Ch3-pain,dyspnea,and Hemoptosis9-3- 2006

Pain Department of Physical Diagnostics 1st Teaching Hospital Zhengzhou University

Definition • “An unpleasant sensory and emotional experience associated with either actual or potential tissue damage, or described in terms of such damage” ---- International Association for the Study of Pain 

Classification: – Dermal pain – Visceral pain – Deep pain – Referred pain

Key Notes in Interviewing of Pain • • • • • • •

Sites Character Causes Duration Radiation Accompanied symptoms Relaxing factors

Abdominal Pain

Abdominal Pain: Pathogenesis Intra-abdominal diseases

extra-abdominal

diseases

Visceral, peritoneal, or abdominal wall N.

Pain

Causes of Abdominal Pain • Diseases of abdominal organs

– Acute: inflammation, fracture, obstruction, perforation, torsion, embolism – Chronic: inflammation, viscera enlargement, obstruction, ulceration, torsion, tumor

• Diseases of extra-abdominal organs

– Thorax diseases: referred pain, pneumonia, pleuritis, myocardial infarction – General diseases: uremia, lead intoxication, Henoch-Sch Ö nlein purpura

Clinical Features • Sites: related to location of the pathological changes • Characters: lancinating, drilling, burning, colic • Onset: continuous, paroxysmal, intermittent • Radiation • Factors triggering or relieving pain: meal

Common Diseases • Acute appendicitis

– Pain is initially localized around the umbilicus (visceral pain) and is vague; As the inflammatory response progresses to involve the parietal peritoneum, the main site of pain shifts to the right iliac fossa (parietal or somatic pain) – Usually accompanied by fever

Peptic Ulcer • Periodical burning pain in epigastrium • Pain is associated with meal – May be accompanied by hematemesis or melena

Acute Gastric Perforation • Outburst acute severe lancinating pain in umbilical region or epigastrium

Acute ileus • Vomiting • Cramping Abdominal pain • distension • obstipation

Ureter Calculi • Paroxysmal abdominal pain • Referred pain to the groin area of the same side • Hematuria

Acute pancreatitis   • Continuous severe pain in umbilical region or epigastrium, paroxysmally enhanced • Associated with meal, esp. heavy drinking

Chest Pain

Causes Esophagus Chestwall

Mediastinum

Pleura

Lung

subphrenic

Heart

Angina pectoris

pleuritis

esophagitis

Site

Pre-cardial

Affected chest Post-sternal

Radiation

L shoulder & arm

No

No

Character

anginal

lacerating

burning

Duration

Several mins

days

weeks

Causes

Excitement, labouring

cough

meal

Relieving

nitroglycerin

Position?

Antacid

Accompany symptoms

Chest distress, Fever, cough Swallowing palpitation discomfort

Dyspnea

Causes • Pulmonary:

– Inspiratory – Expiratory – Mixed

• Cardiac • Toxic • Other:

– Hysterical – hemopathic

Pulmonary Dyspnea • Inspiratory dyspnea • Mechanism: narrowing of larynx or large airway • Features: – Difficult in taking in air – Prolonged inspiration phase – May be accompanied by “three depressions sign” and stridor in inspiration phase

Pulmonary Dyspnea • Expiratory dyspnea • Mechanisms:

– Decreased elasticity of the lung tissue – Narrowing of bronchiole – Bronchioles are pressed in inspiration phase

• Features:

– Difficult in expirate – Prolonged expiration phase – Too much air trapped in the lung

Pulmonary Dyspnea • Mixed: – Mechanisms: • Generalized lesion in the lung • Restricted dilatation of the alveoli due to the thickness of the chest wall and pleura

– Features: • Difficult in inpirate and expirate • Tachypnea • Abnormal breath sounds or adventitious sounds

Cardiac dyspnea • Mechanisms:

– Congestion and decreased compliance of the lung mainly due to left heart insufficiency

• Features:

– Worsen by exertion, relieved by rest – Nocturnal paroxysmal dyspnea – “Cardiac asthma” : large amount of pink frothy sputum, fine rales in both lung fields, relieved by sitting position

Nocturnal Paroxysmal dyspnea

•

Causes: – – – – – –

Ischaemic heart disease Aortic valve disease Hypertension Cardiomyopathy Atrial fibrillation Rarely in mitral valve disease or atrial tumours

Toxic Dyspnea • Mechanism1: respiratory centre is activated by acidosis – Clinical feature: Kussmaul respiration

• Mechansim2: respiratory centre is inhibited by drugs or other illness – Clinical feature: Cheyne-Stokes respiration and Biots respiration

Hysterical Dyspnea • Mechanism: hyperventilation syndrome caused by stimulating of the respiration centre by psychic factor • Feature: – Tachypnea – May be accompanied by numbness of the lips , numbness and convulsion of the four extremities. – Psychic or mental factors exist – Dyspnea may be relived by psychotherapy

Hemoptysis and hematemesis

Definitions • Hemoptysis: the expectoration of any blood, regardless of whether the sputum is grossly bloody or merely blood streaked • Hematemesis: efflux of blood from the GI tract, usually bright red or “coffee-ground” material is vomited

Differences Between Hemoptysis and Hematemesis Causes

Hemoptysis

Hematemesis

Heart or lung dis.

Gastrointestinal , hepatic, biliary tract dis.

Pre-bleeding symptoms bleeding

Itching in the throat, Discomfort in the upper abdomen, nausea, vomitting cough Bright red Coffee-ground, dark or bright red Material in blood Sputum Food residue pH

alkaline

acid

melena

No (unless blood is swallowed) Blood streaked

Yes

Sputum after bleeding

No