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 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– 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

HeadacheCommon causes of HeadachePrimary 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

• 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