What are anginal equivalent ?

Anginal equivalents are symptoms of myocardial ischaemia other than angina such as

• Dyspnoea
• Faintness
• Fatigue 
• Eructations. 

These symptoms are  precipitated by exertion and relieved by rest and nitrates.

What is Angina Pectoris?

Angina is a discomfort in the chest and adjacent area due to myocardial ischaemia. It is due to a mismatch between myocardial oxygen demand and supply.
Functional Classification of Angina (by Canadian Cardiovascular Society)
Class 1- Angina resulting from strenuous or prolonged exertion at work
Class 2- Angina resulting from walking or climbing stairs rapidly, walking uphill
Class 3- Angina resulting from ordinary physical activities like dressing oneself and taking bath
Class 4- Angina present at rest or inability to carry out day to day activity without pain.
Factors resposible for angina are - vascular, myocardial or combination of both
What are the characteristics of Anginal Pain?
Site- Retrosternal in location
Nature of pain - Pressing, squeezing, strangling, constricting, a band across the chest, a weight in the centre of the chest. The patient is unable to pinpoint the site of pain.
Radiation of pain - To both the shoulders, epigastrium, back, neck, jaw, teeth. Anginal pain can radiate in all directions, as mentioned above, but it more commonly radiates to the left shoulder and ulnar aspect of the left arm
Duration of pain -5 to 15 minutes
Aggravating factors - Exertion, emotion, after a heavy meal, or exposure to cold
Relieving factors -Rest, nitrates.
What is Levine Test
Relief of anginal pain by carotid sinus massage.
Depending on duration of pain myocardial pain can be 

• Anginal where duration is > 2 min - < 20 min
• Myocardial infarction duration of pain  >10 min

What is Syncope ?

Syncope may be defined as a transient loss of consciousness due to inadequate cerebral blood flow secondary to abrupt decrease in cardiac output. Depending on the duration of syncope, the symptoms experienced by the patient may vary.
Following are the causes of syncope with episodic fainting.

• Hyperventilation syndrome
• Transient ischemic attack
• Severe anemia
• Hypoglycaemia
• Acute blood loss

Important history to be taken in a patient with syncopal attack are

• Duration of attack
• Associated with exertion – Exertional syncope is seen with aortic sites.
• Convulsion present or absent
• History of repeated attack
• Preceding symptoms such as light headedness

What are the disorders resembling syncope?
Hypoxia, Hypoglycaemia, Anaemia, Diminished carbon dioxide due to hyperventilation
Psychogenic -Anxiety/Hysterical fainting
Seizures.

What is Situational syncope?

Tussive (cough) syncope 
It is rare and it is produced  with a paroxysm of nonproductive violent coughing, resulting in persistent increase in intrathoracic pressure, reduction in venous return to heart and hence reduced cardiac output. The victims are almost exclusively middle-aged, overweight men with lung disease.
Micturition syncope
Is diagnosed when syncope occurs during or after urination.
The person has almost always just arisen from a period of prolonged recumbency.
Onset is abrupt with little or no warning; duration is brief and followed by full recovery.
Deglutition syncope
It is uncommon. Certain types of food or carbonated or cold beverages
can stimulate esophageal sensory- receptors that trigger reflex sinus bradycardia or AV block resulting in syncope.
Defecation syncope 
Occurs in older individuals with constipation and the mechanism is due to valsalva like manoeuvre.

What is Cardiac syncope

Cardiac syncope is due to reduction in the cardiac output
Presyncope / Near syncope –Here the patient feels dizzy, weak and tends to lose postural tone, without loss of consciousness
Reduction of cerebral blood supply for 5 sec - presyncope
Reduction of cerebral blood supply for 10 sec – loss of consciousness
Reduction of cerebral blood supply for 15 sec -seizure.
Causes of cardiac syncope are
1.Electrical abnormalities

• Extreme bradycardia
• Heart block
• Supraventricular or ventricular tachyarrhythmia

2. Mechanical causes

• Aortic stenosis
• Hypertrophic obstructive cardiomyopathy
• Left atrial tumours and thrombus
• Pulmonary stenosis
• Pulmonary hypertension
• Pulmonary embolism
• Tetralogy of Fallot.

Heart rate < 40 and > 160 will produce hemodynamic symptoms in normal person.

What are the causes of Hemoptysis in cardiovascular diseases

The causes of Hemoptysis  in cardiovascular diseases are due to –

• Pulmonary edema it is characterised by pink frothy sputum
• Mitral stenosis - bronchopulmonary apoplexy due to rupture of bronchopulmonary venule
• Pulmonary artery hypertension (PAH ) as in Eisenmenger syndrome - Pulmonary infarct
• Infective endocarditis - Right Ventricular - VSD and tricuspid valvular endocarditis -vegetation results in Pulmonary infarct
• PDA with endarteritis produce vegetation embolise to form Pulmonary infarct
• Congestive heart failure may lead to DVT –which in turn can result in Pulmonary infarct
• Post myocardial infarction  will also lead to  DVT which inturn can result in Pulmonary infarct.

Causes of Fatigue in heart disease

Fatigue  in heart disease are due to the following

• Low output state - obstructive valvular lesion - Aortic stenosis
• Pulmonary artery hypertension(PAH)
• Diffused Myocardial damage - IHD, Cardiomyopathy
• Blood volume and electrolyte imbalance -Diuretics ,Beta blocker
• Super added anxiety and depression.

