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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 wantto 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 22008/2009

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)

http://en.thinkexist.com/quotation/i-know-what-i-should-love-to-do-to-build-a-study/354770.htmlhttp://en.thinkexist.com/quotation/i-know-what-i-should-love-to-do-to-build-a-study/354770.htmlhttp://en.thinkexist.com/quotation/i-know-what-i-should-love-to-do-to-build-a-study/354770.htmlhttp://en.thinkexist.com/quotation/i-know-what-i-should-love-to-do-to-build-a-study/354770.htmlhttp://en.thinkexist.com/quotation/i-know-what-i-should-love-to-do-to-build-a-study/354770.htmlhttp://en.thinkexist.com/quotation/i_studied_the_lives_of_great_men_and_famous_women/147025.htmlhttp://en.thinkexist.com/quotation/i_studied_the_lives_of_great_men_and_famous_women/147025.htmlhttp://en.thinkexist.com/quotation/i_studied_the_lives_of_great_men_and_famous_women/147025.htmlhttp://en.thinkexist.com/quotation/i_studied_the_lives_of_great_men_and_famous_women/147025.htmlhttp://en.thinkexist.com/quotation/i_studied_the_lives_of_great_men_and_famous_women/147025.htmlhttp://en.thinkexist.com/quotes/harry_s_truman/http://en.thinkexist.com/birthday/may_8/http://en.thinkexist.com/birthday/december_26/http://en.thinkexist.com/birthday/december_26/http://en.thinkexist.com/birthday/may_8/http://en.thinkexist.com/quotes/harry_s_truman/http://en.thinkexist.com/quotation/i_studied_the_lives_of_great_men_and_famous_women/147025.htmlhttp://en.thinkexist.com/quotation/i_studied_the_lives_of_great_men_and_famous_women/147025.htmlhttp://en.thinkexist.com/quotation/i_studied_the_lives_of_great_men_and_famous_women/147025.htmlhttp://en.thinkexist.com/quotation/i-know-what-i-should-love-to-do-to-build-a-study/354770.htmlhttp://en.thinkexist.com/quotation/i-know-what-i-should-love-to-do-to-build-a-study/354770.htmlhttp://en.thinkexist.com/quotation/i-know-what-i-should-love-to-do-to-build-a-study/354770.htmlhttp://en.thinkexist.com/quotation/i-know-what-i-should-love-to-do-to-build-a-study/354770.htmlhttp://en.thinkexist.com/quotation/i-know-what-i-should-love-to-do-to-build-a-study/354770.html

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SYMPTOMS

CHEST PAIN

Definition

Is a feeling of uncomfortable or pain at the chest areaCauses

Cardiovascular

Myocardial infarction

Acute aortic dissection

Pericarditis

Gastrointestinal

Gastro-esophageal reflux

Peptic ulcer disease

Gastritis

Oesophageal spasm

Musculoskeletal

Persistent cough

Chest wall injuries

Costochondritis

Rib tumour, fracture

Herpes Zoster

Pulmonary

Pneumonia

Pulmonary embolisme

Pneumothorax

Central bronchial carcinoma

Inhaled foreign body

Further history regarding Chest Pain

1. Location of the painRetrosternally and radiates to jaw and left arm cardiac chest pain and oesophageal

refluxCentrally located and radiates to shoulder pericarditis

Radiates to back aortic dissection

2. Precipitating factorEffort, cold, food and emotion cardiac chest pain

Inspiration (due to movement of thorax) pleuritic chest pain

Posture gastro-oesophageal reflux

3. Relieving factorGTN oesophageal spasm and acute coronary syndrome

Antacid gastro-esophageal refluxAspirin pleuritic chest pain

4. Family and social historyAny history of diabetes, hypercholesterolemia, smoking and dietary intake that mght

become a risk factor for the cardiovascular disease

5. Associated symptomDyspnoea, 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. ECGTo 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 EnzymesLook out for Troponin T presence, creatinine kinase and CK-MB enzyme elevation

3. Chest X-rayObserve 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 cholesterolThe number one factor contributes to ACS which is hyperlipidaemia. Poor diet habit also

can cause elevation of total lipid in the blood

1Referred 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

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DYSPNOEA, ORTHOPNOEA2, PAROXYSMAL NOCTURNAL DYSPNOEA

3

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 historyHistory 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 symptomsCyanosis indicating heart failure

Cough with pink frothy sputum indicating pulmonary oedema, secondary to

pulmonary hypertension

Fever indicating infective endocardiis

4. Drug usedCertain drugs can cause arrhythmia such as beta blockers

5. Medical historyAny 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

2 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

3Paroxysmal Nocturnal Dyspnoea is severe dyspnoea that wakes the patient from sleep that the patient

is to forced to get up gasping for breath

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Pathogenesis and pathophysiology

