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10 QUANTITATIVE ASPECTS OF

CLINICAL REASONING
LEE GOLDMAN

CHAPTER 10 QUANTITATIVE ASPECTS OF CLINICAL REASONING

The process of clinical reasoning is poorly understood but is based on factors such as experience and learning, inductive and deduetivc reasoning, interpretation of evidence (hat itself varies in reproducibility- and validity, and intuition that often is difficult to define. In an effort- to improve clinical reasoning, a number of attempts have been made to analyze quantitatively the many factors involved, including defining the cognitive approaches that clinicians apply to difficult problems, devising computerized decision support fcy stems that are designed to emulate certain features of decision making, and applying decision theory to understand how judgments should be reached. While each of these approaches has advanced the understanding of the diagnostic process, all have practical and/or theoretical problems that limit their direct applicability to the care of the individual patient^ Nevertheless, these preliminary attempts to apply the rigor and logic inherent in the quantitative method have provided significant insights intb the process by which clinical reasoning is accomplished, have identified ways in which the process may be improved, and have made it possible to\minimize certainlfeatures of the workup that arc not cost-effective. Thus, while clinical reasoning cannot be reduced to probabilities or numbers, attempts at quantitative analysis of the process may improve the ways in which Ihe problems of individual patientS arc approached and solved. In a simplified model, quantitative clinical reasoning includes five phases. The first consists of an investigation of the chief complaint through key questions that arc included in the history of the present illness (Tabic 10-1). These questions are supplemented by the past medical history and by a physical examination that emphasizes^ detailed investigation of potential key organ systems. In the second phase, the physician may select from an array of diagnostic tests, each with its own accuracy and usefulness for investigating the possibilities raised in the differential diagnosis. Since each lest has its costs, and some entail risk and discomfort as well, the physician must ask whefhci^the history and physical examination arc sufficiently diagnostic before ordering tests. Third, the clinical data must be integrated with test results to estimate the likelihood of conditions in the differential diagnosis. Fourth, the comparative risks and benefits of further diagnostic and therapeutic options must be weighed to reach a recommendation for the patient. In the fifth and final phase, this recommendation is presented to the patient, and after appropriate discussion of the options, a therapeutic plan is initiated. Each of the five steps in this simplified model of the clinical reasoning proccss can he analyzed individually. HISTORY AND PHYSICAL EXAMINATION It originally had been assumed that physicians begin investigating a patient’s chief complaint by obtaining a comprehensive history, which includes many, if not most, of the questions included in a full review of systems, and by performing an allinclusive physical examination. However, experienced clinicians begin to form hypotheses based on the chief complaint

a systematic, thorough, and complete history of the present illness, past medical history, review of systems, family history, social history, and physical examination. For example, if a patient presents with abdominal pain, the physician should gather information regarding its location and quality as well as the factors that precipitate and/or relieve it. The physician then asks questions relating to the diagnoses that may be suspected based cm the response to the initial questions. If the pain is suggestive of pancreatitis, the clinician would ask about alcohol intake, the use of thiazide diuretics or glucocorticosteroids, symptoms suggestive of concomitant gallbladder- disease, a family history of pancreatitis, and questions aimed at uncovering the possibility of a posterior penetrating ulcer. Alternatively, if the discomfort seems more typical of reflux esophagitis; a different sequence of questions would be- triggered. The use of iterative hypothesis testing encourages the physician to elicit detailed information in high-yield areas, without forgoing a systematic and thorough approach to the patient. Findings on the history and physical examination should influence each other. The history focuses the physical examination on certain organs, and findings on physical examination should encourage more detailed review of certain systems. As physicians procccd through this reasoning proccss with both the history and physical examination, a variety of issues may influence the accuracy of the decision-making process. First is the potential for some historical information or physical findings to be poorly reproducible, either because the patient’s responses vary or because different physicians clicit information differently or vary in the way they interpret, the answers. The careful use of clear and, when possible, precise questions can increase the reproducibility and validity of the medical history but still cannot eliminate all variability. When assessing the reproducibility of findings on the physical examination, two observers frequently agree that an uncommon abnormality such as an enlarged spleen is not present but agree less often when one of them thinks that it is present in a patient in whom it would not usually be expected. This principle can best^be demonstrated by understanding that some agreement always occurs by chance, and the likelihood of chance agreement is higher if the finding is either very common or very uncommon. For example, if two physicians each consider 90 percent of patients to be abnormal in some manner, such as having a systolic heart murmur, they will agree 81 percent of the time by chancc alone. In some studies of the reproducibility of common signs and symptoms, such as an enlarged liver, actual agreement rates have hot been substantially better than chance. Disagreement rates may ho reduced by emphasizing physical examination skills during medical (mining, by looking for other correlative physical findings, and by learning how physical findings correlate with the results of diagnostic tests. Therefore, when a clinician notes an unexpected and somewhat subjective abnormality lor which Ihcrc may be a'high rate of interobservcr disagreement, such as an unexpectedly enlarged spleen, other abnormalities that may often be associated with it, such us hepatomegaly of lyt»|>hailcnoputhy.

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TABLE 10-1 Phases of clinical reasoning and decision making
/ Investij’aiion of the complaint by means of clinical cxiiniiiiatiou (history and physical examination) | 2 Ordering of diagnostic lesls, each with its own intrinsic accnnicy and usefulness J Integration ol clinical findings will) lest results to assess diagnostic probabilities •I Weij'liinj', o| comparative tisks and benefits ol alternative courses ol action if: Determination of patient's preferences and development of a therapeutic plan and on Ihe responses to

initial questioning, and they ask further questions in a sequence that allows them to evaluate the initial hypotheses and, if necessary, shorten or amend the list of possibilities. Only a limited number\of diagnostic hypotheses can be entertained at any one time, and information is used to build a case for or against the most likely. In such a way, high-priority questions are selected from the almost limitless number that might be asked, and these specific questions arc incorporated into the history of the present illness. Often, a key response, such as a history of mclena, will be selected, a list of potential explanations for it will be formulated, and this list will then be trimmed, based on the response to more probing questions, so that a principal diagnosis can be selected and then tested. This process, termed iterative hypothesis testing, is an efficient approach to diagnosis and is preferable to attempts to gather every conceivable piece of information prior to formulating a differential diagnosis. Advocacy of iterative hypothesis testing does not argue against the need for

In the latter situation.e.. such as an abdominal* ultrasound. For example. including prevalence.” Since different physicians may assign different probabilities to the same terms. Although such quantitative estimates would be desirable. A test with a particular sensitivity and specificity has different positive and negative predictive values when used in groups of patients that have different prevalences of disease. There is a tendency to overestimate the likelihood of relatively uncommon conditions. they do depend on the spectrum of patients inf whom the test is being evaluated.spccific antigen for diagnosing carcinoma of the prostate (sec Chap. For example. and negative predictive value (Table 10-2). positive predictive value. measurement of a prostatc. it is likely to be a true positive). Since the physician rarely knows (or enn know) the population on which every test that is ordered has been standardized. the probability is low. In some situations.