Why does my shoulder hurt when I walk uphill? Ask the GP DR MARTIN SCURR 

I take a brisk 30 minute walk three times a week and am relatively fit. But when I come up a slope, I feel a dull ache in my right shoulder and the top of my right arm. My GP dismissed the possibility of it being angina and suggested it could be a muscle problem, and to go back to them if it got worse (I’m 72).

John Coleridge, Cheshire.

The symptom you describe is, in my opinion, strongly suggestive of angina.

The textbook description of angina is that it causes chest pain that can radiate to the left arm.

But my experience over many decades is that it rarely happens this way. In fact, I have rarely seen angina patients with pain in the left shoulder or arm: most often it leads to central chest pain, although the severity varies.

Angina is caused by a partial narrowing of the arteries. The pain occurs when the heart is working harder (for example, during exercise) and not enough blood is getting through.

Taking a walk after a meal may make your symptoms worse and be more likely to happen in colder weather (in both cases the heart has to work harder). In some patients, the pain of angina pectoris is felt in the neck and jaw, in others it is the upper abdomen. But the feeling can spread to both arms — or just the right arm.

In my opinion… Gut bacteria affect our condition

I don’t often write about mice, but I feel compelled to draw your attention to an exceptional study from the University of Pennsylvania, USA — which also affects us.

Like humans, some mice enjoy regular exercise (running on their wheel), while others do nothing. The researchers found no genetic differences between the groups, but what did emerge was a major difference in their microbiome, that is, the microbes that live in the gut.

The microbiome of the sporty mice created compounds that stimulated the reward center in their brains after exercise.

When given antibiotics to wipe out the microbiome, the mice stopped running. Once their microbiome was restored with the help of stool samples, they started running again.

The stage where we have to take care of our microbiome from birth is getting closer.

In addition to the pain, you may also be a little short of breath. But the main pattern to watch for is that this pain starts with exertion and stops when you rest.

I think you should go to a cardiologist for further examination.

This may lead to an angiogram, which involves sending dye through the blood vessels and using a form of X-ray to check how it flows through the coronary arteries.

If a blockage is found, you will be treated with medication, such as a nitrate spray for when angina occurs (it works by widening the blood vessels and increasing blood flow), pending a decision on further treatment.

You will almost certainly need medication to reduce elevated cholesterol or high blood pressure, to lessen any further strain on the heart. You may also be advised to have a procedure to address any restrictions in blood flow in the two arteries – this involves inserting stents (small tubes) into narrowed segments to keep them open.

If there is more narrowing, a heart bypass may be needed. But given – as you say in your longer letter – that you’ve only had the symptoms for six months and they sound relatively mild, I don’t think this will be necessary. Each technique means an end to the angina pectoris.

Go to your GP again and ask for an urgent referral.

Narrowed arteries can increase your risk of heart attack or stroke. So, with the permission of your GP, take one baby aspirin (75 mg) a day pending the visit to the cardiologist, provided you have no medical contraindications.

I have had sudden and profuse nosebleeds for the past few weeks – usually at night and lasting one to two hours. The blood sometimes comes out of the left nostril, sometimes both, and runs down my throat, causing me to cough up large clots. It’s very frightening.

Tests turned up nothing and I had the arteries cauterized twice without success. I have now been referred to an advisor but in the meantime what do you suggest if it happens again?

Jenny Cullen, London.

My first thought is that the blood is coming from the back of the nose, not just the nostrils (the most common site for a nosebleed), not least because the blood sometimes comes from both nostrils.

The tests you’ve had ruled out any problems with blood clotting (and I’m assuming you’re not on low-dose aspirin or any other form of blood thinner), and I agree that you should see an ear, nose, and throat specialist.

My first thought is that the blood is coming from the back of the nose because sometimes the blood comes down both nostrils

They will want to inspect the back of the nasal airway on each side using a fine fiber optic inspection scope. You may need further cautery.

If you have another bleed before your appointment, pinch your nostrils tightly for at least ten minutes, lean forward, and breathe through your mouth.

Failing that, keep pinching your nose and get a taxi or ask someone to take you to the local hospital.

Ideally, to receive proper treatment, you should be examined at the time of the nosebleed.

Write to Dr. Scurr

Write to Dr Scurr at Good Health, Daily Mail, 9 Derry Street, London W8 5HY or email: drmartin@dailymail.co.uk — add contact details. Dr. Scurr cannot respond to personal correspondence. Answers should be taken in a general context. In case of health problems, consult your own doctor.