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Medicine year 2 semester 2 > Case 23- Physiology > Flashcards

Case 23- Physiology Flashcards

1
Q

What is pain

A
  • Stimulus- Nociception, projections to the higher centres in the brain allow integrated, abstract representation of pain
  • Protective- immediate pain warns of imminent tissue damage. Persistent pain- encourages immobilisation of injured area, allowing damaged tissue time to heal
  • Psychological/emotional/social- Dictates our experience and reaction to the noxious stimuli
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2
Q

The pain pathway

A
  • Somatosensory system- information on physical stimuli goes from the periphery to the brain. Records touch, temperature, vibration, proprioception and pain
  • 1st order neurones- Primary afferent fibres, Dorsal horn of the spinal cord
  • 2nd order neurone- Crosses midline at entry to the spinal level. Spinothalamic tracts (contralateral)
  • 3rd order neurones- goes from the Thalamus to the Midbrain/Cortex
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3
Q

Pain in the brain

A
  • 3rd order neurones go from the Thalamus to the Midbrain and the Cortx
  • Midbrain structure- Limbic system, important for emotion, behaviour and memory
  • Cortex- Sensory Homunculus
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4
Q

Acute vs chronic pain

A
  • Acute- <12 week duration from onset. Defined start and end point. Usually related to injury or disease
  • Chronic- continuous, long term pain >12 weeks in duration. Pain that continues after the expected healing time
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5
Q

Types of pain

A
  • Nociceptive (60%)
  • Neuropathic (15%)
  • Combination (25%)
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6
Q

Risk factors associated with pain

A
  • Female sex
  • Age
  • Physical or sedentary occupation
  • Lack of social network support
  • Socioeconomic support
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7
Q

Factors influencing perception of pain

A
  • Emotion- Stressed, Angry, Bored, Lonely

* Physical conditions- Tired, Hungry, Cold

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8
Q

Meaning of pain

A
  • Cancer patients attributing pain to disease progression

* Extrapolate to their own personal prognosis / survival timelines

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9
Q

Religious / Cultural background- Pain

A

• Pain as moral or spiritual atonement – positive perceptions
• Pain as punishment for sins - negative perceptions
Sense of control over pain- Lack of knowledge / helplessness can lead to poor pain control

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10
Q

Pain and mental health

A
  • Depression- correlation between pain and depressive symptoms
  • Anxiety- higher incidence of anxiety disorders in patients with chronic pain. Patients develop fear of pain and are hyper-vigilant to painful stimuli so may avoid activities
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11
Q

Assessment of pain

A
  • Assessment is important for diagnosis of underlying cause, this facilitates selection of appropriate treatment. Allows modification of treatment depending on patients response
  • Component of pain assessment- History (SOCRATES), Physical examination (Vital signs, General observations, facial signs), Pain measurement
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11
Q

Assessment of pain

A
  • Assessment is important for diagnosis of underlying cause, this facilitates selection of appropriate treatment. Allows modification of treatment depending on patients response
  • Component of pain assessment- History (SOCRATES), Physical examination (Vital signs, General observations, facial signs), Pain measurement
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12
Q

Measurement of pain- pain is divided into 3 dimensions

A
  • Sensory, discriminative= Sensory aspect of pain, described in intensity, location and temporal aspects
  • Affective, motivational- emotional and suffering aspects of pain
  • Cognitive, evaluative- how pain is interpreted by the patient, resultant impact on patients function and quality of life
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13
Q

Pain measurement tools

A
  • Unidimensional- measures single dimension i.e. intensity of pain, most commonly found when assessing acute pain
  • Multidimensional- assessment across multiple dimensions, becomes more useful in long term pain
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14
Q

Unidimensional tools for assessing pain

A
  • Categorical scales i.e. verbal descriptive scale (none, mild, moderate, severe). Simple, quick, easy to use. Limited descriptors so is less specific
  • Visual analogue scale- avoids descriptors, requires cognition, no language barrier
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15
Q

Examples of unidimensional tools for assessing pain

A
  • Numerical rating scales= Often used verbally ‘1-10.’ Validated, easy, quick, cognitively challenging
  • Picture scales/pain drawings= simple, easy. Used in children and people with learning difficulties or those with poor language skills.
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16
Q

Multidimensional tools for assessing pain- brief pain inventory

A
  • Validated. Originally for Cancer patients, since adapted for non Cancer patients
  • 17 item, self rating scale, includes demographic data, medication use, sensory & reactive components to pain
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17
Q

Multidimensional tools for assessing pain- McGill pain Questionair

A
  • Uses multidimensional scales looking at; Sensory, Affective, Cognitive experiences of the pain
  • Validated. 16 languages available
  • Lengthy (15 mins) requires good language skills
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18
Q

Multidimensional tools for assessing pain- Short Form McGill Pain Questionaire

A
  • Shortened version of MPQ
  • 2-3 minutes to complete
  • 15 descriptors covered, 11 sensory, 4 affective
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19
Q

