MEDICAL ENGLISH 5.docx

MEDICAL ENGLISH 5

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Symptoms of heart disease

Language functions (pink highlighting)

1. Introducing the subject
2. Disagreeing
3. Introducing oneself

A. PRESENTATION
(Language function - introducing the subject)

Chairman: Good morning, Ladies and Gentlemen and welcome to this cardiology refresher course. Our first speaker this morning is Jeff Gardener who is going to talk about cardiac symptoms. Jeff…

Dr Gardener: Thank you. Good morning Ladies and Gentlemen. This morning I’d like to give you a brief overview of some of the more common symptoms of cardiac disease. Before I begin, I’d just like to say that many organic and inorganic diseases may the symptoms of heart disease and it is a difficult and task for the physician to distinguish between them. Broadly speaking, the symptoms associated with heart disease result from three types of : one, myocardial ischemia; two, disturbance of cardiac contraction; and three, abnormal heart rate or rhythm. As a general rule, the more serious the disease, the more severe the symptoms.

So, to begin, I’d like to look at myocardial , which is usually manifested as chest pain, and is called angina pectoris. Angina pectoris is central and in nature like a “tight band”. It often radiates across the chest and, in about a third of patients, to the arms. On the ECG, there is associated ST segment depression. Stable angina occurs on effort and is by rest. Unstable angina increases on exercise and occurs without warning at rest. Many patients with unstable angina need coronary angiography with a view to possible angioplasty or surgery. Decubitus angina occurs on lying down at night. During REM sleep, of the coronary vessels sometimes occurs.

Next, I want to discuss symptoms related to deficiencies in the pumping of the heart. Fatigue and weakness are common symptoms, but are difficult to assess because they are so subjective. Dyspnea on effort or at rest is very common and is usually classified according to the New York Heart Association criteria of effort tolerance. As increases, orthopnea and paroxysmal nocturnal dyspnea, or PND, can occur. PND is caused by pulmonary edema and is usually accompanied by pink sputum or streaky hemoptysis.

Peripheral cyanosis may be present when there is a poor cardiac output and central cyanosis of cardiac origin may be caused by pulmonary atresia or by right to left shunting. Pitting edema of the , or of the sacrum in the bedridden, is a sign of congestive cardiac failure or pericardial constriction.

Another common symptom of heart disease is or loss of consciousness. There are many causes of syncope; the most common is vasovagal or fainting. Syncope of cardiac origin results from a sudden reduction in cardiac , often caused by a cardiac arrhythmia. As I said, there are other possible causes and, for example, it is important to distinguish between a Stokes-Adams attack and epilepsy. In there is no warning and the period of unconsciousness is short with a rapid recovery.

Finally, let me say a few words about cardiac rhythm . The symptoms often develop suddenly. Many patients complain of palpitations and will tell you that their heart stopped suddenly and then restarted with a . Missed beats are the commonest type of palpitation and are caused by ectopics or premature beats. They can be atrial or ventricular in origin. Tachycardias are often felt as a fluttering sensation in the , sometimes accompanied by pain. Supraventricular tachycardias tend to start and stop suddenly while bradycardias are less common and the patient may be of them. With any arrhythmia a 12-lead ECG or 24-hour ECG monitoring is usually needed.

I hope that you found this brief summary of some benefit and I would be happy to answer any questions that you might have.

B. QUESTION SESSION
(Language function - disagreeing)

Chairman: Thank you, Dr Gardener, for that very interesting and informative talk. Now, if anyone has any questions, I’m sure Dr Gardener would be happy to answer them. Yes…

Dr Evans: Muriel Evans, Bloomington, Indiana. Dr Gardener, I’m not sure I agree with what you said at the start of the lecture, that the of the symptoms indicates the seriousness of the disease. I know of several patients who have never complained of chest pain, but have ECG evidence of previous infarction.

Dr Gardener: That’s a good example, but I would tend to disagree with your interpretation. Severe symptoms often reflect serious disease, but this is not necessarily the case. I was trying to point out that this was a general rule and shouldn’t be taken too . We should remember, for example, that on routine Holter monitoring, 2.5 percent of the male population has been shown to have ST depression.

Mr Pearson: Frank Pearson, senior-year student, Michigan State University. Dr Gardener, I disagree with you about ST depression and angina. In Prinzmetal's angina, which you did not mention, ST elevation . How can you explain this fact?

Dr Gardener: I can’t say that I share your point of view. Where time is limited, such as on this course, it is inevitable that there will be . Prinzmetal's, or variant angina, is not common and so was not included. As you point out, it does have associated ST elevation, but this is thought to be due to transmural ischemia caused by coronary artery spasm. In stable angina the ST depression is caused by subendocardial . I hope that answers your question.

Chairman: Well, it’s time for our now. There are refreshments next door and if you have any further questions, we can continue the discussion there.

C. CONVERSATION
(Language function - introducing oneself)

In the break after Dr Gardener’s presentation, the delegates are standing around the refreshments table.

Marius: I don’t think we’ve met before. How do you do. I’m Marius Wardell . I’m doing my in general medicine here at the Rockefeller.

Robert: Pleased to meet you. My name is Robert Miller. I’m a resident too, in cardiology at Richmond, Virginia. Say, you’re not American, are you?

Marius: No, I’m British and I haven’t been here for long. Look, could I ask you something? In the last session, that reference to Prinzmetal’s angina, do you know much about it?

Robert: A bit, I guess. I know it occurs without at rest and it responds well to vasodilators. There are several theories. I remember one that points to abnormal mast cell infiltrates which histamine and serotonin within the coronary adventia.