*’ “sometimes. but the decision as to whether a lumbar puncture should be performed may depend on this estimate. they may be so low that the test is of limited clinical value. When physicians use the history and the physical examination to arrive at a diagnosis. the spectrum of the diseased and nondiseased patients is altered by including oatients with other ^characteristics (tre. to assess the finding more objectively should be considered if the test is sufficiently reliable. the sensitivity and specificity of the test would change dramatically. Rather. and be the least expensive and/or risky of the available efficacious tests. Although reports of the accuracies of diagnostic tcsts^re commonly expressed initcrms of positive and negative prcdiciivt^valucs. if the*population of patients 'with carcinoma of the prostate were composed principally of those without palpable nodules and with stage 1 disease. a physician may not know whether the probability of bacterial meningitis or of another disease that could be diagnosed by a lumbar puncture in a patient with a severe hcadachc is I in 20 or 1 in 2000. If. because the spectrum of diseased and nondiscased patients has been changed. the sensitivity and specificity of the prostate-specific antigen are not only lower than in the first example. A 10 to 15 percent probability of carcinoma may be interpreted as “unlikely” but from a clinicaLperspccti ve „. and physicians often have^difficulty interpreting test results# It is therefore critical to understand several commonly used terms in test analysis and epidemiology. ordering a diagnostic test. Even experienced physicians often ard unable to estimate accurately the likelihood of particular conditions. Furthermore. All too frequently this probability is not expressed as an actual percentage but rather in such terms as “nearly always. Physicians should be as rigorous and quantitative as possible in their assessments. and they encourage the development in the patient of confidence in the physician. the history and physical examination have other important purposes.negative test = (a +c d)/(a +b results/ all tests battery of blood tests in an asymptomatic person of the same age is unlikely to be due to tumor (i. AND USEFULNESS A diagnostic test should be ordered for specified clinical indications. these imprcci. 188) has been shown to be remarkably accurate in determining the cause of systolic murmurs. the results provide information that is far less decisive than usually thought. These comments about the factors that limit the reproducibility and validity of the medical history and physical examination do not denigrate their critical importance in clinical reasoning. which is so necessary for reaching an agreement on the coming plan of action. they emphasize that care and diligence in the application of these skills arc necessary. As was emphasized in Chap. 1. and physicians are especially poor at quantifying probabilities that are very high or very low!7 For example. they usually are not available in practice. ACCURACY. it would be better to assess the likelihood of the diagnosis in terms of probabilities. while the population without carcinoma of the prostate included elderly men with marked benign prostate hypertrophy).se words frequently lead to major misunderstandings among physicians or between the physician and the patient. . a quantitative expression of probability should be used. a mildly abnormal alkaline phosphatase level in a young adult with a known lymphoma suggests hepatic involvement by the tumor (i.” “commonly. rather than saying that it is unlikely that a radiographic pattern is indicative of a carcinoma of the colon.sc (he likelihood that the CHAPTER 10 QUANTITATIVE ASPECTS OF CLINICAL REASONING spleen would he expected to be abnormal. uncertainty about the sensitivity and specificity of the test in (he type of patient being assessed may limit its clinical value. In both situations. they are rarely certain of it. but more important.. In some situations. Fpr example. Although Ihc sensitivity and specificity of a test do not depend on the prevalence (or percentage of patients being tested who have the disease). anil whe’n feasible. if possible. such as the finding of an elevated level of CK in a patient who has undergone strenuous exercise and is being evaluated for chest pain. it would be preferable. without changing the prevalence of disease in the population being tested.e.. however. Therefore. these calcutateJ values are dependent on the prevalence of the disease in the population being studied (Table 10-3). in this setting it is more likely to be a false positive). 323) will appear to have a nearly perfect sensitivity and specificity if the diseased population has a palpably prostate noclulc and an elevated scrunl acid phosphatase level while the nondiscascd population is composed of normal medicalstudents. They allow the physician to evaluate the emotional status of the patient and td understand how the present problems fit into the context of the patient’s social and family life. specificity. DIAGNOSTIC TESTS: INDICATIONS. careful auscultation of the heart during various bedside maneuvers (see Chap. to provide a more precise indication of the probability of carcinoma with this radiographic pattern. be sufficiently accurate to be efficacious for such indications.” or “rarely.usual ly warrants further evaluation because of the serious consequences of missing a potentially resectable tumor. sensitivity. while the same alkaline phosphatase level as part of a routine screening TAIlLK 10*2 Definitions of commonly used terms In epidemiology and decision making Disease state 43 Test result Positive Negative Prevalence (prior probability) Sensitivity Specificity False-negative rate Pulse positive rale Positive Negative prod id i ve predictivc value value Overall accuracy Present Absent a (true positive) h (false positive) c (false negative) d (true negative) cc)!(a + d) + =b all = (o + + patients with the disease/all patients tested = true-positive test results/all patients with (he disease = true-negative test = d/(b + d) results/all patients without the disease false-negative test rcsul(s/all patient* = c/(a += c) with (he disease a/(a + c) (csl results/all hl{h 1 </) falfcc-niHkiiivc patients without the disease test results/all positive a/(a += b)true-positive test results : d/(c +— d) true-negative test results/all patients with negative results + d) =+true-positive + true. This example also demonstrates the methodologic problems encountered when applying data from one study to a different type of patient or when pooling data fronustudies of different subsets of patients.should be sought to incrca. For example. No diagnostic test is totally accurate. it may be quite difficult to distinguish random laboratory errors from test results that might be falsely positive or negative bccausc of coexistence of a process that can affcct the test. Uccausc no single value or cutoff point of an individual test can be expected to have both a perfect sensitivity and a perfect specificity.

It generally results from stretching of inflamed parietal pleura and is similar in character to the pleural pain of pericarditis (see above). causes pain not only in the anterior part of the chest but also in the upper pail of the abdomen or corresponding region of the buck. the pain is loeated more laterally. In some patients. Patients commonly describe a true pain rather that the vague discomfort that is sometimes described with myocardial ischemia. Musculoskeletal pain The costochondral and chondrostemal articulations are the most common sites of anterior chest pain Objective signs in the form of swelling (Tietze’s syndrome). the discomfort is experienced as a sense of “tightness. are erroneously labeled as having coronary disease." and occasionally it may be sufficiently s evere as to be designated a pain of considerable magnitude. which cun ho confused with comnnry artery disease. 43 Pressure on die chondrostemal and costochondral junctions and on the pectoralis muscles is an essential part of the examination of every patient with chest paint and will reproduce the pain arising from these tissues. or certain foods typically exacerbates this burning discomfort. Occasionally. such as a hiatus hernia or a duodenal ulcer. The location. The pain may be darting and last for only a few seconds or may be a dull ache enduring for hours or days. This discomfort probably results from relative ischemia of the right ventricle brought about by the increased oxygen needs and by the elevated intramural resistance. because the esophagus lies just behind the posterior portion of the heart. Patients mav have accompanying •Ivsplntp. but it may arise from marked inflammation of the relatively insensitive inner parietal surface of the pericardium or from irritated afferent cardiac nerve fibers lying irvthe periadventitial layers of the superficial coronary arteries. An associated feeling of lightness due to muscle spasm (see below) is frequent. especially those who also have minor and innocent T-wave alterations. Intake of aspirin. The several abdominal disorders which may at times mimic anginal pain may usually be suspected from the history. becoming_sharpcr and more lefraded in the supine position and f reduced when the patient sitsjbpright. radiation. The pain due to acute dissection of the aorta (Chap. 226) may resemble that of acute myocardial infarction. quality. leaning forward^It is frequently ^iefcrfctf"tcrthe'neelc and lasts^onger than the pain ofangina pectoris. often a distinct crepitus is heard. turning or twisting of the chest. although this may not be volunteered by the patient. alcohol. and requires unusually large amounts of analgesics for relief. and ihjg. 210) or to an expanding aortic aneurysm results from stimulation of nerve endings in the adventitia. which ivthe hallmark ol acidinduced pain. the latter is sharp. and movements of the shoulder girdle and arm may elicit and duplicate the pain of which the patient complains. and in massive embolism it is located substcrnally. 252) is epigastric or substemal. or aching and persist for hours. and is often altciyd^by a change of body. Substemal discomfort also frequently occurs in the presence of tracheobronchitis. and its aggravatiortby each breath and by coughing distinguishes it Irom the deep. Since the discomfort may be described as a tightness or constriction and is often localized at least in part beneath the sternum. knifejikc. redness. Pneumothorax and tumors involving the pleural space also may irritate the parietal pleura and cause pleural pain. and all forms of acid-peptic disease may be worse in the early morning when acidic secretions arc not neutralized by food. intensity. and heat are rare.e. n*piir)»»iitff»»ii of oiiiliprsfril food. Esophageal spasm. it is commonly described as a burning sensation accentuated by coughing. can cause a squeezing pain that may be indistinguishable from myocardial ischemia and that may even have a similar pattern of radiation. It is sometimes brought on by swallowing. it lasts for a half hour or more. superficial in quality. neck involvement of the more lateral part of the diaphragmatic pleura. and may be associated with hemoptysis. reaches an extremely severe peak rapidly. is plcuritic in nature.” sometimes called “aching. and with slow fluctuation of intensity. is felt in the center of the chest and/or in the back depending on the site of the dissection. Pain resulting from gastric or duodenal ulcer (Chap. The mechanism of this steady substemal pain is not certain. 