Transcript Cardinal Manifestations of Diease

Cardinal Manifestations of Disease:
Dr. Meg-angela Christi Amores
What is PAIN for You?
PAIN
• an unpleasant sensation localized
to a part of the body
• most common symptom that brings a patient
to a physician's attention
• Protects the body and maintain homeostasis
• provide important diagnostic clues
Peripheral Mechanisms of Pain
Central Mechanisms of Pain
Chest Discomfort
Chest Pain / Discomfort
• one of the most common challenges for clinicians
• conditions affecting organs throughout the
thorax and abdomen
• vary from benign to life-threatening
Chest discomfort
Diagnosis if MI is ruled out
Percent
Gastroesophageal diseasea
42
Gastroesophageal reflux
Esophageal motility disorders
Peptic ulcer
Gallstones
Ischemic heart disease
31
Chest wall syndromes
28
Pericarditis
4
Pleuritis/pneumonia
2
Pulmonary embolism
2
Lung cancer
1.5
Aortic aneurysm
1
Aortic stenosis
1
Herpes zoster
1
Chest Discomfort
• Typical clinical features of major causes
– Angina Pectoris :
• 2-10 mins duration
• Pressure, tightness, squeezing, heaviness, burning
• Retrosternal, often with radiation to or isolated discomfort
in neck, jaw, shoulders, or arms—frequently on left
• Precipitated by exertion, exposure to cold, psychologic stress
– Unstable angina:
• 10-20 mins
• More severe Pressure, tightness, squeezing, heaviness,
burning
Chest Discomfort
• Typical clinical features of major causes
– Acute myocardial infarction ( MI )
• Variable; often more than 30 min duration
• Quality and location similar to angina
• Unrelieved by nitroglycerin
– Pericarditis
• Sharp pain lasting hours to days; may be episodic
• Retrosternal or toward cardiac apex; may radiate to left
shoulder
• May be relieved by sitting up and leaning forward
• Presence of pericardial friction rub
Chest Discomfort
• Typical clinical features of major causes
– Esophageal reflux
• Substernal or epigastric burning pain
lasting 10-60mins
• Worsened by postprandial recumbency
• Relieved by antacids
– Gallbladder disease
• Prolonged burning or pressure like pain following meals
• RUQ, epigastric or substernal
Approach to patient
• Acute Chest discomfort
– first assess the patient's respiratory and
hemodynamic status
– stabilizing the patient before the diagnostic
evaluation is pursued
– then a focused history, physical examination, and
laboratory evaluation should be performed to
assess the patient's risk of life-threatening
conditions
Abdominal Pain
Abdominal Pain
• correct interpretation of acute abdominal pain
is challenging
• diagnosis of "acute or surgical abdomen" is
not an acceptable one because of its often
misleading and erroneous connotation
Abdominal Pain
• Mechanisms:
– Inflammation of Parietal peritoneum
• Steady, aching, located directly over inflamed area
• Accentuated by pressure or changes in tension
• e.g. Acute appendicitis, Perforated Gastric ulcers
Abdominal Pain
– Obstruction of Hollow Viscera
• Intermittent or colicky, poorly localized
• e.g. SI obstruction, Gallbladder stones (misleading
biliary colic – steady pain), Kidney stones
Abdominal Pain
• Mechanisms …cont
– Vascular disturbances
• Mild, continuous, diffuse
• Radiation to sacrum, flank,
genitalia for days (AAA)
• e.g. Sup Mes Art obstruction,
Rupturing AAA
Abdominal Pain
– Abdominal wall
• Constant and aching
• Accentuated by movement, prolonged standing,
pressure
Approach to patient
• orderly, painstakingly detailed history
• location of the pain, chronological sequence of
events , accurate menstrual history in a female
patient
• pelvic and rectal examinations are mandatory
in every patient with abdominal pain
• peristaltic sounds, their quality, and their
frequency
Headache
Headache
• among the most common reasons that
patients seek medical attention
• classification system developed by the
International Headache Society characterizes
headache as primary or secondary
– Primary headaches: those in which headache and
its associated features are the disorder in itself
– secondary headaches are those caused by
exogenous disorders
Headache
Common causes of Headache
Primary Headache
Secondary Headache
Type
%
Type
%
Migraine
16
Systemic infection
63
Tension-type
69
Head injury
4
Cluster
0.1
Vascular disorders
1
Idiopathic stabbing
2
Subarachnoid hemorrhage
<1
Exertional
1
Brain tumor
0.1
• Pain usually occurs when peripheral nociceptors
are stimulated in response to tissue injury,
visceral distension, or other factors
Pain-producing cranial structures
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Scalp
middle meningeal artery
dural sinuses
falx cerebri
proximal segments of the large pial arteries
Headache
• The key structures involved in primary headache
appear to be
– the large intracranial vessels and dura mater
– the peripheral terminals of the trigeminal nerve that
innervate these structures
– the caudal portion of the trigeminal nucleus, which
extends into the dorsal horns of the upper cervical
spinal cord and receives input from the first and
second cervical nerve roots (the trigeminocervical
complex)
– the pain modulatory systems in the brain that receive
input from trigeminal nociceptors
Headache
• Serious causes to be considered include meningitis,
subarachnoid hemorrhage, epidural or subdural hematoma,
glaucoma, and purulent sinusitis
Headache
• Primary headache syndromes:
– Migraine Headache
– Tension-type Headache
– Cluster headache
– Chronic Daily Headache
– Others (Hemicrania Continua, Stabbing Headache,
Cough headache, Exertional Headache, Sex
headache, Thunderclap headache, Hypnic
Headache)
Headache
• Tension-type Headache
– Most common
– chronic head-pain syndrome characterized by
bilateral tight, bandlike discomfort
– pain is a product of nervous tension, but there is
no clear evidence for tension as an etiology
– without accompanying features such as nausea,
vomiting, photophobia, phonophobia,
osmophobia, throbbing, and aggravation with
movement
Headache
• Migraine
– second most common cause of headache
– 15% of women and 6% of men
– Episodic, associated with sensitivity to light, sound, or
movement
– Headache can be initiated or amplified by various
triggers, including glare, bright lights, sounds, or other
afferent stimulation; hunger; excess stress; physical
exertion; stormy weather or barometric pressure
changes; hormonal fluctuations during menses; lack
of or excess sleep; and alcohol or other chemical
stimulation
• Secondary Headache
– Meningitis
• Acute, severe headache with stiff neck and fever
• cardinal symptoms of pounding headache, photophobia, nausea,
and vomiting are present.
– Intracranial Hemorrhage
• Acute, severe headache with stiff neck but without fever
– Brain Tumor
• 30% complain of headache
• usually nondescript—an intermittent deep, dull aching of
moderate intensity, which may worsen with exertion or change in
position and may be associated with nausea and vomiting.
– Temporal Arteritis
• common disorder of the elderly
• Headache- uni/bilateral, temporal in location in 50%
• dull and boring, with superimposed episodic stabbing pains
– Glaucoma
• prostrating headache associated with nausea and vomiting
• For the next meeting, read on Cardinal
Manifestations of Disease : ALTERATIONS IN
BODY TEMPERATURE
• Harrison’s Principles of Internal Medicine 17th
edition