PAIN

Dr. Praveen K. Yadav

@SOCRATES
• Site
• Onset
• Character
• Radiation
• Alleviating factor
• Timing
• Exacerbating factor
• Severity
INTRODUCTION

• The word ‘pain’ is derived from Latin word ‘poena’ which means
penalty or punishment.

• 5th vital sign (American Pain Society 2003)

• Pain is an unpleasant sensory and emotional experience associated

with actual or potential tissue damage.
4 TYPES OF PAIN

1. Superficial pain

2. Segmental pain

3. Deep pain

4. Psychogenic pain
SUPERFICIAL PAIN

• Occurs due to direct irritation of peripheral nerve endings in the

superficial tissue.

• Such irritation may be Chemical/Mechanical/Thermal/Electrical

• Pain is sharp

• Can be pointed with a finger tip.

SEGMENTAL PAIN

• Occurs due to irritation of sensory nerve trunk or root.

• It is located in a particular dermatome of the body supplied by the

affected sensory nerve root or trunk.
DEEP PAIN
• Pain occurs due to irritation of deep structures of the body
• e.g. deep fascia, muscles, tendons, bones, joints and viscera
• Pain sensation from the affected structures is conveyed to the brain either
by somatic nerve or by the autonomic nervous system.
• Deep pain is vague compared to superficial pain
• Pain is vaguely localized in comparison to the superficial pain.
• The pain may be referred to some other area of the body due to common
area of representation in the spinal cord(supplied by the same segment)
• Deep pain may cause involuntary spasm of skeletal muscles supplied by
the same spinal cord.
PSYCHOGENIC PAIN

• Pain arises from the brain

• Which may be functional pain either emotional or hysterical

• Or due to lesions in thalamus or spinothalamic tract

• Or due to causalgia
NATURE OF PAIN
Vague Aching Pain
Mild continuous pain which has no other specific features.
Burning Pain
Almost like a burning sensation caused by contact with a hot object
Peptic ulcer, Reflux oesophagitis
Throbbing Pain
Throbbing sensation
Pyogenic abscess
Scalding pain
Type of burning sensation typically felt during micturition
Cystitis, Acute pyelonephritis, Urethritis
Pins and Needle sensation
Injury to peripheral nerve
As if pins and needles are being pricked in that area of skin supplied by the
affected sensory nerve
Shooting pain
Pain shoots along the course of particular nerve
E.g. in Sciatica, along the course of sciatic nerve
Stabbing pain
Sudden, severe, sharp & short-lived pain
Acute perforation of peptic ulcer.
Constricting pain
S/th is encircling and compressing from all directions the relevant part
Angina pectoris
Colic pain
Occurs when muscular wall of a hollow tube is attempting to force certain
content of the tube out of it.
Usu 4 types of colic pain in surgery:
 Ureteric
 Biliary
 Intestinal
 Appendicular
Twisting pain
Feeling that s/th is twistin inside the body
Volvulus of intestine, torsion of testis, ovarian cyst
Just a pain
Often a patient may not describe his pain
He often say that ‘it’s just a pain’ and cannot describe the nature of pain
MOVEMENTS OF PAIN
Pain moves from one place to other

1. Radiation of pain

2. Referred pain

3. Shifting or Migration of pain

1. Radiation of pain

• Extension of pain to another site

• Original pain persists in original site

• Duodenal ulcer penetrates posteriorly

• Pain in epigastrium remains but at the same time the pain spreads or
radiates to the back.
2. Referred pain
• Pain felt at a distance from its source
• No pain at the site of disease
• Irritation/inflammation of diaphragm-pain at tip of shoulder
• Pain occurs when the CNS fails to differentiate between visceral pain
and somatic sensory impulses from the same segment
• In this case diaphragm-phrenic nerve(C3,4,5)
• Cutaneous supply of shoulder-C4,5
3.Shifting or Migration of pain

• Pain is shifted to another site

• Original pain disappears

• Acute appendicitis
SPECIAL TIME OF
OCCURRENCE
• Acute appendicitis-pain on waking up in the morning
• Duodenal ulcer-pain at 4 pm in the afternoon
pain at early morning at 2-3 am
hunger pain
• Migraine-esp. in the morning, either every week end or during
menstruation
• Frontal sinusitis- office headache
PRECEPITATING FACTORS

• Pain of Appendicitis/Ureteric and Vesicular calculi

• gets worse on jolting, running and moving upstairs

• Pain of reflux oesophagitis

• Aggravates when the patient stoops

• Pain of acute pancreatitis

• Become worse when the patient lies down
RELEIVING FACTORS
• Peptic ulcer-taking alkalies and antacids
• Acute pancreatitis-sitting up in the bed in leaning forward position
• Reflux oesophagitis due to sliding hernia
• Proped up position
• Colicky pain of intestinal obstruction
• Gets relieved on passing flatus
• Perforative peritonitis
• If he/she lies still
ASSOCIATED SYMPTOMS
• Severe pain
• Pallor, sweating, vomiting and increase in PR
• Colicky pain
• Sweating, vomiting and clammy extremities
• Migraine is often preceded by visual disturbances and accompanied
by vomiting
• Pain of acute pyelonephrititis
• Rigor and high fever
• Ureteric colic-Hematuria
• Biliary colic-jaundice and pale stool
• Excessive sweating and cold extremities
• Leaking abdominal aneurysm
• Dissecting aneurysm
• Hemorrhagic pancreatitis
SEVERITY OF PAIN
VISUAL ANALOGUE SCALE(VAS)
• The Visual Analog Scale (VAS) is a 10 cm line with anchor statements
on the left (no pain) and on the right (extreme pain).
• The patient is asked to mark their current pain level on the line. They
can also be asked to mark their maximum, minimum, and average
pain.
• The examiner scores the VAS by measuring the distance in either
centimeters (0 to 10) or millimeters (0 to 100) from the “no pain”
anchor point.