Pain

Department of Physical Diagnostics

1st Teaching Hospital
Zhengzhou University
Definition
• “An unpleasant sensory and
emotional experience
associated with either actual
or potential tissue damage, or
described in terms of such
damage”
---- International Association for
the Study of Pain 
Classification:

– Dermal pain

– Visceral pain

– Deep pain

– Referred pain
Key Notes in Interviewing of Pain

• Sites
• Character
• Causes
• Duration
• Radiation
• Accompanied symptoms
• Relaxing factors
Abdominal Pain
 Abdominal Pain: Pathogenesis

Intra-abdominal diseases extra-abdominal

diseases

Visceral, peritoneal, or abdominal wall N.

Pain
Causes of Abdominal Pain
• Diseases of abdominal organs
– Acute: inflammation, fracture, obstruction,
perforation, torsion, embolism
– Chronic: inflammation, viscera enlargement,
obstruction, ulceration, torsion, tumor
• Diseases of extra-abdominal organs
– Thorax diseases: referred pain, pneumonia,
pleuritis, myocardial infarction
– General diseases: uremia, lead intoxication,
Henoch-Sch Ö nlein purpura
 Clinical Features

• Sites: related to location of the pathological

changes
• Characters: lancinating, drilling, burning,
colic
• Onset: continuous, paroxysmal, intermittent
• Radiation
• Factors triggering or relieving pain: meal
Common Diseases
• Acute appendicitis
– Pain is initially
localized around the
umbilicus (visceral
pain) and is vague; As
the inflammatory
response progresses to
involve the parietal
peritoneum, the main
site of pain shifts to
the right iliac fossa
(parietal or somatic
pain)
– Usually accompanied
by fever
Peptic Ulcer
• Periodical burning pain in
epigastrium
• Pain is associated with
meal
– May be accompanied by
hematemesis or melena
Acute Gastric Perforation

• Outburst acute severe

lancinating pain in

umbilical region or

epigastrium
Acute ileus
• Vomiting

• Cramping
Abdominal pain

• distension

• obstipation
Ureter Calculi
• Paroxysmal
abdominal
pain
• Referred pain
to the groin
area of the
same side
• Hematuria
Acute pancreatitis  
• Continuous severe pain in
umbilical region or
epigastrium, paroxysmally
enhanced
• Associated with meal, esp.
heavy drinking
Chest Pain
 Causes

Esophagus

Chestwall

Pleura
Mediastinum

Lung

Heart
subphrenic
 Angina pleuritis esophagitis
pectoris
Site Pre-cardial Affected chest Post-sternal

Radiation L shoulder & No No

arm
Character anginal lacerating burning

Duration Several mins days weeks

Causes Excitement, cough meal

labouring
Relieving nitroglycerin Position? Antacid

Accompany Chest distress, Fever, cough Swallowing

symptoms palpitation discomfort
Dyspnea
Causes
• Pulmonary:
– Inspiratory
– Expiratory
– Mixed
• Cardiac
• Toxic
• Other:
– Hysterical
– hemopathic
Pulmonary Dyspnea
• Inspiratory dyspnea
• Mechanism: narrowing of larynx
or large airway
• Features:
– Difficult in taking in air
– Prolonged inspiration phase
– May be accompanied by “three
depressions sign” and stridor in
inspiration phase
Pulmonary Dyspnea
• Expiratory dyspnea
• Mechanisms:
– Decreased elasticity of the lung tissue
– Narrowing of bronchiole
– Bronchioles are pressed in inspiration
phase
• Features:
– Difficult in expirate
– Prolonged expiration phase
– Too much air trapped in the lung
Pulmonary Dyspnea
• Mixed:
– Mechanisms:
• Generalized lesion in the lung
• Restricted dilatation of the alveoli due
to the thickness of the chest wall and
pleura
– Features:
• Difficult in inpirate and expirate
• Tachypnea
• Abnormal breath sounds or adventitious
sounds
Cardiac dyspnea
• Mechanisms:
– Congestion and decreased compliance
of the lung mainly due to left heart
insufficiency
• Features:
– Worsen by exertion, relieved by rest
– Nocturnal paroxysmal dyspnea
– “Cardiac asthma” : large amount of pink
frothy sputum, fine rales in both lung
fields, relieved by sitting position
Nocturnal Paroxysmal dyspnea

• Causes:
– Ischaemic heart disease
– Aortic valve disease
– Hypertension
– Cardiomyopathy
– Atrial fibrillation
– Rarely in mitral valve disease or atrial
tumours
Toxic Dyspnea
• Mechanism1: respiratory centre is
activated by acidosis
– Clinical feature: Kussmaul respiration
• Mechansim2: respiratory centre is
inhibited by drugs or other illness
– Clinical feature: Cheyne-Stokes
respiration and Biots respiration
Hysterical Dyspnea
• Mechanism: hyperventilation
syndrome caused by stimulating of
the respiration centre by psychic
factor
• Feature:
– Tachypnea
– May be accompanied by numbness of the
lips , numbness and convulsion of the four
extremities.
– Psychic or mental factors exist
– Dyspnea may be relived by psychotherapy
Hemoptysis and hematemesis
Definitions
• Hemoptysis: the expectoration of
any blood, regardless of whether
the sputum is grossly bloody or
merely blood streaked
• Hematemesis: efflux of blood from
the GI tract, usually bright red or
“coffee-ground” material is vomited
Differences Between Hemoptysis and
Hematemesis
Hemoptysis Hematemesis
Causes Heart or lung dis. Gastrointestinal , hepatic,
biliary tract dis.
Pre-bleeding Itching in the throat, Discomfort in the upper
abdomen, nausea, vomitting
symptoms cough
bleeding Bright red Coffee-ground, dark or
bright red
Material in blood Sputum Food residue
pH alkaline acid
melena No (unless blood is Yes
swallowed)
Sputum after Blood streaked No
bleeding