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PAIN
EMERGENCY
CENTER
FIRST AFFILIATED
HOSPITAL
ZHENGZHOU
UNIVERSITY
Definition of pain
– Visceral pain
– Somatic pain
– Referred pain
Visceral pain
The receptors located in the visceral
peritoneum surrounding hollow organs
and the capsules of solid organs.
Distention or ischemia of the abdominal
organs stimulates these receptors. Most
visceral pain is midline in nature.(Because
these organs are simultaneously innervated from
both sides of the spinal column .)
Visceral pain
dull, crampy, and poorly
localized(Because visceral pain fibers are
bilateral and unmyelinated and enter the
spinal cord at multiple levels). It is often
associated with“ visceral” symptoms
such as nausea, vomiting, and
diaphoresis. It usually cannot be
localized to a certain organ.
Somatic pain
The pain receptors located in the
parietal peritoneum and the roots of the
mesentery. This type of pain is more
sharp, and localized.(because Pain
produced by ischemia, inflammation or stretch of
the parietal peritoneum is transmitted through
myelinated afferent fibers to specific dorsal roots
ganglia on the same side and at the same
dermatomal level as the origin of the pain) .
It is responsible for the physical
finding of tenderness to palpation,
guarding, and rebound . The finding of
somatic pain often allows anatomic
localization of pain to a specific organ.
Given somatic tenderness in a certain
quadrant, the differential diagnosis can
be narrowed down solely by anatomic
localization of organ.
Referred pain
The pain that is felt at a cutaneous site
distant from the disease organ. For
instance, visceral afferents from the
diaphragm enter the spinal cord at C3-
C5. Pain from the diaphragm is thus
referred to the cutaneous distribution
of C3-C5 the lateral neck and posterior
shoulder.
Because the lungs and abdomen
share the T9(thoracic nerve 9)
dermatome distribution, pulmonary
processes such as pneumonia and
pulmonary embolus can be perceived
as abdominal pain. Pelvic and inguinal
structures innervated by T11 and T12
can cause referred pain to the lower
abdomen.
DATA GATHERING
Key Notes in Interviewing of Pain
• Sites
• Character
• Causes
• Duration
• Radiation
• Accompanied symptoms
• Relaxing factors
Despite all technologic advances, the
history and physical examination remain the
most important tools in the initial
assessment of a patient who complains of
abdominal pain. Although critically ill
patient may be more difficult to evaluate,
the data from their history and physical
examination are paramount, as this
information either determines a definitive
diagnosis or directs further evaluation.
Pain
History
Onset. Rapid onset of severe pain is
more consistent with a vascular
catastrophe, rupture of a viscus,
ectopic pregnancy. Slower, insidious
onset is more typical of an inflammatory
process such as appendicitis or
cholecystitis.
Pattern of Change
Acute appendicitis
– Pain is initially localized
around the umbilicus
(visceral pain) and is
vague; As the inflammatory
response progresses to
involve the parietal
peritoneum, the main site
of pain shifts to the right
iliac fossa (parietal or
somatic pain)
– Usually accompanied by
fever
Acute Cholecystitis
• Paroxysmal right
hypochondrium pain
• Accompanied by fever
sometimes
• Paroxysmal pain in right
infrascapular area
Acute Gastric Perforation
region or epigastrium
Acute ileus
• Vomiting
• Cramping Abdominal
pain
• distension
• obstipation
Ureter Calculi
• Paroxysmal
abdominal pain
• Referred pain to
the groin area of
the same side
• Hematuria
Rupture of the Liver or Spleen
Inspection : Signs of
distention ,symmetry , prior
surgery , large masses , bruises may
quickly narrow the differential
diagnosis.
Auscultation
Decrease bowel sounds are heard in
peritonitis and other inflammatory
processes that cause an adynamic ileus.
Increased bowel sounds are heard in
patients with nonspecific abdominal
pain and gastroenteritis. Whereas high-
pitched sounds and rushes are classic
for bowel obstruction.
Percussion
Gentle percussion of all four abdominal
quadrants can localize the site of pain
initially. Percussion the abdomen can often
provide information about the size of
certain organs and the origin of abdominal
distention, gaseous or solid. It is also
useful for determining bladder size from
urinary retention.
Palpation
Most of the time and effort in the abdominal
examination is spent on palpation. It is important
to note the patient’s facial expressions during
palpation. A grimace is usually more significant
than the statement “ It hurts.” In pain of
visceral origin, localization of tenderness is
usually not possible . With somatic tenderness is
more likely, and the following associated
findings are assessed.
Muscular Signs
Guarding is the reflex spasm of the abdominal
wall musculature in response to palpation.
Voluntary guarding is less significant than
involuntary guarding. Involuntary guarding is
elicited by asking the patient to take a deep
breath while firm pressure is held on the
tender area. If the spasm is not relieved,
involuntary guarding is present. If the muscles
relax, voluntary guarding is present.
Rebound Tenderness
Rebound is classically the hallmark of
peritoneal Irritation. It is elicited by slow,
gentle, deep palpation of the tender area
followed by abrupt but discreet
withdrawal of the examiner’s hand.
Often this procedure is not necessary
because rebound can be discovered more
gently by asking the patient to cough, or
gentle percussing the area of tenderness.
Special Techniques
Murphy’s Sign: While the physician
palpates deeply in the right upper
quadrant, the patient is asked to take a
deep breath. Abrupt cessation of
inspiration because of pain is consistent
with cholecystitis, hepatitis, or other
right upper quadrant abnormalities.
Fist percussion
Laboratory
Studies
White Blood Cell Count and Differential