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Diagnostic Sciences > Presents with pain > Flashcards

Presents with pain Flashcards

1
Q

What is the definition of pain?

A
  • Unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage
  • Occurs as a consequence of activity in a number of neural pathways
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2
Q

What factors can influence pain?

A
  • attitudes and beliefs
  • cultural factors
  • psychological state
  • social environment
  • age and gender
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3
Q

Describe the mechanism of pain

A
  • complex
  • neural and chemical mechanisms
  • impulse -> nociceptors -> dorsal horn -> ascending pathway (spinothalamic tract) -> brain
  • also connects with limbic system (emotions)
  • brainstem (ANS responses)
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4
Q

Describe nociceptors

A
  • not all body structures have them
  • may perceive mechanical, chemical and thermal stimuli
  • are free nerve endings
  • not all perceive all stimuli
  • 2 types: A-delta and C fibers
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5
Q

Describe A-delta fibers

A
  • large
  • myelinated fibers
  • quick - “fast pain”
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6
Q

Describe C fibers

A
  • small
  • non-myelinated
  • slow - “slow pain”
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7
Q

List the types of pain

A 
Somatic:
• superficial -skin and subcutaneous
• deep - skeletal muscles, joints, tendons, fascia
• occasionally referred
Visceral:
• from organ
• usually referred
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8
Q

What is referred pain?

A
  • felt at a site different from its point of origin
  • diffuse and poorly defined
  • because the viscera synapses on same spot of dorsal grey horn as that skin
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9
Q

List examples of organs that refer?

A
  • myocardial infarction
  • gallbladder
  • stomach & duodenal
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10
Q

Describe acute pain

A
  • caused by injury to tissues
  • activation of nociceptors
  • short
  • goes when pathology resolves
  • protective mechanism
  • maybe anxiety/emotions
  • reflex muscular spasm
  • ANS responses (increase resp, HR, BP)
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11
Q

Describe chronic pain

A

• induced by injury
• long
• variable severity
• influenced by:
-type, frequency of stimulation, functioning of sensory pathway and higher centres
• accompanied by depression, sleep disturbance, anorexia

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12
Q

Describe neuropathic pain

A
  • pain occurring directly as a result of trauma of diseased neurones, without involving nociceptors
  • pressure, physical injury, chemical injury, infection, ischaemia, inflammation
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13
Q

Hypoalgesia

A

reduced pain sensation

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14
Q

Analgesia

A

absence of pain

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15
Q

Allodynia

A

pain after non-noxious stimulus

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16
Q

What is a full blood count?

A 
Basic screening, common
• Hb
• RBC count
• hematocrit
• MCH, MCV
• WBC, and differential
• platelet count
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17
Q

What does increased neutrophils mean?

A

bacterial infection

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18
Q

What does increased lymphocytes mean?

A

viral infection

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19
Q

What does increased monocytes mean?

A

severe infections

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20
Q

What does increased eosinophils mean?

A

parasitic infestation or allergies

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21
Q

Increased basophils

A

very rare

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22
Q

An increase in the total number of circulating white blood cells is?

A

leucocytosis

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23
Q

An increase in the total number of circulating neutrophils is?

A

neutrophilia

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24
Q

An increase in the total number of circulating lymphocytes is ?

A

lymphocytosis

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25
Q

An increase in the total number of circulating eosinophils is?

A

eosinophilia

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26
Q

A decrease in the number of circulating white blood cells is?

A

leucopenia

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27
Q

A decrease in the number of circulating neutrophils is?

A

neutropenia or agranulocytosis

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28
Q

What is an ECG?

A 
• electrocardiogram
• recording of electrical activity of heart
• electrodes arranged as leads
• electrocardiography
• PQRSTU segments
• diagnose:
-cardiac arrhythmia
-loaclise myocardial hypertrophy, ischaemia, infarction
-electrolyte imbalance
-pericarditis
-pulmonary emboli
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29
Q

What is a stress ECG?

A 
• treadmill or bicycle
• can screen for coronary artery disease
• 60-70% accurate
• done with echocardiography
• Investigates:
-ischaemic heart disease
-arrhythmias
-exercise related hypertension
-monitoring
-determination of safe exercise levels
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30
Q

What is a Holter monitor?