Further investigation regarding dyspnoea

1. Arterial Blood GasTo recognize the respiratory failure and the metabolic profile of the patient

2. Peak expiratory flow rateReduce in peak flow may indicates asthma or chronic airflow limitation

3. ECGEliminates probability of cardiac disease related to the symptoms. Look out for axis deviation to

rule out left or right ventricular enlargement

4. FBCTo rule out any pulmonary infection as well as anemia

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

Increase the respiratory effort as a

compensatory mechanism of respiratory

acidosis

DYSPNOEA

Recumbent position

Increase venous return to

the right heart

Increase afterload of the

right heart

Pulmonary congestion

Pulmonary hypertension

In recumbent position

ORTHOPNOEA

When sleeping

Woke up and gasping for

air

PAROXYSMAL NOCTURNAL

DYSPNOEA

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ANKLE SWELLING

Definition

Swelling of the lower limb may be unilateral or bilateral.

Causes

Local Swelling General Swelling

Acute swelling Chronic swelling

Trauma

DVT4

Cellulitis

Allergy Rheumatoid arthritis

Varicose vein

Obstruction to venous return

Lymphoedema

Caongenital malformations

Paralysis

Dependency

Congestive cardiac failure

Hypoproteinaemia

Renal failure

Fluid overload

Myxoedema

Further history regarding ankle swelling

1. Swelling locationBilateral swelling cardiac, renal and hepatic failure

Unilateral swelling trauma, venous disease, lymphatic disease

2. Associated and signs symptomsPain 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 historyTrauma to the limb, recent pregnancy (DVT), abdominal or pelvic malignancy

4DVT 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

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Pathogenesis and pathophysiology

Further investigation regarding ankle sweling

1. FBCLow Hb indicating trauma or fracture secondary to large haematoma. Large haematoma also

associated with reduced platelet count

2. Chest X-rayFinding suggestive cardiomegaly, pulmonary oedema and pleural effusions

3. Limb X-rayMay show fracture, tumour or gas in the tissues associated with gas gangrene

4. VenographyWill confirm Deep Vein Thrombosis

5. LymphangiographyMay demonstrate the cause lymphoedema, e.g hypoplasia or obstruction

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

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EASY FATIGUE, INTERMITTENT CLAUDICATION5, SYNCOPE

6

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

Discomfort and hurt at the skeletal muscle

FATIGUE

5Intermittent 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 felt6

Syncope is a transient loss of consciousness due to the reduce blood supply to the cerebral artery

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 ofconsciousness

SYNCOPE

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PALPITATION

Definition

Awareness of the heartbeat

Causes

Cardiac arrhythmia

Premature ventricular contraction

Premature atrial contraction

Atrial fibrillation

Sinus tachycardia

Anxiety/emotional stress

Caffeine

Nicotine

Alcohol

Supraventricular tachycardia Ventricular tachycardia

Pathogenesis and pathophysiology

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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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 95 fl)

Iron deficiency

Anaemia of chronic disease

Thalassaemia

Acute blood loss

Haemolytic Anaemia

Mixed deficiencies

Secondary anaemia*

Bone marrow failure

Pregnancy

Megaloblastic anaemia

Alcoholism

Liver disease

Hypothyroidism

Addisons disease

Hyperthyroidism

Marrow infiltration

Pathogenesis and pathophysiology

7 Pallor is an abnormal paleness of the skin due to the deficiency of haemoglobin especially in the

mucous membrane of the sclerae

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

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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 arteryNormal heart rate

60 100 bit/minute

Abnormal pulse

1. Rate and rhythmRhythm\Rate Tachycardia Bradycardia

Regular Congestive cardiac failure

Constrictive pericarditis

Hypovolaemic shock

Myocardial ischaemia

Sick sinus syndrome

3rd

degree AV block

2nd

degree AV block

Myocardial infarction

Hypothyroidism

Drugs (-blockers, digoxin)

Irregular Atrial fibrillation

Pulmonary embolisme

Myocardial ischaemia

Left atrial enlargement

Mitral valve disease

Atrial fibrillation

2nd

degree AV block type I

2. VolumeType Description

Thready pulse Difficult to be felt and are not palpable

e.g. hypovolaemic shock

Weak pulse Is not palpable when slight pressure

applied

e.g. hypovolemc shock, atherosclerotic

plaque, congestive cardiac failure

Bounding pulse Feels full and spring like even under

moderate pressure

e.g. aortic regurgitation

3. Charactera) Pulsus alternans alternating weak and strong pulse due to left ventricular failureb) Pulsus parvus et tardus slow uprising of the carotid upstroke in Aortic stenosisc) Pulsus bisferiens a double waveform due to aortic stenosis/regurgitationd) 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

8Hypertension is elevation of blood pressure above the normal range expected in a particular age group

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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 Benign Malignant

aetiology usually primary* primary or secondary*

blood pressure diastolic 90-120, very slow rise diastolic >120, very rapid rise

age middle age, elderly young, middle agecourse very slow (years) rapid (months)

incidence common uncommon