Cardinal Manifestations of Disease:

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

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. 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

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. 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

26. Headache • 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 meningealartery • dural sinuses • falxcerebri • 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 17th edition