Maggie: Hello, excuse me for interrupting, but I was interested in what you were saying about Prinzmetal’s angina. Oh, Perhaps I should introduce myself. I’m Margaret Holder, Maggie for short. I’m from Bristol .

Robert: Hi! Pleased to meet you. Is that lady over there a friend of yours?

Maggie: No, I don't know her at all.

Robert: Excuse me, I saw you looking our way. Have we met somewhere before? I’m Robert Miller.

Kate: No, I don’t think so. I was trying to catch your colleague’s attention. I met him a few weeks ago at a friend’s party. Let me introduce myself. Kate Rubens. I’m at Mount Sinai…

Symptoms of heart disease

Language functions (pink highlighting)

1. Introducing the subject
2. Disagreeing
3. Introducing oneself

A. PRESENTATION
(Language function - introducing the subject)

Chairman: Good morning, Ladies and Gentlemen and welcome to this cardiology refresher course. Our first speaker this morning is Jeff Gardener who is going to talk about cardiac symptoms. Jeff…

Dr Gardener: Thank you. Good morning Ladies and Gentlemen. This morning I’d like to give you a brief overview of some of the more common symptoms of cardiac disease. Before I begin, I’d just like to say that many organic and inorganic diseases may mimic the symptoms of heart disease and it is a difficult and challenging task for the physician to distinguish between them. Broadly speaking, the symptoms associated with heart disease result from three types of dysfunction: one, myocardial ischemia; two, disturbance of cardiac contraction; and three, abnormal heart rate or rhythm. As a general rule, the more serious the disease, the more severe the symptoms.

So, to begin, I’d like to look at myocardial ischemia, which is usually manifested as chest pain, and is called angina pectoris. Angina pectoris is central and crushing in nature like a “tight band”. It often radiates across the chest and, in about a third of patients, to the arms. On the ECG, there is associated ST segment depression. Stable angina occurs on effort and is relieved by rest. Unstable angina increases on exercise and occurs without warning at rest. Many patients with unstable angina need coronary angiography with a view to possible angioplasty or surgery. Decubitus angina occurs on lying down at night. During REM sleep, spasm of the coronary vessels sometimes occurs.

Next, I want to discuss symptoms related to deficiencies in the pumping ability of the heart. Fatigue and weakness are common symptoms, but are difficult to assess because they are so subjective. Dyspnea on effort or at rest is very common and is usually classified according to the New York Heart Association criteria of effort tolerance. As disability increases, orthopnea and paroxysmal nocturnal dyspnea, or PND, can occur. PND is caused by pulmonary edema and is usually accompanied by pink frothy sputum or streaky hemoptysis.

Peripheral cyanosis may be present when there is a poor cardiac output and central cyanosis of cardiac origin may be caused by pulmonary atresia or by right to left shunting. Pitting edema of the ankles, or of the sacrum in the bedridden, is a sign of congestive cardiac failure or pericardial constriction.

Another common symptom of heart disease is syncope or loss of consciousness. There are many causes of syncope; the most common is vasovagal or fainting. Syncope of cardiac origin results from a sudden reduction in cardiac output, often caused by a cardiac arrhythmia. As I said, there are other possible causes and, for example, it is important to distinguish between a Stokes-Adams attack and epilepsy. In the former there is no warning and the period of unconsciousness is short with a rapid recovery.

Finally, let me say a few words about cardiac rhythm disturbances. The symptoms often develop suddenly. Many patients complain of palpitations and will tell you that their heart stopped suddenly and then restarted with a thump. Missed beats are the commonest type of palpitation and are caused by ectopics or premature beats. They can be atrial or ventricular in origin. Tachycardias are often felt as a fluttering sensation in the chest, sometimes accompanied by pain. Supraventricular tachycardias tend to start and stop suddenly while bradycardias are less common and the patient may be unaware of them. With any arrhythmia a 12-lead ECG or 24-hour ECG monitoring is usually needed.

I hope that you found this brief summary of some benefit and I would be happy to answer any questions that you might have.

B. QUESTION SESSION
(Language function - disagreeing)

Chairman: Thank you, Dr Gardener, for that very interesting and informative talk. Now, if anyone has any questions, I’m sure Dr Gardener would be happy to answer them. Yes…

Dr Evans: Muriel Evans, Bloomington, Indiana. Dr Gardener, I’m not sure I agree with what you said at the start of the lecture, that the severity of the symptoms indicates the seriousness of the disease. I know of several patients who have never complained of chest pain, but have ECG evidence of previous infarction.

Dr Gardener: That’s a good example, but I would tend to disagree with your interpretation. Severe symptoms often reflect serious disease, but this is not necessarily the case. I was trying to point out that this was a general rule and shouldn’t be taken too literally. We should remember, for example, that on routine Holter monitoring, 2.5 percent of the male population has been shown to have asymptomatic ST depression.

Mr Pearson: Frank Pearson, senior-year student, Michigan State University. Dr Gardener, I disagree with you about ST depression and angina. In Prinzmetal's angina, which you did not mention, ST elevation occurs. How can you explain this fact?

Dr Gardener: I can’t say that I share your point of view. Where time is limited, such as on this course, it is inevitable that there will be omissions. Prinzmetal's, or variant angina, is not common and so was not included. As you point out, it does have associated ST elevation, but this is thought to be due to transmural ischemia caused by coronary artery spasm. In stable angina the ST depression is caused by subendocardial ischemia. I hope that answers your question.

Chairman: Well, it’s time for our break now. There are refreshments...