228) may be intense and sharp and may radiate from the substemal region to the shoulders. The discomfort caused by acute cholecystitis is more commonly described as an ache. with reduction of the normally large systolic pressure gradient which perfuses this chamber.apericardium and central tendon of the diaphragm. lisophugctil pain commonly prcscnt^a* a deep thoracic burning discomfort. both pleuritic and steady pain may be present simultaneously. however. biceps tendonitis.M. The duration is therefore likely to be cither longer or shorter than untreated angina pectoris. i. and the. it is related to respiratory movements and aggravated by cough and/or deep inspiration. Usually. supplied by branches from the si&jJ] to ninth intercostal nerves. it is not surprising that this type of discomfort is frequently confused with that of myocardial ischemia. lasts for hours. The pain is not aggravated by changes in position or respiration The pain resulting from pulmonary embolism (Chap. dull. Deep breathing. sometimesjjimulating the pain of acute cholecystitis or pancreatitis* Pericardial puin commonly has a pleuritic component. docs not constitute proof that the patient's chest pain is related to it. The pain usually begins abruptly. and arthritis of the shoulder and spine may be precipitated by motion but not by general exertion. Pleural pain from fibrinous pleurisy or any pneumonic process is very common. Emotional disorders are also commonly associated with chest pain. Pain arising in the chest wall or upper extremity may develop as a result of muscle or ligament strains brought on by unaccustomed exercise and felt in the costochondral or chondrostemal junctions or in the chest wall muscles. which may be epigastric or substemal. The pain of mediastinal emphysema (Chap. It most commonly tends to occur an hour or so after meals and not in relation to exertion. but sharply localized tenderness is common. anti the discomfort may he relieved promptly by antacids or even by one or two swallows of food or water. of weight l«»ss The* symptoms of a hiatus hernia fend to be exacerbated by lying down. The pain associated with mediastinitis and mediastinal tumors usually resembles that of plcuritis but is more likely to be maximal in the substemal region. bocause of pleural irritntion. The association with fatigue or emotional strain is usually clear. coughing. is felt characteristically at the tifem-lhc-shoulder. associated feeling of constriction or oppression may cause confusion with myocardial infarction. In patients with smaller emboli. Other causes arc osteoarthritis of the dorsal or thoracic spine and ruptured cenicml disk disease. relatively steady pain of myocardial ischemia. and duration of the episodes arc important. Pain secondary to subacromial bursitis. The pain may be very brief* lasting only a few seconds. usually commences about I to lih after meals. Pain in the left upper extremity and prccordium may be due to compression of portions of the brachial plexus by a cervical rib or by spasm and shortening of the scalenus anticus muscle because of high fixation of the ribs and sternum. Such disorders are frequently asymptomatic and arc not at all uncommon in patients who also have angina pectoris.the adjoining tfapezius ridge. Ordinarily. which may be induced by reflux of gastric acid into an esophagus in which the mucosa has been previously irritated. or other respiratory niiivrmriils will usually point luwaii I tin* pk'iirn mul pericardium or . CHAPTER 10 QUANTITATIVE ASPECTS OF CLINICAL REASONING The presence of an abdominal disorder. Associated hyperventilation cun enuse innocent changes in the T waves and ST segments.. A history of intense aggravation by breathing. which usually lasts for only a few minutes.mat.position. pericardial pain may be described as a steady substemal discomfort . and is usu^ly relieved ill several minutes by antacids or milk. Patients with marked right ventricular hypertension may have exertional pain which is quite similar to that of angina. APPROACH TO THE PATIENT WITH CHEST DISCOMFORT A detailed and meticulous history of the behavior of the pain is the cornerstone of the evaluation.can mimic the pain of acute myocardial infarction. is unrelated to exertion. A large percentage of patients with costochondral pain. Even more so is the story of the aggravating and alleviating factors.

The finding of flat or down-sloping ST-segmenl depressions of 0. caused by myocardial ischemia. Acute chcsl pain. the finding that such maneuvers can cause chest discomfort \loes not mean that such musculoskeletal diseases are the cause of the presenting complaint unless one can b£. Shoulder and arm motion commonly reproduces pain related to these structures. the patient History and physical examination The information obtained from a careful incdical history and physical examination can be used to develop a differential diagnosis of the causes of chcst discomfort in an individual patient. with a duration of minutes to hours prior to the patient's presentation to a physician. experienced clinicians either implicitly or explicitly assess the relative likelihoods of various potential explanations for any chest discomfort syndrome to help guide their future diagnostic evaluations and therapy. many patients have normal tracings between attacks. 203). sure that the patient’s syndrome is reproduced precisely. For example. pulmonary embolism. A careful upper abdominal examination may be the first clue to peptic ulcer disease or cholecystitis. electrocardiographic evidence of myocardial ischemia may occuf at jpe'S't and with or without accompanying chest discomfort. 216). or xanthel. In many situations.asthma. Conversely. although a similar story will occasionally be obtained from patients with skeletal disorders. Evaluation of the patient at the time of.1 mV or greater during an attack of pain substantially increases the likelihood that the pain is anginal in origin. deltoid tendon. Aortography is the definitive test. which would»suggest hyperlipidemia and associated coronary disease. computed tomography. aortic dissection. The finding of lymphadenopathy suggests a tumor. 226) and the evaluation of pulmonary perfusion with a lung scintigram and/or pulmonary arteriography (Chap. However. or magnetic resonance imaging. but because__of^ its i^yasiveness. Careful palpation of the chest wall. even if the description of the discomfort is not perfectly typical for angina pectoris. it is usually reserved for situations *ln which the suspicion of dissection is moderate or high and definitive anatomic documentation or localization is needed. the same man with a history of chcst discomfort that has some characteristics that arc typical for angina pectoris but other characteristics that arc atypical will have a probability of important coronary disease ranging from about 30 to 60 percent. For example. 251). Lung examination may reveal a pleural rub. is so low. 10) should be applied to the evaluation of the patient with chest discomfort. Critical information can often be obtained by attempts to produce or alleviate the pain.mediastinum as the site. although chcst wall pain is likewise affected by respiratory motion. and other structures may be very helpful if it reproduces the chcst discomfort. to rank these diagnostic possibilities. depression of the ST segments. such a diagnosis is relatively unlikely bccausc the prior probability of ischemic heart disease. or mitral regurgitation Frojji papillary muscle dysfunction. Each of the conditions that can cause chest discomfort can have varied (presentations. is also extremely helpful. or with other exertion such as sexual activity. these characteristics must be interpreted in light of the prior probability that a person with a given age and sex and with a particular past mcdical history would have such a cause of chcst discomfort. Similarly. wnen a 20-year-old woman describes the onset of new discomfort in a way that is seemingly classic for angina pectoris. because no single clinical feature can be considered decisive. which suggests hypoxemia from cither diminished cardiac output or impaired respiratory function. Integration of clinical data and test results It is often useful to subdivide patients into those with an acute onset of a new or worsened chcst pain syndrome versus those with more chronic pain. The physical examination may be totally normal in persons with severe myocardial ischemia. ancT often to assign approximate percent probabilities to them. acute myocardial infarction sometimes presents with pain that may be described as burning or even as sharp and may not be principally located in the substemal area. such as is found in pulmonary embolism. such as with nitroglycerin. such as withnrn electrocardiogram during pain. a pain that regularly appears on rapid walking. The accuracy of ambufatory ischemia monitoring in the general population is less dear. and vanishes a few minutes after stopping suggests the diagnosis of angina pectoris. which may range from exceedingly unlikely in a young woman to (he 10 percenf range in a middle-aged man with many coronary risk factors. Alternatively.a spontaneous episode. in which an attempt is made to reproduce die pain by infusing hydrochloric acid into the esophagus. Even persons with chest pain that is decidedly unlikely to represent coronary disease still have some finite . Aortic dissection is often suggested by the routine chcst radiograph. a third or fourth heart sound. For example. The cardiac examination also should search for an increased pulmonic second sound that may indicate elevated pulmonary artery pressure. biliary colic. While data from the history are of cardinal importance in the assessment of chcst discomfort. 