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PAIN : HISTORY TAKING

S Suraj Dhara
Apr 26, 2020 • 17 likes • 5,194 views

 9 of 21  

Health & Medicine

PAIN : HISTORY TAKING

,pain ,history taking ,stabbing ,burning ,scalding ,colicky ,distension ,pins & needles ,gripping ,referred
,radiating ,shi!ing ,migrating

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PAIN : HISTORY TAKING
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 a!ect 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). 4/26/2020 2
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 a!ected 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. 4/26/2020 3drsuraj1997@gmail.com
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 4/26/2020 4drsuraj1997@gmail.com
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 o"en ‘in umbilical region & now it is in RIF’. 4/26/2020 5drsuraj1997@gmail.com
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 a"er a trauma the cause of
pain must be traumatic. Sprain Fracture or dislocation Rupture of kidney or liver. 4/26/2020 6drsuraj1997@gmail.com
7. Severity Not so important to come to a diagnosis. Individuals o"en react di!erently to pain due to di!erence 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 4/26/2020 7drsuraj1997@gmail.com
8. Nature of pain “Very important for making the diagnosis & very di!icult 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. 4/26/2020 8drsuraj1997@gmail.com
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 o! as suddenly as it came. 2) gripping in nature & o"en 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 4/26/2020 9drsuraj1997@gmail.com
10. Constricting pain : something is encircling & compressing from all directions. O"en 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 : o"en patient may not describe his nature of pain & says it’s just a pain. Nature of pain … cont’d 4/26/2020
10drsuraj1997@gmail.com
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. 4/26/2020 11drsuraj1997@gmail.com
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. 4/26/2020
12drsuraj1997@gmail.com
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 di!erentiate 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. 4/26/2020 13drsuraj1997@gmail.com
14. Movements …cont’d Shi!ing / Migration of pain – pain is felt at one site in the beginning & then the pain is shi"ed 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 (shi"ing of pain). 4/26/2020 14drsuraj1997@gmail.com
15. Special time of occurrence Acute appendicitis – pain on waking up in morning, infact pain awakens the patient. Duodenal
ulcer – pain o"en complained at a"ernoon (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 – o"en
known as o!ice time headache. 4/26/2020 15drsuraj1997@gmail.com
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 o"en shows pain free intervals of one months. 4/26/2020
16drsuraj1997@gmail.com
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 li"ing weight from stooping position. Perforative peritonitis – any
movements. 4/26/2020 17drsuraj1997@gmail.com
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. 4/26/2020
18drsuraj1997@gmail.com
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. 4/26/2020
19drsuraj1997@gmail.com
20. 4/26/2020 20drsuraj1997@gmail.com

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