APPROACH TO PAIN Sue Celle T.Saavedra, MD, FPCP, FPRA Cagayan de Oro Medical Center.
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Transcript of APPROACH TO PAIN Sue Celle T.Saavedra, MD, FPCP, FPRA Cagayan de Oro Medical Center.
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