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 discomfortDiagnosis 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

HeadacheCommon 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