What are the causes of prolonged jaundice?

Jaundice present tor more than 6 months may be arbitrarily called as prolonged Jaundice'. The common causes are given below.

• Cholestatic viral hepatitis.
• Chronic hepatitis.
• Cirrhosis of liver.
• Carcinoma of liver (secondary).
• Thalassaemia.
• Drug-induced hepatitis (eg. rifampicin. INH. chlorpromazine).
• Extrahepatic biliary obstruction (eg. stone, stricture, carcinoma of the head of pancreas).
• Alcoholic hepatitis.
• Wilson's disease.
• Other causes like Gilbert's syndrome primary biliary cirrhosis, hereditary spherocytosis, sickle cell anaemia, autoimmune haemolytic anaemia, sclerosing cholangitis etc.

What are the symptomatology in gastrointestinal disease

Symptoms of uppergastrointestinal disease
Symptoms of lowergastrointestinal disease
Symptoms of Hepatobiliary disease
Symptoms of pancreatic disease
General symptoms of gastrointestinal system
Gastrointestinal bleeding
Alimentary symptoms depending on the anatomical site

Evaluation of gastrointestinal bleeding

Evaluation of Hematemesis
What is melaena?
Causes of upper gastrointestinal bleeding
Hematochezia
Assessment of severity of blood loss
Differentiation between Upper Gl and Lower Gl Bleed
Poor prognostic factors of gastrointestinal bleeding
Laboratory Findings in gastrointestinal bleeding
Management of gastrointestinal bleeding

Symptoms of pancreatic disease

Pain abdomen - Due to inflammation or stone
Distention of abdomen
Pleuritic pain - Left
Tetany
In chronic disease - Ascites, steatorrhoea and IDDM.

Symptoms of hepatobiliary disease

Jaundice 
Dark urine
Pain - Right hypochondrium – Congestive heptomegaly
Biliary colic 
Anorexia
Upper Gastrointestinal symptoms and bleeding
Pruritus
Pale stool
Fever
Lethargy
Loss of weight.

General symptoms of gastrointestinal system

Abdominal pain
Abdominal distension
Fever
Loss of weight

Evaluation of abdominal pain

Causes of abdominal pain based on site
Causes of acute abdominal pain
Causes of chronic abdominal pain
Types of Abdominal pain
Mechanism of Abdominal pain
Features to note with abdominal pain
Medical disorders producing abdominal pain

What are the lowergastrointestinal symptoms

Diarrhea

Constipation

Melaena

Hematochezia

Abnormal  stool

Clinical evaluation of diarrhea

Diarrhoea and its mechanisms
Causes of acute Diarrhoea
What are the causes of chronic diarrhoea
Secretory diarrhoea clinical features
Osmotic Diarrhoea
Investigation of  diarrhea
Treatment of diarrhea

Management of gastrointestinal bleeding

Management of a patient gastrointestinal bleeding include

1.Admission of the patient

2.Reassure the patient

3.Establish an IV line

4.Assessment of blood loss by history and vital signs (HR, BP every hour)

5.Introduction of a nasogastric tube for assessment of the quantity and duration of bleed and can also be used for therapeutic cold water lavage in an attempt to arrest the bleed

6.Cross matching of blood to be done and haematocrit value to be determined

7.Indication for transfusion of blood

• Acute or continuous blood loss
• Patient in shock (HR > 120/min; systolic BP < 100 mm Hg; hourly urine output < 0.5 ml/kg/hr)
• Hb < 10 gm% limited value in the management
• PCV < 20% assessment of acute bleed

8.Therapeutic endoscopy: The technique is useful for control of bleeding (coagulating electrodes, heated probes and laser energy).Sengstaken-Blakemore's tube (for variceal bleed).

Poor prognostic factors of gastrointestinal bleeding

• Severe initial bleed based on transfusion requirements and the presence of shock
• Continuous bleeding
• Recurrent bleeding
• Onset of bleeding during hospitalisation
• Age over 60 years
• Presence of other diseases (cardiac, respiratory, renal)
• Variceal bleeding.

Differentiation between Upper Gl and Lower Gl Bleed

Features                          Upper Gl Bleed                             Lower Gl Bleed    
Site                                   Above the ligament of Treitz         Below th ligamentof Treitz
Presentation                     Haematemesis/ melaena                 Haematochezia
Nasogastric aspiration     Blood                                              Clear fluid
BUN/creatinine ratio       Increased (> 25:1)                          Normal (< 25:1)
Bowel sounds                  Hyperactive                                    Normal

Laboratory Findings in gastrointestinal bleeding

• Complete blood count: Mild leucocytosis and thrombocytosis develop within 6 hrs after the onset of bleeding.
• Card test:this is useful for detection of occult blood in stools.
• Endoscopy: It is useful for confirmation and treatment in more than 90% of cases.The risk of of rebleeding is higher if a 'visible vessel' is seen in ulcer crater.
• Angiography: It is useful to detect the exact  site of bleeding (>0.5 ml/min).
• Radio-labelled RBC: It is useful in determining low grade bleeding from gastrointestinal tract and especially when the pathology is out of reach of the endoscope (>0.1 ml/min).