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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
An increase in the total number of circulating eosinophils is?
eosinophilia
26
A decrease in the number of circulating white blood cells is?
leucopenia
27
A decrease in the number of circulating neutrophils is?
neutropenia or agranulocytosis
28
What is an ECG?
``` • 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 ```
29
What is a stress ECG?
``` • 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 ```
30
What is a Holter monitor?
* 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
31
What further investigations can we do after ECG is normal?
* Echocardiography * myocardial perfusion scintigraphy * coronary artery calcium scoring by CT * selective coronary angiography * MRI (#1)
32
List some causes of children get abdominal pain?
* constipation * gastroenteritis * mesenteric adenitis * psychosomatic * food allergy * inguinal hernia * object * trauma * worms * appendicitis
33
What are the causes of abdominal pain in the oesophageal system?
* hiatus hernia * GORD * esophagitis * tumours * ulcers
34
What are the causes of abdominal pain in the hepatobiliary system?
* cholelithiasis * infection (hepatitis, cholecystitis) * biliary tract obstruction * tumours * right heart failure
35
What are the causes of abdominal pain in the intestinal system?
* inflammatory (ulcerative colitis, Crohn's, appendicitis, diverticulitis) * tumours * intestinal obstruction * IBS * malabsorption syndrome
36
What are the causes of abdominal pain in the pancreatic system?
* pancreatitis | * malignancy
37
What are the causes of abdominal pain in the renal system?
* ureteric calculus * pyelonephritis * cystitis * tumours
38
What are the causes of abdominal pain in the gastro-duodenal system?
* gastritis * ulcers * tumours
39
What are the causes of abdominal pain in the cardiorespiratory system?
* inflammation (pneumonia, pleurisy) * ischaemic heat disease * carcinoma * pneumothorax * pulmonary embolism * dissecting aortic aneurysm
40
What are the causes of abdominal pain in the gynaecological system?
* endometriosis * infections (salpingitis, endometritis) * dysmenorrhea * ectopic pregnancy * ovarian cysts * tumours
41
What are the causes of abdominal pain in the testes/epididymis?
* epididymitis * orchitis * torsion of testes
42
What are some causes of middle abdomen pain?
* acute appendicitis * mesenteric adenitis * gastritis * mid-gut referral from small intestine * skin or muscle
43
What is the possible significance of pain worse on movement, coughing, sneezing?
* msk | * peritoneal involvement
44
What is the possible significance of pain Bettie with lying skill?
* msk | * peritoneal involvement
45
What is the possible significance of intermittent or colicky pain?
``` hollow organ • biliary tract • intestine • ureter • uterine tubes ```
46
What is the possible significance of pain accompanied by dysuria, frequency, polyuria?
urinary tract involvement
47
What is the possible significance of pain in upper abdomen radiating through to back?
pancreatic disease
48
What is the possible significance of pain in right upper abdomen radiating around to the back and between the scapulae?
gall bladder / biliary tract disease
49
What is the possible significance of pain around umbilicus?
* small intestine | * proximal large intestine
50
What is the possible significance of pain with tenderness on palpation, guarding and rigidity?
peritoneal involvement
51
What is the possible significance of pain in abdomen and pain or discomfort in sctotum/testes?
* inguinal hernia | * orchitis
52
What is the possible significance of upper abdominal pain in conjunction with respiratory symptoms, no tenderness, but worse on deep inspiration?
pleuritic pain | • pneumonia
53
What is the possible significance of pain over entire abdomen plus tenderness, guarding and rigidity?
generalized peritonitis
54
What is the possible significance of burning pain, in dermatomal distribution, with sensitivity of skin to touch?
* neurogenic -herpes zoster | * referred from vertebrae
55
What is the possible significance of pain improved by leaning forward?
• pancreatic or msk
56
What is the possible significance of pain prior to or accompanied by menses?
dysmenorrhoea
57
What is the possible significance of pain accompanied by constant writhing and movement or patient?
obstruction of hollow viscera
58
What is the possible significance of pain in iliac fossa in middle of menstrual cycle?
mittleschmerz: ovulatory pain
59
What is McBurney's point?
