Pain
PAIN
Pain being a very common symptom in various diseases is
taken for granted. Many a times it is confused with “tenderness”. The patient
feels the ‘pain’ while the doctor elicits ‘tenderness’ and so tenderness is
felt in response to the stimulus given by someone (doctor). Therefore, ‘pain’
is a symptom whereas ‘tenderness’ is a sign.
Types of Pain-
1.
Superficial pain – occurs due to direct
irritation of peripheral nerve endings in the superficial tissues; these could
be chemical, mechanical, thermal or electrical. It is superficial and can be
pointed out.
2.
Segmental pain – due to irritation of
sensory nerves; its located in particular dermatome which is supplied by
affected sensory nerves.
3.
Deep pain – occurs due to irritation of
deep structures (deep fascia, muscles, tendons, bones, joints and visera). This
pain is vague and may cause involuntary spasm of skeletal muscles.
4.
Psychogenic pain – it arises from the
brain (could be because of emotional reasons, lesions of thalamus, causalgia).
Causes of Pain-
I.
Original site of pain?
Ask the patient “where did the pain
started?”. In cases related to abdominal pain, the patient may not be able to
locate the pain with finger, instead would use the whole hand.
II.
How and since when the pain started?
A long gradual pain with possible harmful
effects indicates chronic disease (eg. Chronic pancreatitis, Chronic peptic
ulcer, Subacute appendicitis); whereas if the disease has occurred recently
with sudden onset of pain, indicates acute nature of the disease (eg. Acute appendicitis,
Rupture of aneurysm). Do ask the patient “how the pain started?”. Because it
could be due to traumatic cause also (sprain, kidney or liver rupture).
III.
Severity
of pain?
Though this may differ in different
patients; but in certain situations its similar (eg. Acute pancreatitis ,
Biliary colic, Perforated peptic ulcer produce severe pain).
IV.
Character of pain?
a)
Burning pain – it has burning sensation &
typically experienced in case of peptic ulcer or reflex esophagitis
b)
Vague aching pain – it is a mild continuous pain
which doesn’t spread
c)
Twisting pain – generally its seen in case of
volvulus of intestine, ovarian cyst or testicular torsion with a feeling as if
something is twisting inside the body
d)
Throbbing pain – typically felt in pyogenic
abscess
e)
Scalding pain - it’s a type of burning sensation
which is particularly during micturition due to cystitis, acute pyelonephritis
f)
Pins and needles sensation – typically felt in
case of injury to peripheral sensory nerves
g)
Shooting pain – typically felt in case of
sciatica (pain affecting the back, hip and the outer side of the leg)
h)
Stabbing pain – its sudden, severe, sharp and
short-lived; typically felt in acute perforation of peptic ulcer
i)
Constricting pain –the patient feels as if
something is encircling & compressing; expressed as an iron band tightening
around the chest; typical for angina pectoris
j)
Colic pain – this pain appears suddenly and
goes off suddenly, also the pain is gripping associated with vomiting and
sweating
V.
How the pain progress?
It may begin suddenly with great intensity
or gradually or may be fluctuating.
VI.
Duration of pain?
It means from the time of onset to the time
of disappearance. Eg. Gripping pain of intestinal colic is felt for <1min;
pain due to angina ceases within 5min; pain due to myocardial infarction may
continue for hours.
VII.
How the pain moves?
a)
Radiating pain- the pain extends to another site
while the original pain persists at its original site (eg. When the duodenal
ulcer penetrates posteriorly; the pain still remains in epigastric region, but
at the same time the pain spreads to the back.
b)
Referred pain- when the pain is felt at a
distance from its source & there is no pain at the original site of the
disease. It occurs when the CNS fails to differentiate between visceral and
somatic sensory impulses from the same segment.
c)
Shifting or migrating pain- in this condition
the pain is felt at one site in the beginning and then the pain is shifted to
another site and the original pain disappears.
VIII.
Time of
occurrence?
If the patient comes to you with a history
of having pain on waking up in the morning or the patient gets up in the
morning because of the pain, then suspect Acute appendicitis. On the other hand,
if the patient comes with pain often around 4pm in afternoon & early
morning about 2-3am then it’s most probably because of Duodenal ulcer (this
pain is “hunger pain” & felt when the food is passed out of the stomach and
the stomach is empty). Migraine pain may occur especially in the morning,
either every week or during menstruation.
IX.
Factors aggravating?
Alimentary pain is often aggravated due to
increased consumption of particular foods, musculoskeletal pain becomes worse
by joint movements. Pain of acute pancreatitis becomes worse when the patient
lies down; pain of peptic ulcer gets worse by eating spicy foods and drinking;
Pain of disc prolapsed often gets aggravated on lifting heavy weight from
stooping position.
X.
Relieving factors?
Pain due to peptic ulcer is often relieved
by alkali and antacids in 5-15min; pain of acute pancreatitis is relieved by
sitting up in the bed in leaning forward position & the patient prefers to
sit throughout the night; colicy pain of intestinal obstruction is
relieved on passing flatus; in case of
perforative peritonitis the patient gets relief if he lies still.
XI.
Associated symptoms?
Severe pain is often associated with
sweating, vomiting and increase pulse rate; biliary colic is associated with
jaundice and pale stool; migraine is often preceded by visual disturbances
along with vomiting; colicy pain is often associated with sweating, vomiting
& clammy extremities; pain due to acute pyelonephritis may be associated
with rigor and high fever.
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