Transcript Cardinal Manifestations of Diease

Cardinal Manifestations of Disease:
Dr. Gerrard Dennis Uy
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
• functions to protect the body and maintain
homeostasis
• provide important diagnostic clues and are
used to evaluate the response to treatment
Qualities of Pain
•
•
•
•
•
Stabbing
Burning
Twisting
Tearing
Squeezing
Components of a typical cutaneous
nerve
Primary Afferent Nociceptor
• Peripheral Nerve – consist of 3 different types of
neurons:
– Primary sensory afferents
– Motor neurons
– Sympathetic postganglionic neurons
• Primary sensory afferents:
– A- beta
• respond maximally to light touch or movement
• Present in the nerves of the skin
• In normal individuals, the activity of these fibers does not
produce pain
• Primary sensory afferents:
– A- delta and C fiber axons
• Respond maximally only to intense (painful) stimuli
• Also known as the pain receptors
• Also present in the nerves of the skin and the deep
somatic and visceral structures
Central Mechanisms of Pain
Neuropathic Pain
• is a complex, chronic pain state that usually is
accompanied by tissue injury
• the nerve fibers themselves may be damaged,
dysfunctional or injured and send incorrect
signals to other pain centers
• E.g
– Phantom limb syndrome
– Diabetic neuropathy
– Herpes zoster
Neuropathic Pain
• Typically have an unusual burning, tingling, or electric
shock like quality
• May be triggered by light touch
• Causes:
–
–
–
–
–
–
–
Alcoholism
Amputation
Chemotherapy
Diabetes
HIV infection and AIDS
Multiple sclerosis
Spine surgery
Treatment
• The ideal treatment for any pain is to remove
the cause
– Aspirin
– Acetaminophen
– NSAIDS
– Opioid analgesics
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
– Stable Angina :
•
•
•
•
Also known as effort angina
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:
•
•
•
•
•
Also known as crescendo angina
10-20 mins
More severe and of new onset (within the prior 4 – 6 weeks)
Occurs in a crescendo pattern
Usually accompanied by diaphoresis, dyspnea, nausea, and light
headedness
Chest Discomfort
• Typical clinical features of major causes
– Acute myocardial infarction ( MI )
•
•
•
•
more than 30 min duration
Quality and location similar to angina
Unrelieved by nitroglycerin
Levine’s sign - patient localizes the chest pain by clenching their fist
over the sternum
– Pericarditis
• Sharp pain lasting hours to days; may be episodic
• Retrosternal or toward cardiac apex and maybe aggravated by
coughing, deep breaths or changes in position
• may radiate to left shoulder and neck
• Pain is worse in supine and may be relieved by sitting up and leaning
forward
• Presence of pericardial friction rub
Chest Discomfort
• Typical clinical features of major causes
– Aortic Dissection
• Tear in the intima of the aorta
• maybe due to changes in the components of the
muscle layer of the aorta such as in hypertension
• May also be due to trauma, surgical procedures, and
connective tissue diseases
• Presents with severe chest pain reaching its maximal
intensity in a few minutes
• Pain often radiates to the between the scapula
Chest Discomfort
• Typical clinical features of major causes
– Pulmonary embolism
• Pain is due to the distention of the pulmonary artery or
infarction of a segment of the lung adjacent to the
pleura
• Associated symptoms include dyspnea and hempotysis
• Tachycardia is usually present
Chest Discomfort
• Typical clinical features of major causes
– Esophageal reflux
• Substernal or epigastric burning pain
lasting 10-60mins
• Exacerbated by lying down, alcohol, aspirin, etc
• Usually worse in the morning
• Relieved by antacids
– Gallbladder disease
• Prolonged burning or pressure like pain following meals
• RUQ, epigastric or substernal
Chest Discomfort
• Other causes
– Pneumothorax
– Pneumonia
– Mallory weiss tear
– Musculoskeletal pain
– Anxiety disorders
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
– 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
•
•
•
•
Pain is sudden and catastrophic in nature
Can vary from mild to severe, continuous, diffuse
Radiation to sacrum, flank, genitalia for days (AAA)
e.g. Sup Mes Art obstruction, Rupturing AAA
– 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
• Pain producing cranial structures:
– Scalp
– Middle meningeal artery
– Dural sinuses
– Falx cerebri
– Proximal segments of large pial arteries
• Ventricular ependyma, choroid plexus, pial
veins, brain parenchyma are not pain
producing
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
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
– Usually treated with simple analgesics
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
Hunger
Excess stress
Headache
• Migraine
– Triggers cont:
•
•
•
•
•
•
physical exertion
stormy weather
barometric pressure changes
hormonal fluctuations during menses
lack of or excess sleep
Smoking and alcohol
Headache
• Migraine
– Triggers cont:
• Any processed, fermented, pickled, or marinated foods, as
well as foods that contain monosodium glutamate (MSG)
• Baked goods, chocolate, nuts, peanut butter, and dairy
products
• Foods containing tyramine, which includes red wine, aged
cheese, smoked fish, chicken livers, figs, and certain beans
• Fruits (avocado, banana, citrus fruit)
• Meats containing nitrates (bacon, hot dogs, salami, cured
meats)
• Onions
Headache
• Migraine
– Pathogenesis maybe explained by the dysfunction
of the monoaminergic sensory control systems
– Substance that have been implicated:
• 5-HT (serotonin)
• dopamine
Headache
• Migraine
– High index of suspicion is required to diagnose
migraine
– Migraine aura:
• Visual disturbances with flashing lights or zigzag lines
Headache
• Treatment for migraine headache:
– NSAIDS (Acetaminophen, aspirin)
– 5-HT agonist (ergotamine, triptans)
– Dopamine antagonist (metoclopramide)
• 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 : Neck and Back Pain,
ALTERATIONS IN BODY TEMPERATURE
• Harrison’s Principles of Internal Medicine 17th
edition