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INTRODUCTION

APPROACH TO THE PATIENT Pain

Pain is the most common symptom that brings a pt to a physician's attention. Management depends on determining its cause, alleviating triggering and potentiating factors, and providing rapid relief whenever possible. Pain may be of somatic (skin, joints, muscles), visceral, or neuropathic (injury to nerves, spinal cord pathways, or thalamus) origin. Characteristics of each are summarized in Table 6-1.

NEUROPATHIC PAIN

Definitions: neuralgia: pain in the distribution of a single nerve, as in trigeminal neuralgia; dysesthesia: spontaneous, unpleasant, abnormal sensations; hyperalgesia and hyperesthesia: exaggerated responses to nociceptive or touch stimulus, respectively; allodynia: perception of light mechanical stimuli as painful, as when vibration evokes painful sensation. Reduced pain perception is called hypalgesia or, when absent, analgesia. Causalgia is continuous severe burning pain with indistinct boundaries and accompanying sympathetic nervous system dysfunction (sweating; vascular, skin, and hair changes—sympathetic dystrophy) that occurs after injury to a peripheral nerve.

Sensitization refers to a lowered threshold for activating primary nociceptors following repeated stimulation in damaged or inflamed tissues; inflammatory mediators play a role. Sensitization contributes to tenderness, soreness, and hyperalgesia (as in sunburn).

Referred pain results from the convergence of sensory inputs from skin and viscera on single spinal neurons that transmit pain signals to the brain. Because of this convergence, input from deep structures is mislocalized to a region of skin innervated by the same spinal segment.

CHRONIC PAIN

The problem is often difficult to diagnose, and pts may appear emotionally distraught. Several factors can cause, perpetuate, or exacerbate chronic pain: (1) painful disease for which there is no cure (e.g., arthritis, cancer, migraine headaches, diabetic neuropathy); (2) neural factors initiated by a bodily disease that persist after the disease has resolved (e.g., damaged sensory or sympathetic nerves); (3) psychological conditions. Pay special attention to the medical history and to depression. Major depression is common, treatable, and potentially fatal (suicide).

TABLE 6-1CHARACTERISTICS OF SOMATIC AND NEUROPATHIC PAIN

PATHOPHYSIOLOGY: ORGANIZATION OF PAIN PATHWAYS

Pain-producing (nociceptive) sensory stimuli in skin and viscera activate peripheral nerve endings of primary afferent neurons, which synapse on second-order neurons in spinal cord or medulla (Fig. 6-1). These second-order neurons form crossed ascending pathways that reach the thalamus and are projected to the somatosensory cortex. Parallel ...

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