190) will demonstrate a perfusion defect in about 75 to 85 percent of patients with angina pcetoris and will be falsely positive in about 10 percent of patients who have chest discomfort from noncoronary causes. Blood pressure should be checked in both arms if aortic dissection is being considered. and some may even be normal during an episode of pain. Exercise thallium scintigraphy (Chap. 201). and the diagnosis may be established by echocardiography (especially transesophageal echocardiography). However. the possibility of angina pectoris as a cause of precordial or substemal discomfort must be seriously considered in a middle. The examination of the chest wall should include both inspection and palpation to search for costochondritis and other musculoskeletal abnormalities. Although the various causes of chcst discomfort have typical characteristics. can help establish acid reflux as the cause of pain (Chap. physicians should not be misled into overreliancc on any single feature. Although it is not always possible to assign numerical probabilities to the various causes of chcst discomfort in an individual patient. the demonstration that a localized pain can be completely relieved by infiltration of a local anesthetic will be conclusive in convincing both the patient and the physician. or evidence of congestive heart failure. and the pericardial friction rub that strongly suggests pericarditis. given her age and sex. Thus the principles of clinical reasoning (Chap. signs of pneumonic consolidation. Diagnostic tests Although myocardial ischemia commonly is associated with electrocardiographic changes (Chap. and the diagnostic tests upon which physicians often rely can also have falsepositive or false-negative results. 1'he Bernstein acid perfusion test. could be caused by many of the entities described in this chapter and would be especially suspicious for acute myocardial infarction. Examination of the skin may reveal cyanosis. Aortic stenosis will be accompaniedJ?y its typical murmur (Chap. The evaluation of patients with suspected pulmonary embolism should usually focus on the documentation of deep venous thrombosis (Chap. Esophageal manometry and measurement of lower esophageal sphincter pressure are useful in identifying esophageal spasm. often because of the need to consider a surgical repair. but it also may demonstrate abnormalities of vital signs. CHAPTER 10 QUANTITATIVE ASPECTS OF CLINICAL REASONING possibility of coronary disease. Exercise electrocardiography^'will show ischcmic changes in about 50 to 80 percent of persons with symptomatic coronary disease but also in about 10 to 15 percent of patient^ who do not have coronary disease. APPLICATION OF THE PRINCIPLES OF CLINICAL REASONING The assessment of the probability of the various causes of chest pain requires the integration of multiple pieces of data.aged man with coronary risk factors such as hypercholesterolemia and smoking. typically occurs during exertion and is accompanied by anginal discomfort: moreover. a middle-aged or elderly man with typical characteristics for angina pectoris has about an 80 to 85 percent probability of having hemodynamically significant coronary artery disease. By comparison. or acute musculoskeletal trauma. subacromial bursa. Esophageal or peptic ulcer diseases can often be diagnosed by an upper gastrointestinal roentgenogram. 43 A thorough physical examination can provide important clues to the cause of chest discomfort. abdomen.

which is also frequently present in a patient at rest. and the pain has no relationship to the intake of food. 15). The pain of uremia or diabetes is nonspecific. CHAPTER 10 QUANTITATIVE ASPECTS OF CLINICAL REASONING abnormalities. Here several mcchanism* may|bc at work. or syphilis. because diseases of the upper part of the abdominal cavity such as acute cholecystitis or perforated ulcer are frequently associated with intrathoracic complications. Simultaneous involvement of muscles in other parts of the body usually serves to differentiate myositis of the abdominal wall from an intraabdominnl process which might cause pain in the same region. a mctabolic origin always must IK* considered. Referred pain from the spine. Many patients of this type have died in the radiology department or the emergency room while f awaiting such unnecessary examinations us electrocardiograms or films of the abdomen. The abdominal discomfort is of dull aching chaucter and is poorly localized. now most frequently encountered in association with anticoagulant therapy. Spasm is seldom induced in the abdominal musculature and. It may be caused by herpes zoster. Referred pain of thoracic origin is often accompanied by splinting of the involved hemithorax with respiratory lag and decrease in excursion more marked than that seen in the presence of intraabdominal disease. the latter radiation to be sharply distinguished from the referred subscapular pain caused by acute distention of the cxtrahepatic biliary tree. Restriction of the depth of respiration is the most common respiratory abnormality. it is not associated with food intake. does not persist. Distention of the abdomen is uncommon. or esophageal disease (the intrathoracic diseases which most often masquerade as abdominal emergencies) will often provide sufficient clues to establish the proper diagnosis.* will supplant iiitfordeily. and the pain and tenderness frequently shift in location and intensity. this situation fortunately is relatively rare. Diaphragmatic pleuritis resulting from pneumonia or pulmonary infarction may cause pain in the right upper quadrant and' pain in the supraclavicular area. Diabetic acidosis may be precipitated by acute appendicitis or intestinal obstruction. or changes in respiration. only a few minutes arc required to assess the critical nature of the problem. yet often forgotten dictum is that the possibility of intrathoracic disease must be considered in every patient with abdominal pain. The pain of porphyria and of lead colic usually is difficult to distinguish from that of intestinal obstruction. referred to the abdomen from the testicles or seminal vesicles is generally accentuated by the . This pain may persist over a period of several days before rupture and collapse occur. but in such instances. Systematic questioning and examination directed toward detecting the presence or absence of myocardial or pulmonary infarction. Although exceedingly important. Whenever the cause of abdominal p:iin is ohsciin*. a mass may be present in the lower quadrants of the abdomen. the patient with known biliary tract disease often has epigastric pain during myocardial infarction. an underlying organic problem should be strongly suspected. painstakingly detailed historyt which is far more valuable than any laboratory or roentgenologic . or strain and is associated with hyperesthesia over the involved dermatomes. Persistent localized tenderness is rare. APPROACH TO THE PATIENT WITH ABDOMINAL PAIN There are few abdominal conditions that require such urgent operative intervention that an orderly approach need be abandoned. Severe muscle spasm. C'l esterase deficiency sisMiciiiicil will) angiouctnohc edema is also often associated with episodes of severe abdominal pain. Here the mechanism is hard to define. whereas it is persistent throughout both respiratory phases if it is of abdominal origin. all obstacles must be swept uside. and the operation begun. It occurs in the absence of thoracic splinting or change in the respiratory rate. The most common problem is the hysterical adolescent or young person who develops abdominal pain and who frequently loses an appendix or other organs because of it. The pain is made worse by movement of the spine and is usually confined to a few dermatome segments. Only those patients with exsanguinating hemorrhage must be rushed to the operating room immediately. Even though the pain may be precipitated by gentle palpation. and if found. because severe hyperperistaJsis is a prominent feature of both. massive hemorrhage is present. so if prompt resolution of the abdominal pain docs not result from correction of thi metabolic Pain arising from spinal nerves or roots comes and goes suddenly and is of a lancinating type (see Chap. Ovulation or some other natural event that causes brief mild abdominal discomfort may sometimes be experienced as an abdominal catastrophe. Palpation over the area of referred pain in the abdomen also docs not usually accentuate the pain and in many instances actually seems to relieve it. see Chap. tumors. For example.slightest pressure on either of these organs. impingement by arthritis. or genitalia may prove a vexing diagnostic problem. The frequent coexistence of thoracic and abdominal disease may be misleading and confusing. spine. is characteristically intensified by certain motions such as. which usually involves compression or irritation of nerve roots. Hyperesthesia is very common. if present. Psychogenic pain conforms to none of the aforementioned patterns of disease. Black widow spider bite^ produce intense pain and rigidity of the abdominal muscles and of the back. 11. and pressure accentuate the discomfort and muscle spasm. cough. 2‘H). so differentiation may be difficult or impossible. ITic problem of differential diagnosis is often not readily resolved. abdominal distention. A helpful finding is the demonstration that cutaneous pain spots are now irregularly spaced. no matter how ill the patient. or biliary colic may be referred to the prccor. Pain. A most important. It has a burning character and is usually limited to the distribution of a given peripheral nerve. It is often at its onset markedly accentuated during the night. For an explanation of the radiation of pain to a previously diseased area. METABOLIC ABDOMINAL CRISES Win of metabolic origin may simulate almost any other type of intraabdomipul disease. an area infrequently involved in disease of intraabdominal origin. pericarditis. the muscle spasm in the area is inconsistent and often absent. diabetes.dium or left shoulder in a patient who has suffered previously from angina pectoris. There are no contraindications to operation I 'lien. Abdominal wall Pain arising from the abdominal wall is usually constant unci aching. which can lead to unnecessary laparotomy unless recognized. Abdominal pain is also the hallmark of familial Mediterranean fever (('Imp. Nothin. Under these circumstances. 