A
  • small portable equipment carried for 24 hours
  • also keep diary of activities and problems (pain, palpitations, breathlessness)
  • match with ECG
  • determines intermittent silent arrhythmias and mild ischaemia
  • help find cause of palpitations
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31
Q

What further investigations can we do after ECG is normal?

A
  • Echocardiography
  • myocardial perfusion scintigraphy
  • coronary artery calcium scoring by CT
  • selective coronary angiography
  • MRI (#1)
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32
Q

List some causes of children get abdominal pain?

A
  • constipation
  • gastroenteritis
  • mesenteric adenitis
  • psychosomatic
  • food allergy
  • inguinal hernia
  • object
  • trauma
  • worms
  • appendicitis
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33
Q

What are the causes of abdominal pain in the oesophageal system?

A
  • hiatus hernia
  • GORD
  • esophagitis
  • tumours
  • ulcers
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34
Q

What are the causes of abdominal pain in the hepatobiliary system?

A
  • cholelithiasis
  • infection (hepatitis, cholecystitis)
  • biliary tract obstruction
  • tumours
  • right heart failure
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35
Q

What are the causes of abdominal pain in the intestinal system?

A
  • inflammatory (ulcerative colitis, Crohn’s, appendicitis, diverticulitis)
  • tumours
  • intestinal obstruction
  • IBS
  • malabsorption syndrome
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36
Q

What are the causes of abdominal pain in the pancreatic system?

A
  • pancreatitis

* malignancy

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37
Q

What are the causes of abdominal pain in the renal system?

A
  • ureteric calculus
  • pyelonephritis
  • cystitis
  • tumours
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38
Q

What are the causes of abdominal pain in the gastro-duodenal system?

A
  • gastritis
  • ulcers
  • tumours
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39
Q

What are the causes of abdominal pain in the cardiorespiratory system?

A
  • inflammation (pneumonia, pleurisy)
  • ischaemic heat disease
  • carcinoma
  • pneumothorax
  • pulmonary embolism
  • dissecting aortic aneurysm
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40
Q

What are the causes of abdominal pain in the gynaecological system?

A
  • endometriosis
  • infections (salpingitis, endometritis)
  • dysmenorrhea
  • ectopic pregnancy
  • ovarian cysts
  • tumours
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41
Q

What are the causes of abdominal pain in the testes/epididymis?

A
  • epididymitis
  • orchitis
  • torsion of testes
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42
Q

What are some causes of middle abdomen pain?

A
  • acute appendicitis
  • mesenteric adenitis
  • gastritis
  • mid-gut referral from small intestine
  • skin or muscle
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43
Q

What is the possible significance of pain worse on movement, coughing, sneezing?

A
  • msk

* peritoneal involvement

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44
Q

What is the possible significance of pain Bettie with lying skill?

A
  • msk

* peritoneal involvement

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45
Q

What is the possible significance of intermittent or colicky pain?

A 
hollow organ
• biliary tract
• intestine 
• ureter
• uterine tubes
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46
Q

What is the possible significance of pain accompanied by dysuria, frequency, polyuria?

A

urinary tract involvement

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47
Q

What is the possible significance of pain in upper abdomen radiating through to back?

A

pancreatic disease

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48
Q

What is the possible significance of pain in right upper abdomen radiating around to the back and between the scapulae?

A

gall bladder / biliary tract disease

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49
Q

What is the possible significance of pain around umbilicus?

A
  • small intestine

* proximal large intestine

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50
Q

What is the possible significance of pain with tenderness on palpation, guarding and rigidity?

A

peritoneal involvement

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51
Q

What is the possible significance of pain in abdomen and pain or discomfort in sctotum/testes?

A
  • inguinal hernia

* orchitis

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52
Q

What is the possible significance of upper abdominal pain in conjunction with respiratory symptoms, no tenderness, but worse on deep inspiration?

A

pleuritic pain

• pneumonia

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53
Q

What is the possible significance of pain over entire abdomen plus tenderness, guarding and rigidity?

A

generalized peritonitis

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54
Q

What is the possible significance of burning pain, in dermatomal distribution, with sensitivity of skin to touch?

A
  • neurogenic -herpes zoster

* referred from vertebrae

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55
Q

What is the possible significance of pain improved by leaning forward?

A

• pancreatic or msk

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56
Q

What is the possible significance of pain prior to or accompanied by menses?

