Approach & evaluation of patient with somatic pain

1. Approach & evaluation of patients with
somatic pain
1
Dr. Md Rashedul Islam
FCPS, MRCP(UK)
Registrar, Neurology,
BIRDEM

2. •Pain is one of the earliest signs of
morbidity, and it stands preeminent among
all the sensory experiences by which
humans judge the existence of disease
within themselves.
•Indeed, pain is the most common symptom
of disease.
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3. INTRODUCTION
• Pain is a sensory experience of special
significance to physicians and basic scientists.
• Pain is the commonest symptom which
physicians are called upon to treat.
• Apart from its obvious applied value, study of
physiology of pain has taught us a lot about
neural function in general.
• Pain is an intensely subjective experience, and is
therefore difficult to describe.
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4. RELATED TERMS
• Dysesthesia: Any abnormal sensation described
as unpleasant by the patient
• Hyperalgesia: Exaggerated pain response from a
normally painful stimulus
• Hyperpathia: Abnormally painful and
exaggerated reaction to a painful stimulus
• Hyperesthesia (hypesthesia): Exaggerated
perception of touch stimulus
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5. RELATED TERMS
• Allodynia: Abnormal perception of pain from a
normally nonpainful mechanical or thermal
stimulus; usually has elements of delay in
perception and of aftersensation
• Hypoalgesia (hypalgesia): Decreased sensitivity and
raised threshold to painful stimuli
• Anesthesia: Reduced perception of all sensation,
mainly touch

6. RELATED TERMS
• Paresthesia: Mainly spontaneous abnormal
sensation that is not unpleasant; usually described
as "pins and needles"
• Causalgia: Burning pain in the distribution of one or
more peripheral nerves
• Pallanesthesia: Loss of perception of vibration
• Analgesia: Reduced perception of pain stimulus

7. 7
CLASSIFICATION OF PAIN
PAIN
Somatic
(somasthetic)
Visceral (from viscera)
e.g. angina pectoris,
peptic ulcer, intestinal
colic, renal colic, etc.
Superficial (from skin &
subcutaneous tissue) e.g.
superficial cuts/burns, etc.
Deep (from
muscles/bones/fascia/periosteum)
e.g. fractures/arthritis/fibrositis,
rupture of muscle belly

8. PRACTICAL CLINICAL CLASSIFICATION OF PAIN
(Cranial )
General
Classification
Origin of Pain Quality of Pain
Extra cranial
Structure
Craniofacial region Varies
Referred pain from
remote pathologic
sites
Distant organs and
structures
Aching and
pressing
Intracranial
pathosis
Brain and related
structures
Varies
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9. Neurovascular Blood Vessels Throbbing,
pulsing or
pounding
Neuropathic Sensory nervous
system
Shooting, sharp,
burning pain
Causalgic Sympathetic
nervous system
Burning
Muscular Muscles Deep aching,
tight
PRACTICAL CLINICAL CLASSIFICATION OF PAIN
(Cranial )
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10. •Location
•Mode and time of onset
•Associated features, e.g., nausea, muscle spasm
•Quality and time-intensity attributes
•Duration
•Severity
•Provoking and relieving factors
Whenever pain…

11. Whenever pain…
Some physicians find it helpful, particularly in
gauging the effects of analgesic agents, to use a
"pain scale," i.e., to have the patient rate the
intensity of his pain on a scale of zero (no pain)
to 10 (worst pain) or to mark it on a line (the
Visual Analog Pain Scale).

12. Whenever pain…
chronic pains fall into one of four categories:
•pain from an obscure medical disease, the nature
of which has not yet been disclosed by diagnostic
procedures
•pain associated with disease of the central or
peripheral nervous system
•pain associated with psychiatric disease
•pain of unknown cause.

13. Some pain syndromes
• Pain is not primarily a pathological phenomenon, but
serves a protective function.
• Conditions with loss of pain perception exemplify
this,resulting in frequent injuries, burns and
subsequent mutilations
• Pathological conditions do, however, cause pain – as
a symptom of cancer, injury or other disease.

14. Some examples
CAUSALGIA
• Causalgia is an intense, continuous, burning pain
produced by an incomplete peripheral nerve injury.
Touching the limb aggravates the pain,and the
patient resents any interference or attempt at limb
mobilisation.

15. Some examples
POSTHERPETIC NEURALGIA
• Following activation of a latent infection with
varicella zoster virus lying dormant in the
dorsal root or gasserian ganglion,
• Patient develops a burning, constant pain with
severe, sharp paroxysmal twinges over the
area supplied by the affected sensory neurons.

17. CAUSES OF UPPER LIMB PAIN

18. CAUSES OF LOWER LIMB PAIN

19. MUSCLE PAIN (MYALGIA)
• Muscle pain is a common medical complaint.
• Mechanical pain results from excessive muscle
tension or contraction and is ‘cramp like’.
• Inflammatory pain results from disruption of
muscle fibres, inflammatory exudate and fibre
swelling.

20. MUSCLE PAIN (MYALGIA)
• Ischaemic pain results from metabolic change,
usually in response to exercise and is deep and
aching.
• Muscle pain may be physiological – as a
consequence of extreme exercise or pathological –
as a consequence of muscle, soft tissue or systemic
illness.

21. APPROACH TO MUSCLE PAIN
History
Is muscle pain – present at rest?
• – Polymyalgia rheumatica
• – Fibromyalgia
• – Parkinson’s disease
• – Collagen vascular disease
present with exercise?
• – Physiological
• – Metabolic myopathies
• – Benign myalgic encephalomyelitis (ME)

22. History
localised?
• Muscle haematoma, abscess, tumour or
fibromyalgia
generalised?
• – Polymyalgia rheumatica
• – Parkinson’s disease
family history?
• – Metabolic myopathies
exposure to toxins?
• – Drug induced myopathies
• – Alcoholic myopathy

23. Examination
Is there
• – wasting/weakness? – Inflammatory myopathies
• – Metabolic myopathies
• – Drug induced myopathies
• – Alcoholic myopathy
Skin rash?
• – Inflammatory myopathy (dermatomyositis)
• – Collagen vascular disease

24. Examination
stiffness or spasms?
• – Tetanus
• – Tetany
• – Spasticity
• – Neuroleptic malignant syndrome
muscle swelling?
• – Muscle abscess, tumour
• – Metabolic myopathy

25. THANK YOU

26. THANK YOU