43 REFERRED PAIN IN ABDOMINAL DISEASES Pain referred to the abdomen from the thorax. apparent abdominal muscle spasm caused by referred pain will diminish during the inspiratory phase of respiration. and the respirations are not disturbed. In addition. such as hyperlipemia. Again. although occasionally the patient reports these symptoms. prolonged standing. Normal stimuli such as touch or change in temperature may be transformed into this type of pain. especially if the pain is in the upper part of the abdomen. and this tnay be the only indication of an old nerve lesion underlying causalgic pain.aortic aneurysm. Psychogenic pain varies enormously in type and location but usually has no relation to meals. NEUROGENIC CAUSES Causalgic pain may occur in diseases that injure nerves of sensory type. herniated nucleus pulposus. the metabolic disease itself may be accompanied by an intraabdominal process such as pancreatitis. In certain instances. especially if the attention of the patient can be distracted. Movement. during which time repeated questioning and examination will provide the proper explanation. The ultimate decision as to the origin of abdominal pain may require deliberate and planned observation over a period of several hours. adequate access for intravenous fluid replacement obtained. In the case of hematoma of the rectus sheath. Nausea and vomiting are rarely observed. sneeze. rigidity of the abdominal muscles is absent. is common but is either relievedjpr is not accentuated by abdominal palpation. as in the gastric crises of tabes dorsalis. pneumonia. but this is in the nature of a smothering or choking sensation and is part of an anxiety state.

in whom evaluation of the abdomen may be difficult because of other multiple injuries to the spine. the possibility of this diagnosis must always be kept in mincer (see Chap. This kind of history is laborious and time-consuming. Br Med Bull 33:163. 1989 Vaiman J 282:IH58. Laparoscopy is especially helpful in diagnosing pelvic conditions such as ovarian cysts. It is important to remember that abdominal signs may be minimal but nevertheless. Leukocytosis should never be the single deciding factor as to whether or not operation is indicated. the forceful demonstration of rebound tenderness will startle and induce protective spasm in a nervous or worried patient in whom true rebound tenderness is not present. Radioisotopic scans (HIDA) may help differentiate acute cholecystitis from acute pancreatitis. As in history taking. The diagnosis of anemia may be more helpful than the whitcj^lood cell count. In rare instances. an enlarged ovary. their quality. Br Med Cope's computcr-aidct# diagnosis? IB: Acute abdominal . In the examination. The hematocrit and urinalysis permit an accurate estimate of the severity of dehydration so that adequate replacement can be carried out. or a tubal pregnancy. acute cholecystitis. In cases of acute abdominal pain. but pancreatitis. However. The same information can be obtained by gentle percussion of the abdomen (rebound tenderness on a miniature scale). 19X1 liarly Diagnosis iif (he Acme AMimcn. when the proximal part of the intestine above an obstruction becomes markedly distended and edematous. Laboratory examinations may be of enormous value in assessment of the patient with abdominal pain. Sometimes. Assessment of the patient's stale of hydration is important. may occur in the presence of normal peristalsis. films may be diagnostic. e. PWR: Tin* plain x-ray »in the acute abdomen: A surgeon's evaluation. Asking the patient to cough will elicit true rebound tenderness without the need for placing a hand on the abdomen. On the other hand. accurate assessment by the next examiner becomes almost impossible. peritoneal lavage has been replaced by ultrasound and laparoscopy. 1977 Sil.. accurate pain. the patient will usually provide the diagnosis. and respiratory activity.g. barium enema is of inestimable value in cases of colonic obstruction and should be used with greater frequency where the possibility of perforation does not exist.wn. REFERENCES D. whereas success is not so frequently achieved in patients with chronic pain. Recent studies of computer-aided diagnosis of abdominal pain indicate that this technique provides no advantage over clinical assessment alone.k HI1": Abdominal and pelvic visceral rcccptors. tubal pregnancies or salpingitis. Once a patient with peritoneal inflammation has been examined brusquely. Peritoneal lavage is a safe and effective diagnostic maneuver in patients with acute abdominal pain. Should that decision be questionable. because these agents often make it more difficult to securc and to interpret the history and physical findings. a definitive diagnosis cannot be established at the time of the initial examination.examination. Signs may be virtually or actually totally absent in cases of pelvic peritonitis. The determination of the serum lipase may have a somewhat greater accuracy than the serum amylase. may be associated with very marked increase in the serum amylase. diverticulitis. 1991 Sutton GC: How is I Lancet 2:905. The presence of tenderness on pelvic or rectal examination in the absence of other abdominal signs must lead the examiner to consider such important operative indications as perforated appendicitis. there is no substitute for sufficient time spent in the examination. simple critical inspection of the patient. peristaltic sounds may lose the characteristics of borborygmi and become weak or absent even when peritonitis is not present. Nevertheless.7(»3. Hr J Surg ft3. and intestinal infarction may be associated with marked leukocytosis. perforated ulcer. a maneuver which can be far more precise and localizing. position in bed. in cases of intestinal obstruction.. 43 Plain and upright or lateral decubitus roentgenograms of the abdomen may be of the greatest value. and acute appendicitis. and their frequency. It is usually the severe chemical peritonitis of sudden onset which is associated with the truly silent abdomen. a diagnosis is readily established in most instances. Ultrasonography has proved to be useful in detecting an enlarged gallbladder or ^pancreas. making it not especially popular. or urinary infection. 1991 Li. even under the best of circumstances with all available auxiliary aids and with the greatest of clinical skill. 256). if accompanied by consistent symptoms. and listens. Much attention has been paid to the presence or absence of peristaltic sounds.EN W: 15th cd. The amount of information to be gleaned is directly proportional to the gentleness and thoroughness of the examined. and many others. strangulating intestinal obstruction. The serum amylase determination is overrated.i:. Conversely. even though a reasonably accurate diagnosis can be made on the basis of the history alone in the majority of eases. In the absence of trauma. perforated ulcer. e. may be exceptionally meaningful. or ribs and in whom blood in the peritoneal cavity produces only a very mild peritoneal reaction. An accurate menstrual history in a female patient is essential. especially when combined with the history. diabetes. twisted ovarian cyst. For example. despite lack of a clear anatomic diagnosis. barium or water-soluble medium examination of the upper part of the gastrointestinal tract may demonstrate partial intestinal obstruction which may elude diagnosis by other means. They are usually unnecessary in patients with acute appendicitis or strangulated external hernias. so careful pelvic and rectal examinations are mandatory in every patient with abdominal pain. may provide valuable clues. It is of special^value in patients with blunt trauma to the abdomen.i. pelvis. pH Li-. Ur J Surg 7S:1178. eliciting rebound tenderness by sudden release of a deeply palpating hand in a patient with suspected peritonitis is cruel and unnecessary. but it should be used only for specific questions such as these. Narcotics or analgesics should be withheld until a definitive diagnosis or a definitive plan has been formulated. A normal white blood cell count is by no means rare in cases of perforation of abdominal viscera. of facies. watchful waiting with repeated questioning and examination will often elucidate the true nature of the illness and indicate the proper course of action. it may be abundantly clear to an experienced and thoughtful physician and surgeon that on clinical grounds alone operation is indicated. pelvic inflammatory disease. yet with but a few exceptions they rarely establish a diagnosis. great care must be exercised CHAPTER 10 QUANTITATIVE ASPECTS OF CLINICAL REASONING in denying an operation to a patient solely on the basis of an elevated serum amylase level. and a variety of other conditions. and acute cholecystitis. the presence of gallstones. Determination of the blood urea nitrogen. Since many diseases other than pancreatitis. Oxford Press. The chronological sequence of events in the patient’s history is often more important than emphasis on the location of pain. Furthermore. oral administration of barium sulfate should be avoided. A computed tomography (CT) scan may demonstrate an enlarged pancreas or a ruptured spleen. London. The urinalysis is also of great value in indicating to some degree the state of hydration or to rule out severe renal disease. Severe catastrophes.s All ct al: Ultrasonography m the acute abdomen. Since the irritable bowel syndrome is one of the most common causes of abdominal pain.g. and scrum bilirubin levels also may be helpful. A white blood cell count greater than 20. asks the proper questions. such as strangulating small intestinal obstruction or perforated appendicitis. If the examiner is sufficiently open-minded and unhurried. If there is any question of obstruction of the colon. Careful attention should be paid to the extraabdominal regions which may be responsible for abdominal pain. Auscultation of the abdomen is probably one of the least rewarding aspects of the physical examination of a patient with abdominal pain. A palpable gallbladder will be missed if palpation is so brusque that voluntary muscle spasm becomes superimposed on involuntary muscular rigidity. blood sugar.000/mm' may be observed with perforation of a viscus.