A

dysmenorrhoea

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57
Q

What is the possible significance of pain accompanied by constant writhing and movement or patient?

A

obstruction of hollow viscera

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58
Q

What is the possible significance of pain in iliac fossa in middle of menstrual cycle?

A

mittleschmerz: ovulatory pain

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59
Q

What is McBurney’s point?

A
  • junction of lateral and middle thirds of a line joining the right ASIS and the umbilicus
  • means acute appendicitis
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60
Q

List the tests that can be done for acute appendicitis?

A
  • McBurney’s point
  • psoas sign (retrosecal)
  • obturator sign (retrosecal)
  • exquisite tenderness on right side of rectal exam
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61
Q

What is a normal body temperature? How does this differ when taken in different parts of the body?

A
  • 37
  • higher in rectum
  • now we use armpit
  • most accurate is oesophagus
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62
Q

What is the normal heart rate in an adult?

A

70-100 bpm

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63
Q

What is the normal respiratory rate in an adult?

A

12-20 breaths per minute

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64
Q

What does a high ESR indicate?

A

organic disease present

65
Q

What type of stimuli can stimulate nociceptors in the abdominal cavity, and hence cause pain?

A
  • mechanical bowel obstruction
  • irritation of peritoneum
  • twisted bowel
  • strangulated hernia
  • abdominal ischemia
  • inflammation / infection
  • enlarged organ
66
Q

Why do you get abdominal pain with excessive air in the intestine?

A

stretching intestines

67
Q

Why do you get abdominal pain with shingles?

A

neuropathic pain

68
Q

Why do you get abdominal pain with ischemic colitis?

A

necrosis

69
Q

Why do you get abdominal pain with mechanical bowel obstruction?

A

increased peristalsis

stretching

70
Q

Why do you get abdominal pain with acute hepatitis?

A

liver capsule stretch

71
Q

Why do you get abdominal pain with appendicitis?

A

increased peristalsis
inflammation
if rupture -> involves peritoneum

72
Q

What are the big 3 of chest pain?

A
  • massive pulmonary embolism
  • myocardial infarction
  • dissecting aortic aneurysm
73
Q

List the causes of chest pain in the cardiovascular system?

A
  • ischaemia (angina pectoris, myocardial infarct)
  • pericarditis
  • dissecting aortic aneurysm
  • massive pulmonary embolus
74
Q

List the causes of chest pain in the chest wall system?

A
  • herpes zoster
  • rib fracture
  • costochondritis
  • pleurodynia
  • muscular (DOMS, strain, myositis)
75
Q

List the causes of chest pain in the oesophageal system?

A
  • oesophagitis
  • diffuse oesophageal spasm
  • tumours
76
Q

List the causes of chest pain from vertebrae?

A
  • costotransverse joint

* costovertebral joint

77
Q

List the causes of chest pain that is pleuritic?

A
  • pneumonia
  • pulmonary embolus with infarct
  • malignancies (mesothelioma, pleurisy)
  • pneumothorax
78
Q

List the causes of chest pain of referred source?

A
  • back
  • abdomen
  • biliary tract
79
Q

What structures in the thoracic cavity are pain sensitive?

A
  • pleura
  • oesophagus
  • ischaemic
  • tearing of aorta
80
Q

What is the possible significance of chest pain, retrosternal and initiated by exertion, relieved by rest?

A

temporary ischaemia -angina pectoris

81
Q

What is the possible significance of chest pain sharp, stabbing and worse with inspiration?

A
  • pleuritic
  • costochondral joint
  • costovertebral joint
  • intercostal muscle spasm
82
Q

What is the possible significance of chest pain with fever?

A
  • infection (pneumonia, pleurisy, chest wall infections)
  • infarction
  • neoplasm
83
Q

What is the possible significance of chest pain worse lying flat, better sitting / standing?

A
  • oesophageal reflux

* msk

84
Q

What is the possible significance of chest pain worse with movement, with tenderness on palpation of chest?

A
  • chest wall (myositis, costochondritis)
  • thoracic IVD
  • thoracic vert. fracture
85
Q

What is the possible significance of chest pain described as pressure, tightness, band around chest or crushing?

A
  • ischaemic (MI)

* costoverterbral complex

86
Q

What is the possible significance of chest pain relieved by belching or passing flatus?

