The document discusses the definition and types of pain. It defines pain as an unpleasant sensory and emotional experience arising from actual or potential tissue damage. It describes four main types of pain: superficial, segmental, deep, and psychogenic. The document emphasizes the importance of a thorough pain history in order to make an accurate diagnosis. It provides a list of key factors to assess in a pain history, including location, onset, severity, nature, progression, duration, aggravating/relieving factors, and any associated symptoms. Assessing these factors can provide clues to determine the underlying cause of a patient's pain.

1. BY SURAJ DHARA
(MIDNAPORE MEDICAL COLLEGE)

2. Short Introduction
 Definition : According to IASP (International Association for the Study
of Pain), it is an unpleasant sensory and emotional experience arising
from actual or potential tissue damage or described in terms of such
damage.
 Pain is not just a physical sensation. It is influenced by attitudes,
beliefs, personality and social factors, and can affect emotional and
mental wellbeing.
 Very common symptom that all of us have experienced.
 Latin word ‘poena’ = penalty / punishment; => pain.
 Tenderness means pain which occurs in response to a stimulus.
 Patient feels pain, while doctor elicits tenderness (sign).
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3. TYPES
 Superficial pain : due to direct irritation of the peripheral nerve endings
in the superficial tissues. Such irritation may be by chemical,
mechanical, thermal or electrical. Sharp pain & can be pointed with
fingertip.
 Segmental pain : due to irritation of the sensory nerve trunk or root.
This is located in a particular dermatome of body supplied by the
affected trunk or root.
 Deep pain : due to irritation of deep structures of the body (deep fascia,
muscles, tendons, bones, joints & viscera).pain sensation is conveyed to
the brain by somatic or autonomic nervous system. Deep pain is a vague
pain compared to superficial pain. It is vaguely localized, may be
referred to some other area of body & may cause involuntary spasm of
skeletal muscles supplied by same spinal cord segment.
 Psychogenic pain : functional pain either emotional or hysterical or due
to lesions in the thalamus or spinothalamic tract or due to causalgia.
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4. If careful history is not taken about pain, it may frequently
confuse the clinician to make a wrong diagnosis
The following points are to be assessed during history taking -
 Original site of pain
 Origin & mode of onset
 Severity
 Nature or character
 Progression
 Duration
 Movements
 Time of occurrence
 Periodicity
 Precipitating / Aggravating factors
 Relieving factors
 Associated symptoms
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5. Original site of pain
 Ask “where did the pain started?”
 Patient usually fails to locate the pain with finger tip & uses whole
hand to locate the site, particularly in abdominal pain.
 So exact localization may not be possible particularly in deep pain
originating from thoracic or abdominal viscus.
 It must be remembered that when patient comes to surgeon the site of
pain may have changed.
 A patient of acute appendicitis when brought to surgeon may locate
the pain at right iliac fossa. Ask ‘where did pain start ?’ & his answer is
often ‘in umbilical region & now it is in RIF’.
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6. Origin & mode of onset
 Ask “how did the pain start?”
 A long continued pain with insidious onset indicates chronic nature of
the disease.
 Chronic pancreatitis
 Chronic peptic ulcer
 Subacute appendicitis
 Recent onset of pain with sudden arrival indicates acute nature .
 Acute pancreatitis
 Acute appendicitis
 Rupture of aneurysm
 When the pain starts after a trauma the cause of pain must be
traumatic.
 Sprain
 Fracture or dislocation
 Rupture of kidney or liver.
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7. Severity
 Not so important to come to a diagnosis.
 Individuals often react differently to pain due to difference in their
pain perception threshold.
 A severe pain to one person may be simple dull ache to another.
 Few diseases are associated with severe pain-
 Acute pancreatitis
 Biliary colic
 Perforated peptic ulcer
 Dissecting aneurysm of aorta
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8. Nature of pain
 “Very important for making the diagnosis & very difficult for the
patients to describe.”
Vague aching pain : mild continuous pain having no other specific
features.
Burning pain : burning sensation caused by contact with a hot object.
 Peptic ulcer
 Reflux esophagitis
Scalding pain : type of burning pain, particularly felt during
micturition in presence of
 Cystitis
 Acute pyelonephritis
 Urethritis
Throbbing pain : throbbing sensation
 Pyogenic abscess.
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9. Pins & needles sensation : as if pins & needles are being pricked in the
area of skin d/t injury to peripheral sensory nerve.
Shooting pain : shoots along the course of the nerve -
 Sciatica
Stabbing pain : sudden, severe, sharp & short-lived pain -
 Acute perforation of peptic ulcer
Colicky pain : muscular wall of hollow tube is attempting to force
certain content out of it.