most sufferers report the contrary. first issue to resolve in confronting the patient who complains of headache is to make the distinction between benign and more ominous causes. severe. “Neuralgias" arc painful disorders characterized by paroxysmal. in contrast to its prior usage referring to an aggregation of certain symptoms. neck. cold. sharp cephalic pain.itingMone. duration. Migraine attacks build up over hours. it may properly be regarded as a Headaches that bear a relationship to certain biologic events or to physical environmental changes are essential data for triage of patients. A throbbing # quality and tight muscles about the head. Meningitis. such as brain tumor or giant. This phenomenon occurs with other centrally mediated pain syndromes. is always inconsistent. thunderclaplike. Contrary to common belief. yc *tscll is seldom the cause of aeulc orbital pain if die sclerae are while and not injcctcd. often electric shocklike episodes (hat are caused by dcmyelinativc lesions of nerves (the trigeminal or glossopharyngeal nerves in cranial neuralgias) that result in the activation of a CNS pain. A ruptured aneurysm results in head pain that peaks in an instant. It is important to make this context clear to the patient or else valuable information may be lost. especially the second and third trimesters. as in giant cell arteritis. brain tumors. When there is striking accentuation of pain with eye movement. • __ ' Duration and time-intensity curves of headaches are particularly useful. brief. Ouster headache attacks reach their peak over 3 to 5 min.” about 30 percent of the population. suggesting that intra. * GENERAL CONSIDERATIONS The quality. Head pain appearing abruptly after bending. photo. often occulting multifocally (ice picklike pain). Trigeminal and glossopharyngeal neuralgia are common causes of facial pain. teeth. It was formerly believed that tight “hat-band” headachep indicated anxiety or depression. or coughing can be the clue to a posterior fossa mass or the Arnold Chiari malformation. RASKIN Few of us arc spared the experience of head pain during our lifetimes. However. Headache is usually a benign symptom and only occasionally is the manifestation of a serious illness. organic odors. much less often. it is. There is no evidence that placebo responders have lower pain levels than nonresponders or do not really have pain. and then taper off. sustained exertion. provocation by hot. Headache arising de novo in a patient with known malignancy suggests cither cerebral mctastascs or carcinomatous meningitis. are maintained for several hours to days. If the Mturcc is an cxtracranial structure.CHAPTER 10 QUANTITATIVE ASPECTS OF CLINICAL REASONING 14 HEADACHE NEIL H. is the signature of a benign disorder. Activation of the mechanism by red wine and hunger. for reasons that are unclear. It simply identifies a “placebo responder.stci headache also produce intense cranial pain. Physicians should be cautious#ibout assessing pain intensity by visually inspecting a patient. the most common cause of facial pain by far is dental. the validity of the observation is in question. Similarly. Now Y«»tk. but one that is still referred in a regional distribution that is quite constant.” resulting in susceptibility to more frequent or more severe head pain. Intracranial lesions in the posterior fossa cause pain that is usually occipitonuchal. resulting in unnecessary neuroimaging. amelioration of headache during pregnancy. 43 normal aspect of living. remain at maximal levels for about 45 * min. and time course of the headache and the conditions that produce. location. disabling headache is reported to occur at least annually by 40 percent of individuals worldwide. eves. The application of a cold stimulus will repeatedly induce dental pain whereas in neuralgic disorders a refractory period usually occurs after the initial response so that pain cannot be repeatedly induced. indeed. and clu. Symptom Nausea Vomiting Diarrhea Photophobia Visual disturbances Ponilication s|>ccU'a Photopsia Paivsthi'sias Nvalp lomlciness Lighihcailetlness Vertigo Alteration of consciousness Sc i /. the headache produced by a brain tumor is not usually particularly or distinctively ftcvcrc. but docs not occur among patients with somatic disease as the cause of pain. a red eye is die sign ol ophthalmic disease.and phonophobia arc also more likely to be reported. A history of amenorrhea or galactorrhea should lead one to question whether the polycystic ovary syndrome or a prolactin. the »om with tin* mi«» of fairly precise Inflammation TABLE 14-1 Symptoms accompanying severe migraine attacks in 500 patients Percentage affected 87 56 16 82 36 10 26 33 65 72 33 18 4 4 11: Nil Kn tkm. Patients with continuous benign headaches often observe a pain-free interlude of several minutes upon awakening before head pain commences.ti iv Sytieiipc of an extrvemnfaf artery causes pain and cx tcmtiva iMrfmM to the site of the vessel. lifting. hunger. especially the former. The term migraine is used nowadays to refer to such a mechanism. The phenomenon is more likely to be ordinary than extraordinary. The mechanism generating such "benign” headaches may be activated by stress and anxiety. such as thalamic pain. Most headaches are dull. Prom tlu*' therapeutic perspective. and are characteristically relieved by sleep. M «t. purulent nasal exudate. Response to placebo nieilicaiion or procedures produces no useful injonnation— either diagnostic or therapeutic. of course. or relieve it should be carefully reviewed with the patient. and supratentorial lesions most often induce fronto.secreting pituitary adenoma is the source of headache. Sleep disruption is characteristic of headaches produced by The analysis of facial pain requires a disparate approach. The cessation oi.tcmporal pain. lack of sleep#weather change. patients commonly respond negatively to initial inquiries in the mistaken belief that because the relationships are not consistent. (Ii'inlull l. fleeting. and of aching character. exacerbate. Pain inii'iisity seldom has diagnostic value—in the head or in any other somatic location. it then follows that the mechanism for such a common Since headache is a ubiquitous symptom. is also pathognomonic of migraine. and menses. Patients entering emergency department with the most severe headache of their lives usually have migraine. I/re* 10 hnbr. and shoulder girdle arc common nonspecific accompaniments of headache. Orthostatic headache arises after lumbar puncture and also occurs with subdural hematoma and benign intracranial hypertension. mechanism.vbut investigations have not supported this view.mal Male generating mechanism« Certain maneuvers characteristically^ trigger paroxysms of pain.. acute sinusitus nearly always declares1 itself through a dark green. but emotional factors arc not necessary for thc#symptom to occur. or sweet foods is typical. This incidence. the more likely it is to be associated with nausea and to be cxpcricnccd as a pulsing or pounding discomfort.and cxtracranial arteries and skeletal muscle surrounding • the. Jabbing. ccll arteritis. The association of diarrhea with attacks (Table 14-1) is pathognomonic of a benign disorder (migraine). a systemic infection and particularly meningitis should be seriously considered. In attempting to elicit this information. for example. the single as|>ecl of pain that is most important. Inquiries as to how pain disturbs day-to-day function may extract more useful information. siihaiacltnoitl In'iuoiiliafc. Moreov er. and upper cervical vertebrae induce less sharply localized pain. unmptured aneurysms may signal their presence in the same way. there does no£ appear to be any utility in having headache. The more severe the headache. It is useful to clarify to the patient that it is of interest to learn about all the pain elements that have been experienced regardless of their frequency or intensity. # . Thq. People respond to pain in a variety of ways that range lrom overt histrionic behavior to stoicism. Superimposed on such nondescript pain may be other pain elements tfiat have greater diagnostic value.head and neck are activated by a generic head pain-generating. The following exacerbating phenomena make the benign nature of the syndrome highly probable: provocation by red wine. Lesions of paranasal sinuses. deeply located. IWX. This “ordinary” headache-generating mechanism appears to be influenced by hereditary factors that may “turn up the gain. The presence of refractory periods can nearly always be elicited in the history so that patients need not be put through a painful experience. occurs whether subjects live in large urban environments or in rural villages. Oat a rci'ardiii}* liHiiiimi of headachc may be informative. Ascertaining the quality of cephalic pain is occasionally helpful.

