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DIVINE WORD UNIVERSITY

FACULTY OF HEALTH SCIENCES RURAL HEALTH PROGRAM CLINICAL MEDICINE BLOCK M DAIMEN- SMO PHYSICIAN, MODGH INTERNAL MEDICINE- ADJUNCT LECTURER

M DAIMEN- SMO Internal Medicine, MADANG

PAIN
GENERAL SYMPTOMS IN MEDICINE

M DAIMEN- SMO Internal Medicine, MADANG

PAIN- What you must know?


What pain is?
Description of pain(s)
Know the causes of pain Classify and grade the pain

Manage the pain

M DAIMEN- SMO Internal Medicine, MADANG

OUTLINE
Definition

Causes
Pathophysiology Classification/grading

Clinical description/features
Management Summary

References

M DAIMEN- SMO Internal Medicine, MADANG

DEFINITION
PAIN- is an unpleasant sensation/feeling in the body

ranging from mild discomfort/ache to an agonizing/excruciating distress as a result of potential or real tissue damage1.

M DAIMEN- SMO Internal Medicine, MADANG

ORIGIN OF PAIN
CONNECTIVE TISSUES- skin, subcutaneous tissues,

muscles- (skeletal, smooth), ligaments & tendons.


NERVES BONES-

M DAIMEN- SMO Internal Medicine, MADANG

Causes
Injury- blunt/penetrating trauma, chemicals,

thermal
Infections- viruses, bacterial, protozoa,

fungal, helminthes
Poisons- stings & bites Spasms- chemical/electrolytes imbalances
M DAIMEN- SMO Internal Medicine, MADANG

Pathophysiology
Pain arises when there is presence of inflammation and

or electrolyte imbalance within the tissues.

Release of certain chemicals,(Interlukins, Prostagladins,

chemokins, e.t.c) at the site of the injury

Stimulation of pain fibers Pain centre activation Certain actions in response to this discomfort.
M DAIMEN- SMO Internal Medicine, MADANG

Grading/Classification

MILD
MODERATE SEVERE

ACUTE/CHRONIC

M DAIMEN- SMO Internal Medicine, MADANG

Clinical features & Description


Mild- no alteration in ones daily activity, normal

vitals observations- PR/RR/BP


Moderate- may/may not affect daily activities; vital

observations- may increase a little


Severe- patient is usually in distress, vital obs usually

raised and patient is sick.


PR- pulse rate, RR-respiratory rate, BP- blood pressure, obs-observations
M DAIMEN- SMO Internal Medicine, MADANG

Clinical features & Description


CharacterAches dull Sharp, (needle prick/knife stabbing-like), burning sensation- hotness

Consistency- colicky/constant
Frequency- how often?; intermittent Aggravating factors- what makes it worse Relieving factors- what makes it cool down.

M DAIMEN- SMO Internal Medicine, MADANG

Clinical features & Description


Associated signs of inflammation- WCC, ESR,

C-RP, Temperature.
Electrolyte imbalance- Ca++, Na+-

(spasms/cramps)

(WCC- white cell count, ESR- erythrocyte sedimentation rate, C-RP- C-reactive protein)

M DAIMEN- SMO Internal Medicine, MADANG

Management
This covers 3 things- INVESTIGATIONS,

TREATMENT & EDUCATION


INVESTIGATIONS- pain is a systemic symptom so

tests must be ordered where appropriate- WCC, ESR, C-RP, ASOT, X-Rays, ECG, U&E, e.t.c..
ASOT- anti-streptolysin O titre, ECG- electrocardiograph, U&E- urea & electrolytes

M DAIMEN- SMO Internal Medicine, MADANG

Treatment
GUIDELINES FOR SUCCESS
Review and chart each pain carefully and individually
Explanation and reassurance contributes greatly to pain relief. Give regular analgesics rather than on an as required basis Choose the best route: PO/PR/SC/IM/IV/INHALATION/epidural Allow patients to be in-charge as this will promote patient well-being and

reduce misuse.

Refer or get expert help where appropriate


PO- per os, PR- per rectum, SC- subcutaneous, IM- intra-muscular, IV- intra venous

M DAIMEN- SMO Internal Medicine, MADANG

GRADE OF PAIN
MILD- aches/discomforts

Treatment

TREATMENT
Massages, acupunctures, physiotherapy NON-ADDICTIVE DRUGS: paracetamol NSAIDS- aspirin, indomethasin, ibuprofen, diclofenac NSAIDS SE: PUD, asthma, clotting problems, anti-coagulants drugs CAUTION: renal/liver impairment, pregnancy, elderly. Children no ASPIRIN.

MODERATE
SEVERE

As above
ADDICTIVE-DRUGSmorphine/diamorphin less additive Pethidine, fentenyl more addictive Adjuvant drugs- hyosin butylbromide, steroids, anti-depressives/psychotics for neuropathic pain. Local anesthetic/epiduralstings/bites/cancers/post-operative.

Give electrolytes if low (Ca, Na)


M DAIMEN- SMO Internal Medicine, MADANG

Education
Explanation and reassurance is very important in

pain management
Drugs side-effects education Prognosis of the cause of pain

Long term management

M DAIMEN- SMO Internal Medicine, MADANG

Summary
Pain is one of those common symptoms you will

encounter in your every day clinical practice

Not all pains are due to disease or abnormalities but

may be psychosomatic in nature.

Pain is located systematically so find out: where?,

what?, Grading, how to treat it.

For cancer pains ADDICTION is a non issue.


M DAIMEN- SMO Internal Medicine, MADANG

Reference
1. Oxford medical dictionary, 4th edition 2. Oxford handbook of clinical medicine, 7th

edition

M DAIMEN- SMO Internal Medicine, MADANG