Multidimensional tool for assessing pain- Hospital anxiety and Depression scale

A
  • Screening tool for presence & severity of Anxiety / Depression
  • Validated for hospital, community & primary care settings
  • Does not assess pain
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20
Q

Pain management

A
  • Pharmacological therapies
  • Regional analgesia
  • Physical therapies
  • Psychological based therapies
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21
Q

Stepwise approach to pain management

A
  • Mild pain Step 1= Non opioid Analgesics: Aspirin, Paracetamol, NSAIDS with or without Adjuvants
  • Moderate pain Step 2= Weak opioid Analgesics= Tramadol, Codeine, with or without Non opioids and Adjuvants
  • Sever pain Step 3= Strong opioid Analgesics= Morphine, Fentanyl, Buprenorphine, Methadone. With or without Non-opioids and adjuvants
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22
Q

Regional analgesia

A
  • Plane blocks= Fascia Iliaca block, good for a fractured NOF
  • Specific nerve blocks= Femoral nerve for post operative pain
23
Q

Physical therapies- Pain

A

Splints, ice packs

Physical therapies- TENS
• Transcutaneous electrical nerve stimulation
• Non-invasive, Easy to use
• Works because of the Gate controlled theory of pain
• Good for: Post-op pain, Labour, Orofacial pain, Angina, Dysmenorrhoea
• Contraindications/Cautions- Pacemakers (may malfunction), Uterus (stimulates contractions), Neck position (Laryngospasm, bradycardias via vagal stimulation), Spinal cord stimulators (Reprogramming)

24
Q

Gate controlled theory of pain

A
  • Concept of a ‘spinal’ gate
  • Small fibres carrying nociceptive stimuli
  • Large fibres alternate stimuli (vibration, temperature)
  • Interneurone blocked at synapse
  • Transmission to ascending spinal pathways blocked
25
Q

Physical therapies- Temperature

A
  • Cooling- sports injuries. Good for spastic muscles after intense exercise. Diminishes reflex activity in muscles allowing for therapeutic effect. Lasts for hours once muscles cooled
  • Heat treatment- increased blood flow and decreased muscle spasm. Counterirritant effect which works on the principles of the Gate theory, there is a reduction of oedema. Can cause caution burns
26
Q

Physical therapy- short wave diathermy

A
  • Low intensity lasers

* Good for osteoarthritic joints and muscular sprains

27
Q

Psychological based therapies

A
  • Used as adjuncts to pharmacological/physical therapies
  • Proven physiological benefits- decreased stimulation of the sympathetic system, muscle relaxation, decreased heart rate, improved oxygenation, low blood pressure
28
Q

Examples of Psychological based therapies for pain

A
  • Cognitive behavioural therapy (CBT)- improves patient understanding/changes perception of pain. Promotes active perception in assessment/control of pain
  • Biobehavioural- procedures focused on teaching self control/modify behavioural patterns
  • Mind-body – interventions that stress cognitive/psychological and physical interactions involved with patients pain assessment/control
29
Q

Acute/chronic pain psychological techniques

A
  • Relaxation
  • Distraction- focus attention/concentration elsewhere and away from the pain
  • Imagery- use of imagination to create mental picture using all 5 senses
  • Biofeedback- measurement of neuromuscular / Autonomic activity. Then relayed to the patient to awareness and psychological control
  • Hypnosis
30
Q

Pain- patient information and education

A
  • Patients report less pain
  • Fewer analgesic requirements
  • Ideally education delivered before pain experienced
  • Often very helpful during painful procedures
  • Very effective for obstetrics
31
Q

Other beneficial therapies for pan management

A
  • Urinary catheterisation for retention
  • Use of warming blankets
  • Reassurance
  • Music
  • Virtual Reality
32
Q

Factors which lead to autoimmune disease

A 
Breakdown of tolerance
Genetics
Sex hormones
Mutations in immune components
HLA allele
Aging Treg cells
Environmental factors
Infections
Drugs
Tissue injury
33
Q

Myasthenia Gravis

A

What is it- Muscle weakness (Organ-specific disease affecting neuromuscular junctions)
Commonly affects- Females 20-40 and Males aged 60-80
Genes- HLA-DR3
Extrinsic risk factors- smoking, obesity and viral infections i.e. polio

34
Q

Myasthenia gravis symptoms

A

Drooping eyelids, Double vision, Slurred speech, Difficulty chewing & swallowing and Difficulty making facial expressions

35
Q

Myasthenia gravis mechanism of action

A
  • Autoantibodies bind to α chain of nicotinic acetylcholine receptor on skeletal muscle cells at neuromuscular junctions
  • No receptor activation
  • Receptors internalized and degraded
  • Neuromuscular transmission blocked
36
Q

Lupus (SLE)

A

What is it- Chronic inflammation of the joints, skin and organs (systemic disease)
Commonly affects- females aged 20-40 (most common in black and asian women)
Genetics- HLA-DR2 & HLA-DR3 and genetic complement deficiency
Extrinsic risk factors- Smoking, UV light exposure, drugs i.e. hydralazine, oestrogen and viral infections i.e. EBV and COVID-19