as in the pain resulting from scalded skin or appendicitis. Hcadachc can occur as the result of (I) distention. Vague. it is inexplicably and remarkably ameliorated by indomcthacin at doses ranging from 50 to 200 mg daily. This pattern of symptoms results from migraine far more often than from brain tumor. Thus most of the brain is insensitive to electrode probing.migraine with dramatic local neurologic features. or visual symptoms.# continuous facial pain is characteristic of the condition that may result from nasopharyngeal carcinoma and other somatic diseases.sensitive cranial structures/The following are sensitive to mechanical Simulation: the scato and^aponeurotica. or the hcadacbes that are so common in febrile illnesses and systemic lupus erythematosus. mechanism underlies these varying headache profiles is not entirely clear and remains to be investigated further. and is associated with nausea and vomiting. or from benign intracranial hypertension after the pressure is reduccd. or exeil If action on vessels. Hashimoto’s thyroiditis. and purulent sinusitis. and the proximal segments of the large pial arteries/The ventricular ependyma. or encroachment upon pain. PRINCIPAL CLINICAL VARIETIES OF HEADACHE Normally there is little difficulty in diagnosing the headache of „ glaucoma. (filial sliut fines. such patients have sometimes had their syndromes categorized as “atypical facial pain” as if this were a well-defined clinical entity. there is a hereditary predisposition toward attacks. are very abrupt in onset. It is by far more common in women. Hemicra. Many patients with migraine note that attacks of headache may be provoked by sustained physical exertion. It has become clear that severe headache attacks. or the taste of the food that elicits pain? Chewing points toward trigeminal neuralgia. In the first instance. a burning painful element often supervenes as dcaffcrcntation occurs and evidence of cranial neuropathy appears. sneezing. motor.serotonergic projections. may originate from either mechanism. Such headaches build up over hours. the probability of finding a potentially serious cause is considerably greater than in the second. if they persist for hours or are accompanied by vomiting. “Facial pain of unknown cause'' appears to be a more reasonable tentative diagnosis than “atypical facial pain. The headache syndromes described below should be considered (see Table 14-2).s ol 40 and 70 year*. lifting. CHAPTER 10 QUANTITATIVE ASPECTS OF CLINICAL REASONING Many patients with the complaint oT facial pain do not describe stereotypic syndromes. subarachnoid hemorrhage must be excluded through a CSF examination and CT scanning. Head pain persists for seconds to a few minutes. It is wlien headache is chronic. occurs intermittently. ovulation. glaucoma. but a particular midbrain site is nevertheless a putative locus for hcadachc generation Sensory stimuli from the head arc conveyed to the central nervous system via the trigeminal nerves for structures above the tentorium in the anterior and middle fossae of the skull and via the first three cervical nerves for those in the posterior fossa and infradural structures. vomiime. The passage of time has proved this to be a misleading designation for a condition manifested by latcralizcd head pain in less than 60 percent of those affected. regardless of cause. bacterial meningitis. intracranial masses cause headache when they deform. The ninth and lentil cranial nerves supply part of the posterior fossa and refer pain to the ear and throat. glucocorticoid withdrawal. . distinctly different from the cough headache syndrome. By and large. Many patients date the origins of the syndrome to a lower respiratory infection accompanied by severe coughing or to strenuous weight-lifting programs. Furthermore.promoting medications. Magnetic resonance imaging is indicated for most of these patients. Focal neurologic disturbances without hcadachc or vomiting have come to. Occasionally. Cough headache One of the male-dominated (4:1) syndromes. inflammation. pial veins. and trauma lo cranial and cervical inuuln. displace.'' PAIN-SENSITIVE STRUCTURES OF THE HEAD The most common type of pain is that resulting from activation of peripheral nociceptors in the presence of a normally functioning nervous system. in parallel with most painful conditions. Perturbation of intracercbral serotonergic projections has. the latter is by far the most frequent clinical problem.nia was later corrupted into low Latin as hemigranea and migranea\ eventually the French translation. athus overlapping with classic migraine: it has also been used to connote a persisting neurologic dcficit that is a residuum of a migraine attack. falx cerebri. bandlike discomfort often involving the entire . Another type of pain is the result of injury or activation of the peripheral or central nervous system. The term effort migraine has been used for this syndrome to avoid the ambiguous term exertional headache. the prevalence of migraine among the elderly is substantial. Hie term complicated migraine has generally been used to describe. inflammatory bowel disease. lumbar racrani a|ve i n s o r t h c i r d u r a I envelope. in a few minutes if coitus is interrupted. middjejmeningeal artery. of moderate intensity. temporomandibularjoint dysfunction i or giant cell arteritis (“jaw claudication’’). considerably higher than giant cell arteritis. The last two examples are the exceptions to the generalization that hypertension per sc is a very uncommon cause of headache. necessitating periodic follow-up until further clues appear (and they usually do). the swallowing. is worsened by exertion or change in position.be known as migraine equivalents or accompaniments and appear to occur more commonly in patients between the agi. whereas swallowing and taste provocation points toward glossopharyngeal neuralgia. However. are more likely to be described as throbbing an<^ associated with vomiting and scalp . some illnesses arc characteristically associated with headache. 43 Clinical subtypes The designation classic migraine (migraine with aura) denotes the syndrome of headache associated with characteristic premonitory sensory. severe headache with stiff neck and fever means meningitis and without fever means subarachnoid hemorrhage. and subside. poorly localized. and relief by dark surroundings and sleep. a deep. chronic pulmonary failure with hypercapnia (early morning headaches). dural sinuses. and the acute blood pressure elevations that occur in pheochromocytoma and in malignant hypertension. gained acceptance in the eighteenth century and has prevailed ever since. recurrent. These are nearly always benign events and usually occur sporadically. A working definition of migraine offered here is benign recurring headache and/or neurologic dysfunction usually attended by pain-free interludes and almost always # provoked by stereotyped stimuli. or stooping. choroid plexus. Headache. Milder headaches tend to be nondescript—tight. subarachnoid hemorrhage.head — the profile of '‘tension headache. (5) meningeal irritation and raised intracranial pressure: and (6) perturbation of intracerebraf . and the cranial drculatory phenomena that attend attacks appear to be secondary to a primary CNS disorder. severe head pain upon coughing. Hcadachc alone is nondescript. fcain upon swallowing is common among patients with/carotidynia) (facial migraine. bending. or inflammation of cranial and spinal nerves. Brain tumor headache About 30 percent of patients with brain tumors consider headache to be their chiefi complaint. formerly believed to originate peripherally. oi cranial nerves al (lie base ol the brain* this often happens long before intracranial pressure rises. (3) compression. The benign disorder may persist for a few years. Headache caused by systemic illness"* There is hardly any illness that is never manifested by headache. tender carotid artery abuts