Cardinal Manifestations of Disease:

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Cardinal Manifestations of Disease

• Dr. Gerrard Dennis Uy

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What is PAIN for You?
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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

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Qualities of Pain

• Stabbing
• Burning
• Twisting
• Tearing
• Squeezing

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Components of a typical cutaneous nerve
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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

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• 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

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Central Mechanisms of Pain
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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

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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

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Treatment

• The ideal treatment for any pain is to remove the
  cause
• Aspirin
• Acetaminophen
• NSAIDS
• Opioid analgesics

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Chest Discomfort
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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

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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
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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
  armsfrequently 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

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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
• Levines 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

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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

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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

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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

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Chest Discomfort

• Other causes
• Pneumothorax
• Pneumonia
• Mallory weiss tear
• Musculoskeletal pain
• Anxiety disorders

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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

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Abdominal Pain
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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

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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

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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

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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

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Headache
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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

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• 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

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Headache
Common causes of Headache Common causes of Headache Common causes of Headache Common causes of Headache
Primary Headache Primary Headache Secondary 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 lt1
Exertional 1 Brain tumor 0.1

• Pain usually occurs when peripheral nociceptors
  are stimulated in response to tissue injury,
  visceral distension, or other factors

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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

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Headache

• Serious causes to be considered include
  meningitis, subarachnoid hemorrhage, epidural or
  subdural hematoma, glaucoma, and purulent
  sinusitis

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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)

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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

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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

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Headache

• Migraine
• Triggers cont
• physical exertion
• stormy weather
• barometric pressure changes
• hormonal fluctuations during menses
• lack of or excess sleep
• Smoking and alcohol

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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

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Headache

• Migraine
• Pathogenesis maybe explained by the dysfunction
  of the monoaminergic sensory control systems
• Substance that have been implicated
• 5-HT (serotonin)
• dopamine

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Headache

• Migraine
• High index of suspicion is required to diagnose
  migraine
• Migraine aura
• Visual disturbances with flashing lights or
  zigzag lines

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Headache

• Treatment for migraine headache
• NSAIDS (Acetaminophen, aspirin)
• 5-HT agonist (ergotamine, triptans)
• Dopamine antagonist (metoclopramide)

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• 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 nondescriptan 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
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• dull and boring, with superimposed episodic
  stabbing pains
• Glaucoma
• prostrating headache associated with nausea and
  vomiting

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• For the next meeting, read on Cardinal
  Manifestations of Disease Neck and Back Pain,
  ALTERATIONS IN BODY TEMPERATURE
• Harrisons Principles of Internal Medicine 17th
  edition