1. Cardinal Manifestations of Disease: Dr. Meg-angela Christi Amores

2. What is PAIN for You?

6. PAIN an unpleasant sensation localized to a part of the body most common symptom that brings a patient to a physician's attention Protects the body and maintain homeostasis provide important diagnostic clues

7. Peripheral Mechanisms of Pain

8. Central Mechanisms of Pain

9. Chest Discomfort

10. 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

11. Chest discomfort Diagnosis if MI is ruled out Percent Gastroesophageal disease a 42 Gastroesophageal reflux Esophageal motility disorders Peptic ulcer Gallstones Ischemic heart disease31 Chest wall syndromes28 Pericarditis4 Pleuritis/pneumonia2 Pulmonary embolism2 Lung cancer1.5 Aortic aneurysm1 Aortic stenosis1 Herpes zoster1

12. Chest Discomfort Typical clinical features of major causes – Angina Pectoris : 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: 10-20 mins More severe Pressure, tightness, squeezing, heaviness, burning

13. Chest Discomfort Typical clinical features of major causes – Acute myocardial infarction ( MI ) Variable; often more than 30 min duration Quality and location similar to angina Unrelieved by nitroglycerin – Pericarditis Sharp pain lasting hours to days; may be episodic Retrosternal or toward cardiac apex; may radiate to left shoulder May be relieved by sitting up and leaning forward Presence of pericardial friction rub

14. Chest Discomfort Typical clinical features of major causes – Esophageal reflux Substernal or epigastric burning pain lasting 10-60mins Worsened by postprandial recumbency Relieved by antacids – Gallbladder disease Prolonged burning or pressure like pain following meals RUQ, epigastric or substernal

15. 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

16. Abdominal Pain

17. 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

18. 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

19. Abdominal Pain – Obstruction of Hollow Viscera Intermittent or colicky, poorly localized e.g. SI obstruction, Gallbladder stones (misleading biliary colic – steady pain), Kidney stones

20. Abdominal Pain Mechanisms …cont – Vascular disturbances Mild, continuous, diffuse Radiation to sacrum, flank, genitalia for days (AAA) e.g. Sup Mes Art obstruction, Rupturing AAA

21. Abdominal Pain – Abdominal wall Constant and aching Accentuated by movement, prolonged standing, pressure

23. 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

24. Headache

25. 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

26. Headache Common causes of Headache Primary HeadacheSecondary Headache Type% % Migraine16Systemic infection63 Tension-type69Head injury4 Cluster0.1Vascular disorders1 Idiopathic stabbing2Subarachnoid hemorrhage<1 Exertional1Brain tumor0.1 Pain usually occurs when peripheral nociceptors are stimulated in response to tissue injury, visceral distension, or other factors

27. Pain-producing cranial structures Scalp middle meningeal artery dural sinuses falx cerebri proximal segments of the large pial arteries

28. 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

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

30. 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)

31. 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

32. 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, or other afferent stimulation; hunger; excess stress; physical exertion; stormy weather or barometric pressure changes; hormonal fluctuations during menses; lack of or excess sleep; and alcohol or other chemical stimulation

33. 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

34. For the next meeting, read on Cardinal Manifestations of Disease : ALTERATIONS IN BODY TEMPERATURE Harrison’s Principles of Internal Medicine 17 th edition