A

excessive gas in bowel

87
Q

What is the possible significance of chest pain worse with movement of neck or trunk flexion?

A
  • thoracic vertebrae
  • discs
  • soft tissues
88
Q

What is the possible significance of chest pain of ischaemic nature plus anxiety restlessness, cool hammy skin, weak pulse, hypotension, crackles, arrhythmias?

A
  • myocardial infarction
  • massive pulmonary embolus
  • dissecting aortic aneurysm
89
Q

What is the possible significance of chest pain of pleuritic nature, dyspnoea, cough, fever?

A
  • pneumonia

* lower respiratory tract infection

90
Q

What are common DDx of dysphagia?

A
  • URT infection
  • oesophageal
  • msk
  • scleroderma
  • ALL ossification
91
Q

What are the possible causes of sore throat?

A
  • infection of oral cavity, tonsils, pharynx, larynx, epiglottis, trachea
  • allergies
  • tumours (laryngeal)
  • trauma
  • chronic fatigue syndrome
  • aphthous ulceration
  • neuralgia (glossopharyngeal)
  • referred from thyroid, oesophagus, cervical spine
92
Q

Why does someone with a sore throat get a “dragging feeling” in the abdomen?

A

enlarged lymph nodes

93
Q

pharyngeal erythema

A

red throat

94
Q

petechiae

A

small red/purple spots from bleeding in skin

95
Q

lymphadenopathy

A

abnormal size, number, consistency of nodes

96
Q

What is the significance of petechiae on the palate?

A

glandular fever (#1)

or bleeding tendency

97
Q

What is the significance of generalized, tender lymphadenopathy?

A

systemic infection

98
Q

What is the significance of recurrent sore throat?

A

allergies

chronic fatigue syndrome

99
Q

What is the significance of sore throat in immunosuppressed person?

A

candidiasis

100
Q

What is the significance of sore throat after recent dental work and dysphagia?

A

retropharyngeal abscess

101
Q

What is the significance of multiple painful vesicles in oral cavity and sore throat?

A
  • herpangia (coxackie virus)

* herpes simplex infection

102
Q

What is the significance of sore throat with yellow exudate on swollen tonsils?

A

strep infection

103
Q

What is the significance of sore throat with unilateral vesicles?

A

herpes zoster (shingles)

104
Q

What is the significance of sore throat and white patches in oral cavity?

A

candida

105
Q

What is the significance of sore throat with greyish membrane / covering on posterior pharynx?

A
  • diphtheria

* Vincent’s angina

106
Q

What is the significance of sore throat with anterior cervical lymphadenopathy?

A

bacterial infection

107
Q

What is the significance of sore throat with posterior cervical lymphadenopathy?

A

viral infection

108
Q

What is the significance of sore throat with hoarse voice?

A

laryngeal or recurrent laryngeal nerve

109
Q

What is the significance of high IGM? of IGG?

A

IGM: epstein barr virus (mono)

IGG: if they had epstein bar over 3 months ago

110
Q

Quickly describe peritonitis

A
  • infection of peritoneum
  • severe pain
  • worse on movement
  • maybe shoulder tip
  • vomiting, fever, tachycardia, tenderness, rigidity, rebound tenderness, no bowel sounds
111
Q

Quickly describe acute diverticulitis

A
  • acute infection of one or more diverticuli
  • left sided “appendicitis”
  • starts central then moves to L iliac fossa
  • acute onset
  • fever, vomiting, local, tenderness, guarding, vague mass in L iliac fossa
112
Q

Quickly describe shingles

A
  • herpes zoster
  • neuropathic pain by dermatome
  • burning, red rash, scales
113
Q

Quickly describe acute appendicitis

A
  • starts centre -> R iliac fossa
  • colicky then maybe constant
  • malaise, anorexia, nausea, change bowel habit
114
Q

Quickly describe mesenteric adenitis

A
  • inflammation of mesenteric lymph nodes often following an upper respiratory tract infection
  • umbilical or R iliac fossa
  • rhinorea
115
Q

Quickly describe acute cholecystitis

A
  • acute inflammation of gallbladder
  • epigastric & R hypochondrium, around to the back
  • fever, rigors
116
Q

Quickly describe acute pyelonephritis

A
  • acute infection of kidney pelvis and parenchyma
  • aching in loins
  • fever, rigors, vomiting, change bowel habits, dysuria, frequency, cloudy urine
117
Q