* junction of lateral and middle thirds of a line joining the right ASIS and the umbilicus * means acute appendicitis
60
List the tests that can be done for acute appendicitis?
* McBurney's point * psoas sign (retrosecal) * obturator sign (retrosecal) * exquisite tenderness on right side of rectal exam
61
What is a normal body temperature? How does this differ when taken in different parts of the body?
* 37 * higher in rectum * now we use armpit * most accurate is oesophagus
62
What is the normal heart rate in an adult?
70-100 bpm
63
What is the normal respiratory rate in an adult?
12-20 breaths per minute
64
What does a high ESR indicate?
organic disease present
65
What type of stimuli can stimulate nociceptors in the abdominal cavity, and hence cause pain?
* mechanical bowel obstruction * irritation of peritoneum * twisted bowel * strangulated hernia * abdominal ischemia * inflammation / infection * enlarged organ
66
Why do you get abdominal pain with excessive air in the intestine?
stretching intestines
67
Why do you get abdominal pain with shingles?
neuropathic pain
68
Why do you get abdominal pain with ischemic colitis?
necrosis
69
Why do you get abdominal pain with mechanical bowel obstruction?
increased peristalsis | stretching
70
Why do you get abdominal pain with acute hepatitis?
liver capsule stretch
71
Why do you get abdominal pain with appendicitis?
increased peristalsis inflammation if rupture -> involves peritoneum
72
What are the big 3 of chest pain?
* massive pulmonary embolism * myocardial infarction * dissecting aortic aneurysm
73
List the causes of chest pain in the cardiovascular system?
* ischaemia (angina pectoris, myocardial infarct) * pericarditis * dissecting aortic aneurysm * massive pulmonary embolus
74
List the causes of chest pain in the chest wall system?
* herpes zoster * rib fracture * costochondritis * pleurodynia * muscular (DOMS, strain, myositis)
75
List the causes of chest pain in the oesophageal system?
* oesophagitis * diffuse oesophageal spasm * tumours
76
List the causes of chest pain from vertebrae?
* costotransverse joint | * costovertebral joint
77
List the causes of chest pain that is pleuritic?
* pneumonia * pulmonary embolus with infarct * malignancies (mesothelioma, pleurisy) * pneumothorax
78
List the causes of chest pain of referred source?
* back * abdomen * biliary tract
79
What structures in the thoracic cavity are pain sensitive?
* pleura * oesophagus * ischaemic * tearing of aorta
80
What is the possible significance of chest pain, retrosternal and initiated by exertion, relieved by rest?
temporary ischaemia -angina pectoris
81
What is the possible significance of chest pain sharp, stabbing and worse with inspiration?
* pleuritic * costochondral joint * costovertebral joint * intercostal muscle spasm
82
What is the possible significance of chest pain with fever?
* infection (pneumonia, pleurisy, chest wall infections) * infarction * neoplasm
83
What is the possible significance of chest pain worse lying flat, better sitting / standing?
* oesophageal reflux | * msk
84
What is the possible significance of chest pain worse with movement, with tenderness on palpation of chest?
* chest wall (myositis, costochondritis) * thoracic IVD * thoracic vert. fracture
85
What is the possible significance of chest pain described as pressure, tightness, band around chest or crushing?
* ischaemic (MI) | * costoverterbral complex
86
What is the possible significance of chest pain relieved by belching or passing flatus?
excessive gas in bowel
87
What is the possible significance of chest pain worse with movement of neck or trunk flexion?
* thoracic vertebrae * discs * soft tissues
88
What is the possible significance of chest pain of ischaemic nature plus anxiety restlessness, cool hammy skin, weak pulse, hypotension, crackles, arrhythmias?
* myocardial infarction * massive pulmonary embolus * dissecting aortic aneurysm
89
What is the possible significance of chest pain of pleuritic nature, dyspnoea, cough, fever?
* pneumonia | * lower respiratory tract infection
90
What are common DDx of dysphagia?
* URT infection * oesophageal * msk * scleroderma * ALL ossification
91
What are the possible causes of sore throat?
