of the leg. May be caused by prolonged immobility, heart failure, pregnancy, injury and surgery predispose to thrombosis by encouraging sluggish blood flow ONN0809

Pathogenesis and pathophysiology

Right heart failure Reduce afterload of the right heart Blood congested in the right heart Backflow of the blood in the Inferior Vena Cava, precipated by gravity Blood become congested in the lower limb, precipated by left heart pumping Increase hydrostatic pressure Exudation of interstitial fluid to extravascular space ANKLE SWELLING Further investigation regarding ankle sweling 1. FBC Low Hb indicating trauma or fracture secondary to large haematoma. Large haematoma also associated with reduced platelet count 2. Chest X-ray Finding suggestive cardiomegaly, pulmonary oedema and pleural effusions 3. Limb X-ray May show fracture, tumour or gas in the tissues associated with gas gangrene 4. Venography Will confirm Deep Vein Thrombosis 5. Lymphangiography May demonstrate the cause lymphoedema, e.g hypoplasia or obstruction

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EASY FATIGUE, INTERMITTENT CLAUDICATION5, SYNCOPE6 Definition

Is a state of increased discomfort and decreased efficiency due to prolonged or excessive exertion Causes Cardiac Failure Lack of Sleep Anemia Depression Hypoglycemia Peripheral vascular disease Pathogenesis and pathophysiology Cardiac failure Low cardiac output Poor blood supply (oxygen) to the skeletal muscle Exercise/strenuous work Anaerobic respiration produces energy and lactic acid Increase level of lactic acid Lactic acidosis
Walking Pain in the thigh and calves INTERMITTENT CLAUDICATION Poor blood supply to the carotid artery Poor blood supply to the cerebral artery Transient loss of consciousness SYNCOPE

Discomfort and hurt at the skeletal muscle FATIGUE

Intermittent claudication is related to the claudication distance which is the distance the patient walk until the pain in one or both calves, thighs and buttocks can be felt 6 Syncope is a transient loss of consciousness due to the reduce blood supply to the cerebral artery ONN0809

PALPITATION Definition Awareness of the heartbeat Causes Cardiac arrhythmia Premature ventricular contraction Premature atrial contraction Atrial fibrillation Supraventricular tachycardia Pathogenesis and pathophysiology

Sinus tachycardia Anxiety/emotional stress Caffeine Nicotine Alcohol Ventricular tachycardia

Cardiac failure Inadequate cardiac output Reduced blood supply (Oxygen) to the body tissue Ischaemic tissue release substance Stimulate the sympathetic activity as a compensatory mechanism Increase heart rate to increase cardiac output Hyperdynamic circulation Ventricular tachycardia Awareness of the heart beat due to the hyperdynamic circulation PALPITATION

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SIGNS CACHEXIA, POOR WEIGHT GAINED Definition Is a condition of abnormally low weight, weakness and general bodily decline associated with chronic disease Causes Systemic disease Malignancy Cardiac failure Chronic respiratory disease Malabsorption Renal failure Liver failure Infective Infective endocarditis Tuberculosis HIV Helminth infection

Endocrine Hyperthyroidism Diabetes mellitus Addisons Disease

Psychiatric Anorexia Nervosa Depression

Systemic Infection Cardiac failure Inflammatory reaction Release of TNF- Stimulate the release of the cachectin factor Cachectin factor enters blood circulation Suppress appetite center of the hypothalamus Lost of appetite CACHEXIA Reduced blood supply to the body Compensatory mechanism Stimulate the sympathetic nervous system Long standing sympathetic stimulation Growth retardation POOR WEIGHT GAINED/CARDIAC CACHEXIA

ONN0809

ANAEMIA AND PALLOR7 Definition Is defined as a haemoglobin concentration of less than 13.5 g/dl in adult males and 11.5 g/dl in adult females Causes Microcytic (MCV <80 fl) Iron deficiency Anaemia of chronic disease Thalassaemia

Normocytic (MCV 80 95 fl) Acute blood loss Haemolytic Anaemia Mixed deficiencies Secondary anaemia* Bone marrow failure Pregnancy

Macrocytic (MCV >95 fl) Megaloblastic anaemia Alcoholism Liver disease Hypothyroidism Addisons disease Hyperthyroidism Marrow infiltration

Pathogenesis and pathophysiology

Systemic Infection (infective endocarditis) Inflammatory reaction Release of TNF- Suppress the bone marrow Reduce production of red blood cell Reduce total haemoglobin in the blood Normocytic nomochromic anaemia PALLOR

Pallor is an abnormal paleness of the skin due to the deficiency of haemoglobin especially in the mucous membrane of the sclerae

ONN0809

ARTERIAL PULSE NORMAL AND ABNORMAL PULSE Definition Is a series of pressure waves within an artery caused by contractions of the left ventricle corresponding with the heart rate which is usually palpated at the radial artery Normal heart rate 60 100 bit/minute Abnormal pulse 1. Rate and rhythm Rhythm\Rate Regular Tachycardia Congestive cardiac failure Constrictive pericarditis Hypovolaemic shock Myocardial ischaemia Sick sinus syndrome Atrial fibrillation Pulmonary embolisme Myocardial ischaemia Left atrial enlargement Mitral valve disease Bradycardia 3rd degree AV block 2nd degree AV block Myocardial infarction Hypothyroidism Drugs (-blockers, digoxin) Atrial fibrillation 2nd degree AV block type I

Irregular

2. Volume Type Thready pulse Weak pulse Description Difficult to be felt and are not palpable e.g. hypovolaemic shock Is not palpable when slight pressure applied e.g. hypovolemc shock, atherosclerotic plaque, congestive cardiac failure Feels full and spring like even under moderate pressure e.g. aortic regurgitation

Bounding pulse

3. a) b) c) d)

Character Pulsus alternans alternating weak and strong pulse due to left ventricular failure Pulsus parvus et tardus slow uprising of the carotid upstroke in Aortic stenosis Pulsus bisferiens a double waveform due to aortic stenosis/regurgitation Spike and dome pulse double carotid impulse due to hypertrophic obstructive cardiomyopathy
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CHEST EXAMINATION FOR RESPIRATORY AND ITS SIGNIFICANT (check Clinical Examination textbook for the method) 1. INSPECTION OF THE CHEST

BLOOD PRESSURE AND HYPERTENSION8 Definition

8

Hypertension is elevation of blood pressure above the normal range expected in a particular age group ONN0809

Can be define as pressure of the wall against the wall of the arteries or total peripheral resistance times cardiac output Classification *Primary hypertension/essential hypertension is due to unknown causes *Secondary hypertension is due to certain disease that leads to rise in blood pressure

characteristic aetiology blood pressure age course incidence

Benign usually primary* diastolic 90-120, very slow rise middle age, elderly very slow (years) common

Malignant primary or secondary* diastolic >120, very rapid rise young, middle age rapid (months) uncommon

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