Quickly describe acute intestinal ischaemia

A
  • blood flow to intestine reduced causing necrosis
  • sudden, severe,
  • bloody diarrhoea, hematemesis, shock
118
Q

Quickly describe mechanical bowel obstruction

A
  • obstruction of a section of intestines
  • from tumour, adhesions, strangulated hernia
  • colicky
  • vomiting, distension, absolute constipation, + pulse, + bowel sounds
119
Q

Quickly describe urinary tract calculi

A
  • obstruction of ureter by stone
  • dull loin or extreme pain
  • vomit, sweat, hematuria
120
Q

Quickly describe salpengitis

A
  • infection of uterine tubes
  • iliac fossa pain
  • systemically ill (fever, malaise)
  • Ddx of appendicitis
121
Q

Quickly describe endometriosis

A
  • endometrial tissue outside the uterus
  • dysmenorrhoea, dyspareunia
  • infertility, abnormal menstruation, malaise, frequency, hematuria
122
Q

Quickly describe acute pancreatitis

A
  • sudden, severe
  • epigastric and R hypochondrium
  • radiating through to back
  • relieved by forward crouch
  • nausea, shock, + pulse, (-) temp, abd. guarding, tetany, jaundice
123
Q

Quickly describe chronic pancreatitis

A
  • episodes of same pain as acute pancreatitis

* steatorrhoea, malabsorption, (-) weight, diabetes, jaundice

124
Q

Compare glomerulonephritis to pyelonephritis

A 
Glomerulo:
• infection from autoimmune 
• sore throat
Pyelo:
• from blood or UTI
• systemically ill. cloudy urine
125
Q

Quickly describe acute gastritis

A
  • inflammation of stomach
  • epigastric
  • anorexia, coated tongue, persistent vomiting, massive bleed
126
Q

Quickly describe peptic ulceration

A

• epigastric pain

Gastric: worse with eating
Duodenal: relieved by eating

127
Q

Quickly describe biliary colic

A
  • obstruction of part of biliary tract with stone
  • severe pain that plateaus
  • epigastric
  • band across chest
  • around to back
  • restless
128
Q

What are the causes of acute right iliac fossa pain?

A
  • bleed, torsion of ovarian cyst
  • ovulation pain (meckleshmets)
  • acute appendicitis
  • heckles diverticulum
  • Crohn’s
  • herpes zoster
  • ectopic pregnancy
  • salpengitis
  • muscle strain
  • ureter
  • mesenteric adenitis
129
Q

What is the number one cause of gastritis?

A

alcohol

130
Q

What are the Ddx of sudden severe sharp epigastric pain?

A
  • gastritis
  • peptic ulceration
  • oesophagitis
131
Q

What is Murphy’s sign?

A
  • asking the patient to breathe out and then gently placing the hand below the costal margin on the right side at the mid-clavicular line (the approximate location of the gallbladder)
  • if positive, means gallbladder inflammation
132
Q

Quickly describe pleurisy

A
  • inflammation of pleura
  • chest stabbing, worse on inspiration
  • rapid, shallow breath
  • pleural rub
  • tachypnoea
133
Q

Quickly describe aortic aneurysm dissection

A
  • abnormal movement of blood between layers of aortic wall
  • sudden, severe ripping
  • retrosternal
  • shock
134
Q

What is shock?

A
  • palor
  • clammy
  • tachycardia
  • increase respiration rate
135
Q

Quickly describe shingles

A
  • infection caused by reactivation of the varicella-zoster virus
  • burning neuropathic pain by dermatome
  • red, rash and scales, vesicles
136
Q

Quickly describe costochondritis

A
  • inflammation of the costal cartilages
  • chest, sides of sternum
  • worse by cough, tender
  • swelling
  • worse on movement
  • no systemic signs
137
Q

Quickly describe rib fracture

A
  • break in continuity of a rib
  • sharp pain on inspiration, movement
  • achy
  • bruising
  • no systemic signs
138
Q

Quickly describe myocardial infarction

A
  • clinical diagnosis, resulting from a permanent decrease in blood supply to a part of the heart causing infarction
  • severe, <30min
  • tight, crushing retrosternal chest pain
  • referral to shoulder
  • shock
139
Q

