Cardinal Manifestations of Disease:

1. Cardinal Manifestations of Disease: Dr. Gerrard Dennis Uy

2. What is PAIN for You?

5. 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

6. Qualities of Pain • Stabbing • Burning • Twisting • Tearing • Squeezing

7. Components of a typical cutaneous nerve

8. 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

9. 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

10. Central Mechanisms of Pain

11. 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

12. 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

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

14. Chest Discomfort

15. 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

16. Chest discomfort

17. 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 arms—frequently 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

18. 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 • Levine’s 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

19. 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

20. 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

21. 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

22. Chest Discomfort • Other causes • Pneumothorax • Pneumonia • Mallory weiss tear • Musculoskeletal pain • Anxiety disorders

23. 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

24. Abdominal Pain

25. 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

26. 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

27. 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

29. 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

30. Headache

31. 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

32. 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

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

34. 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

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

36. 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)

37. 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

38. 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

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

40. 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

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

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

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

44. 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 nondescript—an 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 50% • dull and boring, with superimposed episodic stabbing pains • Glaucoma • prostrating headache associated with nausea and vomiting

45. For the next meeting, read on Cardinal Manifestations of Disease : Neck and Back Pain, ALTERATIONS IN BODY TEMPERATURE • Harrison’s Principles of Internal Medicine 17th edition