APPROACH TO PAIN

Sue Celle T.Saavedra, MD, FPCP, FPRA Cagayan de Oro Medical Center

CASE:

46 M with acute left ankle swelling

PAINSignal of diseaseMost common symptom that brings a

patient to a physician’s attentionDifferent diseases produces

characteristic patterns of tissue damage Quality, time course, and location of a

patient's pain complaint and the location of tenderness provide important diagnostic clues

Pain Unpleasant sensation localized to a part of the

body Described

Penetrating or tissue-destructive process Stabbing burning, twisting, tearing, squeezing

and/or of a bodily or emotional reaction Terrifying, nauseating, sickening

Pain of moderate or higher intensity is accompanied by anxiety and the urge to escape or terminate the feeling

Sensation and emotion

Acute Pain Associated with behavioral arousal and a

stress response Increased blood pressure, heart rate, pupil

diameter, and plasma cortisol levels Local muscle contraction

Limb flexion, abdominal wall rigidity

Chronic Difficult to diagnose Demanding patient Traditional medical approach of seeking an

obscure organic pathology is usually unhelpful

Psychological evaluation and behaviorally based treatment paradigms are frequently helpful

Depression is the most common emotional disturbance or problem

Seven Attributes of a Symptom

Location – radiationQuality – gnawing, pricking, etc.Quantity or Severity – Scale of 10Timing SettingAggravating or Relieving factorsAssociated manifestations

Muskuloskeletal system Joints, bones, muscles, tendons,

ligaments, tissues surrounding the joints

7 attributes Location

? Show or localized area of pain ? Other areas involved ? Radiation ? Migratory/Unilateral/Symmetrical

Quality and Quantity/Severity ? Character of pain

Gnawing, burning, throbbing Scale 1/10

Timing ? Onset

Acute/subacute/chronic Sudden/insidious/gradual/progressing

Duration Frequency

Setting in which they occur ? Activity/Environment/Emotions

Aggravating or Relieving factors ? Setting

Associated manifestations ? Other symptoms ? ROM ? Swelling/warmth/tenderness/redness

Myalgias Arthritis vs arthralgia

Stiffness Perception of tightness Resistance to movement Timing

APPROACH TO RESPIRATORY SYMPTOMS

Cough Most common and frequent symptom Reflex response to a stimuli that irritate

receptors in the larynx, trachea or large bronchi

Inflammation of the respiratory mucosa and pressure or tension on the air passages

Indicate the presence of lung disease Cough per se is not useful for the differential

diagnosis

Cough

? 7 attributes Setting, Severity, Relieving or Aggravating

factors, Associated Symptoms Presence of sputum often suggests airway

disease Asthma, chronic bronchitis, or bronchiectasis

? Smoking, frequency, acute or chronic? Seasonal ? Productive or dry/hard? Phlegm - describe

Dyspnea

Difficulty of breathing/Shortness of breathNonpainful but uncomfortable awareness

of breathingFrequently accompanies anxiety? Setting

When it occurs? At rest or on exertion?? Severity – based on daily activities? Aggravated/Relieving factors? Associated symptoms

Determine the time course Acute

Over a period of hrs to days Asthma attack Pulmonary parenchyma involvement

Pulmonary edema, pneumonia, pneumothorax, pulmonary embolism

Subacute Over days to weeks Exacerbation of pre-existing airways disease

Chronic Months to years Indicates chronic obstructive lung/interstitial

disease or a cardiac disease

Orthopnea

Dyspnea that occurs when lying down and improves upon sitting

Quantified - # of pillows

Paroxysmal nocturnal dyspnea Sudden dyspnea and orthopnea that wakens one

from sleep Usually 1-2 hrs after going to sleep

Tachypnea Rapid shallow breathing

SOB Short of breath - dyspnea

Wheezing Musical respiratory sounds audible to

the patient and othersSuggests partial airway obstruction? Setting ? Severity? Aggravated & Relieving factors? Associated symptoms