 It has two features – 1) appears suddenly & goes off as suddenly as it
came. 2) gripping in nature & often associated with vomiting & sweating.
 Ureteric / Biliary / Intestinal / Appendicular colic.
Twisting pain : something is twisting inside the body
 Volvulus of intestine
 Torsion of testes
 Torsion of ovarian cyst.
Nature of pain … cont’d
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10. Constricting pain : something is encircling & compressing from all
directions. Often expressed as iron band tightening around the chest –
 Angina pectoris
Distension : pain is experienced in diseases of any structure encircled
or restricted by a wall (hollow viscus). When tension increases inside
such hollow viscus it causes a pain which is typically felt as a
distension or tightness.
Just a pain : often patient may not describe his nature of pain & says
it’s just a pain.
Nature of pain … cont’d
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11. Progression
 Ask “how is the pain progressing?”
 Pain may begin in a weak note & gradually reaches a peak / a plateau
& then gradually declines.
 It may begin at its maximum intensity & remains at this level till it
disappears.
 Severity of pain may fluctuate – intensity may increase and decrease at
intervals.
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12. Duration
 Period from the time of onset to the time of disappearance of pain.
 Gripping pain of intestinal colic – less than a minute.
 Pain of angina – ceases within 5 mins of resting.
 Pain of myocardial infarction – may continue for hours.
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13. Movements
 Radiation - extension of pain to another site whilst the original pain
persists at its original site.
Radiated pain has almost the same character to the original site.
When duodenal ulcer penetrates posteriorly the pain in epigastrium
remains but at the same time it spreads or radiates to back.
 Referred pain – pain felt at a distance from its source & there is no pain
at the site of disease.
It occurs when CNS fails to differentiate b/w visceral & somatic sensory
impulses from the same spinal segment.
Irritation of diaphragm causes pain at the tip of shoulder. In this case
diaphragm is supplied by phrenic nerve (C3, 4 & 5) and cutaneous
supply of shoulder is also C4 & C5.
Diseases of hip joint may be referred to the knee joint as both of them
are supplied by articular branches of femoral, obturator & sciatic nerve.
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14. Movements …cont’d
 Shifting / Migration of pain – pain is felt at one site in the beginning &
then the pain is shifted to another site & the original pain disappears.
In case of acute appendicitis pain is first felt at umbilical region which
is also supplied by the T9 & T10 (referred pain).
But later the parietal peritoneum overlying the inflamed appendix is
involved & pain is felt at right iliac fossa with disappearance of
umbilical pain (shifting of pain).
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15. Special time of occurrence
 Acute appendicitis – pain on waking up in morning, infact pain
awakens the patient.
 Duodenal ulcer – pain often complained at afternoon (4 p.m.) & in
early morning (2 to 3 a.m.). It’s a hunger pain & felt when food has
passed out of stomach.
 Migraine – especially in the morning either every weekend or during
menstruation.
 Frontal sinusitis pain – often known as office time headache.
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16. Periodicity of the pain
 Sometimes an interval of days, weeks, months or even years may
elapse between two painful attacks .
 Particularly in peptic ulcer, a periodicity is noticed and pain recurs in
episodes lasting for one to several weeks, interspersed with pain free
intervals of weeks or months.
 Trigeminal neuralgia often shows pain free intervals of one months.
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17. Aggravating factors
 This history is of great importance.
 Alimentary tract pain - by eating particular types of foods.
 Musculoskeletal pain – by joint movements.
 Pain of appendicitis, ureteric & vesical calculus – on jolting, running &
moving up the stairs.
 Pain of reflux esophagitis – when patient stoops forward.
 Pain of acute pancreatitis – when lies down.
 Peptic ulcer pain – ingestion of hot spicy food or drink.
 Pain of disc prolapse – on lifting weight from stooping position.
 Perforative peritonitis – any movements.
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18. Relieving factors
 As important as aggravating factors.
 Peptic ulcer pain – by alkalis & antacids in 5 to 15 min.
 Pain of acute pancreatitis – by sitting up in bed in leaning forward
position & the patient prefers to sit up even throughout the night.
 Pain of hiatus hernia – propped up position.
 Intestinal colicky pain – on passing flatus.
 Perforative peritonitis – lies still.
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19. Associated symptoms
 Severe pain may be associated with pallor, vomiting & inc. pulse rate.
 Colicky pain – sweating, vomiting & clammy extremities.
 Migraine – preceded by aura (visual, auditory) & accompanied by
vomiting.
 Pain of acute pyelonephritis – rigor and high fever.
 Ureteric colic – hematuria.
 Biliary colic – jaundice & pale stool.
 Leaking abdominal aneurysm, dissecting aneurysm & hemorrhagic
pancreatitis – excessive sweating & cold extremities.
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