* 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
Why does someone with a sore throat get a "dragging feeling" in the abdomen?
enlarged lymph nodes
93
pharyngeal erythema
red throat
94
petechiae
small red/purple spots from bleeding in skin
95
lymphadenopathy
abnormal size, number, consistency of nodes
96
What is the significance of petechiae on the palate?
glandular fever (#1) or bleeding tendency
97
What is the significance of generalized, tender lymphadenopathy?
systemic infection
98
What is the significance of recurrent sore throat?
allergies chronic fatigue syndrome
99
What is the significance of sore throat in immunosuppressed person?
candidiasis
100
What is the significance of sore throat after recent dental work and dysphagia?
retropharyngeal abscess
101
What is the significance of multiple painful vesicles in oral cavity and sore throat?
* herpangia (coxackie virus) | * herpes simplex infection
102
What is the significance of sore throat with yellow exudate on swollen tonsils?
strep infection
103
What is the significance of sore throat with unilateral vesicles?
herpes zoster (shingles)
104
What is the significance of sore throat and white patches in oral cavity?
candida
105
What is the significance of sore throat with greyish membrane / covering on posterior pharynx?
* diphtheria | * Vincent's angina
106
What is the significance of sore throat with anterior cervical lymphadenopathy?
bacterial infection
107
What is the significance of sore throat with posterior cervical lymphadenopathy?
viral infection
108
What is the significance of sore throat with hoarse voice?
laryngeal or recurrent laryngeal nerve
109
What is the significance of high IGM? of IGG?
IGM: epstein barr virus (mono) IGG: if they had epstein bar over 3 months ago
110
Quickly describe peritonitis
* infection of peritoneum * severe pain * worse on movement * maybe shoulder tip * vomiting, fever, tachycardia, tenderness, rigidity, rebound tenderness, no bowel sounds
111
Quickly describe acute diverticulitis
* 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
Quickly describe shingles
* herpes zoster * neuropathic pain by dermatome * burning, red rash, scales
113
Quickly describe acute appendicitis
* starts centre -> R iliac fossa * colicky then maybe constant * malaise, anorexia, nausea, change bowel habit
114
Quickly describe mesenteric adenitis
* inflammation of mesenteric lymph nodes often following an upper respiratory tract infection * umbilical or R iliac fossa * rhinorea
115
Quickly describe acute cholecystitis
* acute inflammation of gallbladder * epigastric & R hypochondrium, around to the back * fever, rigors
116
Quickly describe acute pyelonephritis
* acute infection of kidney pelvis and parenchyma * aching in loins * fever, rigors, vomiting, change bowel habits, dysuria, frequency, cloudy urine
117
Quickly describe acute intestinal ischaemia
* blood flow to intestine reduced causing necrosis * sudden, severe, * bloody diarrhoea, hematemesis, shock
118
Quickly describe mechanical bowel obstruction
* obstruction of a section of intestines * from tumour, adhesions, strangulated hernia * colicky * vomiting, distension, absolute constipation, + pulse, + bowel sounds
119
Quickly describe urinary tract calculi
* obstruction of ureter by stone * dull loin or extreme pain * vomit, sweat, hematuria
120
Quickly describe salpengitis
* infection of uterine tubes * iliac fossa pain * systemically ill (fever, malaise) * Ddx of appendicitis
121
Quickly describe endometriosis
* endometrial tissue outside the uterus * dysmenorrhoea, dyspareunia * infertility, abnormal menstruation, malaise, frequency, hematuria
122
Quickly describe acute pancreatitis
* sudden, severe * epigastric and R hypochondrium * radiating through to back * relieved by forward crouch * nausea, shock, + pulse, (-) temp, abd. guarding, tetany, jaundice
123
Quickly describe chronic pancreatitis
* episodes of same pain as acute pancreatitis | * steatorrhoea, malabsorption, (-) weight, diabetes, jaundice
124
Compare glomerulonephritis to pyelonephritis
``` Glomerulo: • infection from autoimmune • sore throat Pyelo: • from blood or UTI • systemically ill. cloudy urine ```
125
Quickly describe acute gastritis
* inflammation of stomach * epigastric * anorexia, coated tongue, persistent vomiting, massive bleed
126
Quickly describe peptic ulceration
• epigastric pain Gastric: worse with eating Duodenal: relieved by eating
127
Quickly describe biliary colic
* obstruction of part of biliary tract with stone * severe pain that plateaus * epigastric * band across chest * around to back * restless
128
What are the causes of acute right iliac fossa pain?