Cough

Hemoptysis Coughing or spitting up of bloodBlood-streaked or pure bloodOriginate from disease of the airways,

the pulmonary parenchyma, or the vasculature

? 1st time or has Hx before? Volume Differentiated from hematemesis

Pain Chest pain Lung tissue – no pain fibers Due:

Inflammation of adjacent parietal pleura Muscle strain Cardiac problems – pericarditis

Accentuated by respiratory motion (pleuritic) ? Radiation ? Associated Sx: Exertion MC

Adults – Costochondritis Children – Anxiety

APPROACH TO COMMON GIT SIGNS AND SYMPTOMS

GIT

EsophagusAbdomen LiverPancreasSmall and large intestines

Dysphagia

Difficulty in swallowing, the sense that food or liquid is sticking, hesitating, or “won’t go down right”

Sensation of a lump in the throat or in the retrosternal area

Difficulty in transferring food from mouth to the esophagus

Show where the dysphagia is felt Chest – esophageal disorder Throat

Timing ? Start, intermittent or persistent, progressing

Precipitating factors Liquid or solid food Solid – mechanical narrowing of the esophagus Both – esophageal motility

Associated symptoms Pain - Odynophagia

Odynophagia Pain on swallowingSharp burning pain suggests mucosal

inflammationSqueezing cramping pain suggests a

muscular cause

Indigestion Distress associated with eating

HeartburnExcessive gasAbdominal fullnessAbdominal painNausea and vomiting, etc.

Heartburn

Sense of burning or warmth that is felt retrosternally and may radiate from the epigastrium to the neck

Originates in the esophagusReflux of gastric acid into the

esophagusPrecipitated by a heavy meal, lying

down or bending forwardSuggests reflux esophagitis

Excessive gas Frequent belching, abdominal bloating or distention or flatus Normal: 600 ml of gas per day

Abdominal fullness

Inability to eat a full meal

Abdominal pain Mechanisms

1. Visceral pain• Hollow abdominal organs contraction or

distension or stretched• Poorly localized• Near the midline • Gnawing, burning, cramping or aching• Assocd with sweating, pallor, nausea,

vomiting and restlessness

2. Parietal pain

• Inflammation of the parietal peritoneum• Steady, aching pain, more severe than

visceral pain• Localized over the involved structure• Aggravated by movement or coughing• Relieved by lying still• Acute appendicitis

3. Referred pain

• Pain at distant sites that are innervated at approximately the same spinal levels

• Often as initial pain becoming intense and seems to radiate from the initial site

• Well localized, superficially or deeply

? Show or localized the painDescribe the pain? Severity? Timing ? Precipitating/Relieving factors? Associated symptoms

Anorexia Loss of appetite

Nausea “feeling sick to my stomach”

Retching Spasmodic movements of the chest and

diaphragm that precedes and ends in vomiting

Vomiting Forceful expulsion of gastric contents out

through the mouth

Regurgitation

Raising of esophageal or gastric contents in the absence of nausea or retching

Occurs when there is narrowing of the esophagus or incompetent esophageal sphincter

Bowel function Diarrhea

Excessive frequency in the passage of stools that are usually unformed or watery

Constipation Decrease in the frequency of bowel movements

Obstipation Complete constipation, with passage of neither

stool nor gas

Normal: 3 times a day to twice a week

Melena Passage of black and tarry stools

Hematochezia Passage of red blood in the stools

Jaundice or Icterus Yellowish discoloration of the skin and eyes Increased amount of bilirubin, a bile pigment

derived chiefly from the breakdown of hemoglobin

Mechanism Increased production of bilirubin Decreased uptake of bilirubin by the liver cells Decreased ability of the liver to conjugate the bilirubin Decreased excretion of bilirubin into the bile with

resulting escape of some bilirubin into the blood

? Associated symptoms Color of stools, urine Buccal mucosa Itchiness Pain Fever Anorexia