Quickly describe oesophagitis

A
  • epigastric or retrosternal

* dysphagia, hematemesis, nausea, vomit, fever

140
Q

Quickly describe GORD

A
  • gastroesophageal reflux disease
  • burning epigastric or retrosternal
  • worse lying down, after large meal, halitosis
141
Q

Quickly describe intercostal myositis

A
  • aching, localized, lateral
  • tender, swelling
  • no systemic signs
142
Q

Quickly describe oesophageal muscle spasm

A
  • spasm of oesophageal musculature

* dysphagia

143
Q

Quickly describe angina pectoris

A
  • clinical diagnosis, resulting from temporary decrease in blood supply to a part of the heart, just short of infarction
  • discomfort, epigastric, pressure, not severe, <30min
  • shoulder, worse on exercise, emotions
144
Q

Quickly describe pulmonary embolism with infarction

A
  • obstruction of one or more emboli in the pulmonary vasculatory, causing some necrosis within lungs
  • pleuritic pain
  • consequence -> pleural effusion
  • hemoptysis, sings of DVT
145
Q

Quickly describe acute pericarditis

A
  • acute inflammation of pericardium
  • often as complication of heart disease, adjacent structures, generalized disease
  • pleural, central chest
  • varies on movement, posture, respiration
  • better lying down
  • pericardial rub
  • absent apex beat
146
Q

Quickly describe pneumothorax

A
  • air in pleural cavity, entering via break in continuity of lungs, or from outside environment via chest wall injury
  • sudden, tight, unilateral, maybe no symptoms
  • dyspnoea, cyanosis, deviated trachea, hyper resonant, decreased fremitus and resonance
147
Q

Quickly describe massive pulmonary embolus

A
  • obstruction of pulmonary trunk, R or L pulmonary artery by a large embolus -> acute heart failure
  • sudden pleuritic pain
  • shock, R heart failure
148
Q

Quickly describe pneumonia

A
  • consolidation of alveoli, most commonly caused by infective agents
  • pleuritic pain
  • fever, dyspnoea, hemoptysis, malaise
  • rusty sputum
149
Q

Quickly describe Bornholme syndrome

A
  • viral illness (usualy coxsackie viruses) in older children with pleuritic chest pain
  • pleuritic pain
  • fever, sore throat, malaise
150
Q

What conditions have: hyerresonant percussion, and decrease vocal resonance & fremitus?

A

Increase air in lungs
• pneumothorax
• asthma
• emphysema

151
Q

What conditions have: dull percussion, and increase vocal resonance & fremitus?

A

solid /fluid in alveoli

• pneumonia

152
Q

What conditions have: dull percussion, and decrease vocal resonance & fremitus?

A

Increased density in pleura
• pleural effusion
• mesothelioma

153
Q

What examinations do you do for a patient with acute dyspnoea, right sided chest pain that is sharp and worse on inspiration.

A
  • vitals (heart rate, rythm, volume, BP, resp rate Rhythm, volume)
  • percussion
  • vocal frem and res
  • Homan test or palp. head of gastroc
  • ankles (red, hot, oedema if DVT)
154
Q

What investigations do you do for a patient with recurrent central chest pain episodes at the gym. Pressure or tension type pain.

A
  • stress ECG
  • blood test for cardiac enzymes (rule out MI)
  • chest x-ray (LV hypertrophy)
  • CT angiography of heart
155
Q

What is the pathophysiology of GORD?

A
  • gastroesophageal sphincter dysfunctional (incompetent) -> content of stomach (acidic) reflux into oesophagus -> damage cells -> inflammation and burning
  • eating -> more chyme
  • lying flat -> gravity -> more reflux
156
Q

What investigations do we to confirm suspected GORD?

A
  • endoscopy

* barium swallow x-ray

157
Q

What are the complications of untreated GORD?

A
  • repeated erosion -> fibrosis -> oesophageal stricter -> dysphagia
  • metaplasia -> displasia -> malignancy
158
Q

What is the DDx of a patient with a 2 day history of diffuse chest pain, sometimes sharp, or tight, worse on movement, sore between the ribs. Recent URT infection.

A
  • intercostal myositis
  • costochondritis
  • shingles (early)
159
Q

What is the significance of right hypochondriac pain that is constant? or colicky?

A

liver issue

gall bladder

Diagnostic Sciences (7 decks)

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