Pain a common presenting complaint

Pain is the commonest presenting problem, accounting for ahout half of all consultations. Specific presentations of pain that arise in each system are described in the chapters

Cardiovascular system No cardinal symptoms

Respiratory system

No cardinal symptoms

Gastrointestinal system Nausea reported

Details of this symptom

Other relevant gastrointestinal symptoms reported or absent

Establish how much of a problem for the patient

Fig. 1.6 The layers of the HPC. In the absence of cardinal cardiorespiratory symptoms, the clinician rapidly proceeded to eliciting gastro-intestinal symptoms which were described in detail before continuing to the next system.

that follow: here the approach to all presentations of pain is described as an example of the multilayered history.

Charactenstrci of the pain. Although Table 1.6 may seem complex, with practice, information can he gathered within a few minutes and accurately and briefly summarised as in the ease of a patient presenting with a myocardial infarction.

A 58-year-old man with a history of infrequent angina of effort for the previous 6 years developed retrosternal chest pain radiating to his left arm. The pain appeared suddenly while he was watching television, was crushing in nature and associated with nausea and sweating. It was not relieved by sublingual glyceryl trinitrate used to control his angina but settled spontaneously on his arrival in hospital 2 hours later.

Associated symptoms. Symptoms thai develop along with the pain often help towards making the diagnosis. However, part of the body's response to pain or stress is autonomic arousal. As a result, the patient may experience symptoms, such as fairuness. sweating, nausea, vomiting, diarrhoea and increased frequency of micturition. The effects of pain on sleep and appetite should be noted. The persistent disturbance of sleep by pain suggests a physical as opposed to a psychological cause.

Effects on lifestyle. "How has the pain affected your life?' Areas to be considered arc presented in Table 1.7. and reflect the normal psychosocial adaptation to disease or disability. Plainly, these issues are irrelevant in the acutely ill.

Attitudes to illness. This is a difficult area to evaluate. In most chronic conditions insight into patients' response to illness may be obtained by considering their overall attitude

TABLE 1.6 Charact

eristics of the pain

Main site

Somatic pain often well localised, e.g. sprained ankle; visceral pain more diffuse, e.g. angina pectoris

Radiation

Through local extension, or referred by a shared neuronal pathway to a distant, unaffected site e.g, in diaphragmatic pain at the shoulder tip via the phrenic nerve (C3, CJ

Character

Described by adjectives, e.g. sharp/dull, burning/tingling, boring/stabbing, crushing/tugging, perferably using the patient's own description rather than offering suggestions

Severity

Difficult to assess as so subjective. Sometimes helpful to compare with other common pains, e.g. toothache

Onset

Speed of onset and any associated circumstances

Duration

Since onset

Course

Episodic or continuous. If episodic, duration and frequency of attacks; if continuous any changes in the severity

Pattern

Variation by day or night, during the week or month (e.g. relating to menstrual cycle)

Aggravating factors

Circumstances in which pain is provoked or exacerbated (e.g. food). Specific activities or postures, and any avoidance measures that have been taken to prevent its onset

Relieving factors

Effects of specific activities or postures. Includes effects of medication - painkillers in particular and alternative medical approaches

toward their illness. This is subject to numerous influences: that two people may behave quite differently and yet suffer from the same disease.

TABLE 1.7

The social effects of chronic pain

Employment

Ability to maintain work If so, any changes to duties If not, duration off work and reasons for not working Attitude to work

Compensation claim Deprivations

Relationships

Effects on key relationships Changes in physical anci emotional aspects of marriage

Changes in role, decision-making, etc. within the family

Changes in contact with family or friends

Leisure

Effects on social activities, holidays, hobbies and Interests

Changes in habits such as smoking and drinking Increased Interest in illness, e.g. joining a patients' group

• The pain threshold can be increased considerably by factors like physical activity and analgesic drugs, a positive emotional state and suggestion, Autohypnosis is an example of this.

• Patients vary in their tolerance of pain and their willingness to commwtiiule this to others; anxious patients lend to request more pain relief.

• Past experiences, both personal and family, influence how patients respond to symptoms. For instance a family history of death from heart disease can affeel how a patient interprels and reacts to chesl pain.

• Somatisation is the development of physical symptoms as an expression of emotional distress or illness. I( is sometimes easier and more acceptable for patients to present a physical complaint to the doctor rather than a worry. For example, they will concentrate on the headache rather than the source of the stress responsible for the tension headache.

• Cains from remaining sick: where these exist they are not always obvious or fully appreciated and frequently are not disclosed by the patient. Benefits may include financial advantages, avoiding unenjoyable or stressful work, or obtaining opiate medication. Alternatively there may be emotionally based needs, such as trying to stabilise an insecure marriage. In such circumstances patients may be poorly motivated to get well but may continue to attend their doctor.

Failure by the clinician to recognise anxiety, somatisation and abnormal illness behaviour may lead lo unnecessary investigation and inappropriate treatment.

Past medical history (PMH)

Some clinicians obtain llie pasl medical history after the presenting complaint because it is often highly relevant. Indeed, others take the past history first. Certainly it is not uncommon lo discover a direct relationship between the previous history and the presentation which may he mapparent to the patient. For instance, a patient w ith a pasl history of rheumatic heart disease, who presents with recurrent fever and malaise, may have developed infective endocarditis.

It is useful to begin with an open inquiry such as "what significant illnesses have you had?' Patients who report all episodes of ill health may be anxious, obsessional or hypochondriacal: what matters are illnesses that are clinically significant or potentially relevant to the presenting complaint. For example, if a patient complains of haemoptysis, it is relevant to ask if the patient has ever been treated for tuberculosis or has been in contact with thai disease. Any positive response establishes a nest which should be explored by further questions,

The past psychiatric history should be incorporated into the PMH as this helps to establish the sequence of events and any interactions among medical and psychiatric episodes.

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