* 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
What is the number one cause of gastritis?
alcohol
130
What are the Ddx of sudden severe sharp epigastric pain?
* gastritis * peptic ulceration * oesophagitis
131
What is Murphy's sign?
* 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
Quickly describe pleurisy
* inflammation of pleura * chest stabbing, worse on inspiration * rapid, shallow breath * pleural rub * tachypnoea
133
Quickly describe aortic aneurysm dissection
* abnormal movement of blood between layers of aortic wall * sudden, severe ripping * retrosternal * shock
134
What is shock?
* palor * clammy * tachycardia * increase respiration rate
135
Quickly describe shingles
* infection caused by reactivation of the varicella-zoster virus * burning neuropathic pain by dermatome * red, rash and scales, vesicles
136
Quickly describe costochondritis
* inflammation of the costal cartilages * chest, sides of sternum * worse by cough, tender * swelling * worse on movement * no systemic signs
137
Quickly describe rib fracture
* break in continuity of a rib * sharp pain on inspiration, movement * achy * bruising * no systemic signs
138
Quickly describe myocardial infarction
* 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
Quickly describe oesophagitis
* epigastric or retrosternal | * dysphagia, hematemesis, nausea, vomit, fever
140
Quickly describe GORD
* gastroesophageal reflux disease * burning epigastric or retrosternal * worse lying down, after large meal, halitosis
141
Quickly describe intercostal myositis
* aching, localized, lateral * tender, swelling * no systemic signs
142
Quickly describe oesophageal muscle spasm
* spasm of oesophageal musculature | * dysphagia
143
Quickly describe angina pectoris
* 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
Quickly describe pulmonary embolism with infarction
* 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
Quickly describe acute pericarditis
* 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
Quickly describe pneumothorax
* 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
Quickly describe massive pulmonary embolus
* obstruction of pulmonary trunk, R or L pulmonary artery by a large embolus -> acute heart failure * sudden pleuritic pain * shock, R heart failure
148
Quickly describe pneumonia
* consolidation of alveoli, most commonly caused by infective agents * pleuritic pain * fever, dyspnoea, hemoptysis, malaise * rusty sputum
149
Quickly describe Bornholme syndrome
* viral illness (usualy coxsackie viruses) in older children with pleuritic chest pain * pleuritic pain * fever, sore throat, malaise
150
What conditions have: hyerresonant percussion, and decrease vocal resonance & fremitus?
Increase air in lungs • pneumothorax • asthma • emphysema
151
What conditions have: dull percussion, and increase vocal resonance & fremitus?
solid /fluid in alveoli | • pneumonia
152
What conditions have: dull percussion, and decrease vocal resonance & fremitus?
Increased density in pleura • pleural effusion • mesothelioma
153
What examinations do you do for a patient with acute dyspnoea, right sided chest pain that is sharp and worse on inspiration.
* 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
What investigations do you do for a patient with recurrent central chest pain episodes at the gym. Pressure or tension type pain.
* stress ECG * blood test for cardiac enzymes (rule out MI) * chest x-ray (LV hypertrophy) * CT angiography of heart
155
What is the pathophysiology of GORD?
* 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
What investigations do we to confirm suspected GORD?
* endoscopy | * barium swallow x-ray
157
What are the complications of untreated GORD?
* repeated erosion -> fibrosis -> oesophageal stricter -> dysphagia * metaplasia -> displasia -> malignancy
158
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.
* intercostal myositis * costochondritis * shingles (early)
159
What is the significance of right hypochondriac pain that is constant? or colicky?
liver issue gall bladder

Diagnostic Sciences (7 decks)

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