37
Q

Symptoms of Lupus (SLE)

A

Butterfly rash on the face, appetite loss, hair loss, fever, fatigue, photosensitivity, mouth ulcers, painful and swollen joints & Raynauds phenomenon

38
Q

Lupus (SLE)- mechanism of action

A
  • Chronic production of IgG Ab directed at ubiquitous self antigens e.g. dsDNA
  • Autoantigens are released from dead/dying cells due to tissue injury
  • Continuous small immune complex formation
  • Deposition of immune complexes
  • Phagocytic cells activated through Fc receptor
  • Inflammation due to overproduction and/or defective clearance of immune complexes leading to further tissue damage
39
Q

Rheumatoid arthritis

A

What is it- chronic systemic disease that causes inflammation and progressive joint destruction
Commonly affects- females aged 30-55
Genetics= HLA-DR4 and HLA-DR1
Extrinsic risk factors- smoking and oestrogen

40
Q

Symptoms of rheumatoid arthritis

A

Joint pain, swelling and stiffness, often with tiredness, decreased energy, high temperature and weight loss

41
Q

Rheumatoid arthritis mechanism of action

A
  • Initial trigger causes inflammation attracting WBCs into tissue
  • CD4 T cells activate macrophages causing cytokine release and further inflammation
  • Cytokines induce fibroblasts to produce MMPs and RANK ligands
  • MMPs attack tissue and RANK ligands activate osteoclasts resulting in joint destruction
  • B cells also activated producing rheumatoid factor leading to immune complex formation and an amplified inflammatory response
42
Q

Rheumatoid arthritis pathology

A

1) Genetic and extrinsic susceptibility
2) Inflammatory synovitis
3) Activated CD4+ T cell causes TNF to be released resuliting in bone erosion and osteoclast activation
4) The activated CD4+ T cell causes activation of B cells. In 75% this produces rheumatoid factor (IgM anti-IgG Ans)
5) The IgG-IgM complexes activate complement and amplify inflammatory responses

43
Q

Proximal humerus fracture

A

Older osteoporotic patient-fall onto an outstretched arm.

Younger patients-high impact trauma.

Sling immobilisation or surgery

44
Q

Anterior dislocation of the shoulder

A

95% of dislocations
The humeral head is located underneath the coracoid proccess
In the lateral view- the humeral head is no longer in the centre of the Y

45
Q

Posterior dislocation of the shoulder

A

Humeral head becomes more rounded-’light bulb sign’
There is no overlap between the glenoid and the humeral head
Less common than anterior dislocation
Most often in the elderly, post-seizure and electrocution
The growth plates of the proximal humerus fuse at around 16 years.

46
Q

Clavicle fracture

A

Mostly occur in the middle third segment
FOOSH or direct trauma
Sling immobilisation or surgery

46
Q

Clavicle fracture

A

Mostly occur in the middle third segment
FOOSH or direct trauma
Sling immobilisation or surgery

47
Q

Distal fracture humerus

A

Fracture through the lateral epicondyle of the humerus
High energy injury- sport or RTC
Older adults- osteoporosis
Cast immobilisation or surgery

48
Q

Radial head fracture

A

Fall onto outstretched hand

Management: Conservative (sling), ORIF

49
Q

Posterior elbow dislocation

A

Can also have an associated fracture

Management: Closed reduction and splinting, ORIF with ligament repair

50
Q

Wrist= Colles’ fracture

A 
Fractured distal radius with dorsal impaction
'Dinner fork' deformity
Typically caused by FOOSH
Undisplaced > cast alone
Mild displacement > closed reduction
Significant deformity > ORIF
50
Q

Wrist= Colles’ fracture

A 
Fractured distal radius with dorsal impaction
'Dinner fork' deformity
Typically caused by FOOSH
Undisplaced > cast alone
Mild displacement > closed reduction
Significant deformity > ORIF
51
Q

Wrist= Smith’s fracture

A

Fractured distal radius with volar (palmar) displacement
Direct blow to dorsal forearm or fall on flexed hand
Depending on impact, there may be one or several fragments
Non-displaced > cast
Mild displacement > closed reduction
Significant deformity/displacement > ORIF

52
Q

Wrist- Barton’s fracture

A

Intra-articular fracture of distal radius with radiocarpal dislocation
Fracture line extends into distal articular surface via the volar aspect
Fall on extended pronated forearm
Intra-articular component distinguishes it from Colles’ or Smith’s
It generally requires ORIF with plates and screws

53
Q

Ulna Styloid fracture

A

Can cause instability at the distal radio-ulnar joint
Seldom require fixation, even when in conjunction with a distal radius fracture
Exception is when there is instability or significant deformity

54
Q

Wrist- Scaphoid fracture

A 
Scaphoid fracture (waist)
Mechanism: Fall on outstretched hand
Tenderness over the anatomical snuffbox suggests a scaphoid fracture.
Beware of avascular necrosis-if a# cannot be seen on x-ray then immobilise the thumb and ask the patient to return for follow up.

Medicine year 2 semester 2 (47 decks)

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