the esophagus during deglutition. Headache is usually diffuse but is lateralized in about one-third of patients. dull ncniug quality.s a common cause. Is it the chewing. photophobia* recurrence at regular intervals. migraine. traction.aura) denotes one in which them is no focal neurologic disturbance preceding the occurrence of headache. Whether a single common. The head pain syndrome is nondescript. There is only scant evidence that nondescript facial pain is caused by emotional distress. undue emphasis on the dramatic features of migraine has often led to the illogical conclusion that periodic hcadachc#lacking such features is not migrainous in mechanism. systemic lupus erythematosus. Suefi mechanical displacement nicelianisms do mil explain (he headaches resulting from cerebral ischemia. the cause of a pain problem cannot be resolved promptly. The incidence of serious intracranial structural anomalies causing thisj condition is about 25 percent. Coital headache Another male-dominated (4:1) syndrome. electric^'stimulation near midbrain dorsal raphe cells has resulted in migrainelikc headaches. as has sometimes been alleged. com/hon migraine (migraine without. ancTmuch o f m e brain parenchyma jire pain^lnsensitivcjOn the other hand. and unattended by other important signs of disease that the physician faces a challenging but ultimately gratifying medicaJ problem. however. and focul neurologic disturbances arc more common during headache attacks than as prodromal symptoms. purulent sinusitis. These include infectious mononucleosis. attacks occur periorgasmically. M) Spasm. traction.’’ These differing clinical profiles of headaches that are not caused by an intracranial structural anomaly g or systemic disease probably represent different points on a continuum rather than disparate clinical entities.Mealtimes offer the physician an opportunity to gain needed insight into the mechanism of a patient's facial pain. APPROACH TO THE PATIENT WITH HEADACHE Entirely different diagnostic possibilities are raised by a patient who presents with the first severe headache ever and a patient who has had recurrent headache over many years. and brain tumor because of the clues provided by the associated symptoms and signs. (2) traction or displacement of 1 arge J n t tenderness. Headache may arise from dysfunction. Headache disturbs sleep in about 10 percent of patients. been posited as a possible mechanism for these phenomena. some of the causes that should be considered include meningitis. it is characterized by transient. when confronted with such a patient. MIGRAINE. diastolic pressures of at least 120 mmHg are requisite for hypertension to cause headache. displacement. Vomiting that precedes the appearance of headache by weeks is highly characteristic of posterior fossa brain tumors. The term migraine stems from Galen's usage of liemierania loyicscribc a periodic disorder comprising paroxysmal blinding heitiicramal pain. the ArnokJ-Chiari malformation i. epidural or subdural hematoma. In general. oral contraceptives. many of the HIV-associatecUllnesses. acute. sec below) because the inflamed. or dilation of intracranial or extracrania! arteries. such as during the third mile of a 5-mile run.

et al: Incidence of migraine headache: A population-based study in Otmsled (Anility. and protect the vertebral column. Neurology 42:1657. as well as the paraspinal muscles and fascia. and the neurologic and psychological evaluation. L = lamina. 2d ed. 1992. muscles. Churchill Livingstone. abdominal.se Brain Metab Rev 3:1. there is a greater-than. Neurology 42:1225. Acute persistent headache and fever is often the manifestation of an acute systemic viral infection. Stout transverse and spinous bony processes project laterally and posteriorly and serve as the attachments of nfuscles which move. Cerebrova. 1976 r/ cl al: Pain mechanisms underlying vascular hcadachcs. 1991 JE: Subcutaneous sumatriptan in cluster headache —A time study of the eflect on pain and autonomic symptoms. The stability of the spine depends on. Involvement of structures that contain no sensory endings is painless. intraocular pressure measurement and refraction. Headache 30:197. 1992 PJ. anterior dura. The pain may radiate to the head but is not easily confused with headache per se. 1980 REFERENCES The bony spine is anatomically divisible into two parts. and epidural veins. The central. two types of support: that provided by the bony articulations (principally by the diskal joints and the synovial articulations of the posterior elements) and a second type provided by the ligamentous (passive) and muscular (active) supporting structures. SP: Sumatriptan. Vinken PJ. Drugs 43:776. The ligamentous structures arc quite strong. J Neurol Neurosurg Psychiatry 39:1226. Many patients in chronic daily pain cycles become depressed. Pain 52:193 1993 D: Benign sexual headache within a family. AL: Localization of 3 H-dihydroergoiamine-binding sites in the cm ccntral nervous system: Rclevance tu migraine. Fortunately. annulus iibrosus. Klawans HI. (eds): Handbook of Clinical Neurology. The sinu vertebral nerve reenters (he spinal canal through the intervertebral foramen to provide sensory innervation to the posterior longitudinal ligament. including the psychiatric assessment. L: The trigeminovascular system and migraine—Studies characterizing ccrchrovascular and neuropeptide changes seen in humans and cats. The other major nerve supply to the spinal and paraspinal structures arises from the posterior primary ramus. (Adapted from DD Levine. Med Clin North Am 77:141. in Arthritis and Allied Conditions: A Textbook of Rheumatology. Minnesota. if the neck is supple in such a patient. but bccausc neither they nor the vertebral body-disk complexes have sufficient integral strength to resist the enormous forces acting on the column during even simple movements. 1992 Si AND PI. MANKIN / LAWRENCE F. lumbar puncture may be deferred. whereas cortical fractures or tears and distortions of the periosteum. and( hamstring muscles afford much of the stability. which is considered the major sensory nerve supply to the structures of the lumbar spine. Ann Neurol 29:91. nervous system by The adolescent with chronic daily frontal or holoccphalic headache represents a special type of problem. and hence are most frequently subject to injury. 1992 Sjaastad O: Cluster Headache Syndrome. Butterworth Scientific. drugs with antidepressant actions are effective in migraine also. Lancet: 339:1202. the cervical spine by the effect oJ' passive movement of the bead and imaging. 1988 RASMUSSEN BK. Rev Neurol (Paris) MS: 181. Local pain is caused by any pathologic process that impinges on or irritates sensory endings. A review. the upper three lumbar spinal nerves provide cutaneous sensation to the skin of the low back. On the other hand. 1992 R et al: Muscle tenderness and pressure pain thresholds in headache—A population study. London. Isa Hrhigcr. SF = superior articular facet. London. SP . which together with ligamentous structures form the vertebral canal. Arch Neurol 43:1158. all within the spinal canal. Philadelphia. P = pedicle. many actions ol I lie spine are reflex in nature and are the basis of posture. joint dysfunction is an example. the cycle has usually ended. B ~ body. radicular. synovial membranes. DJ McCarty (ed). 1992. In addition. FISHMAN RA: Spontaneous intracranial hypotension. CHAPTER 10 QUANTITATIVE ASPECTS OF CLINICAL REASONING ANATOMY AND PHYSIOLOGY OF THE LOWER PART OF THE BACK 43 When the signature of migraine has not clarified the cause of recurring headache. local. Neurology 42:1118. without evocation of pain. 1961 JN: Migraine: Theories of pathogenosis. for example. 1991 RANDO TA. GENERAL CLINICAL CONSIDERATIONS TYPES OF LOW BACK PAIN Four types of pain may be differentiated. Ann Neurol 33:48. Treatment of the headache problem is largely ineffectual until the cause of the primary pain problem is dealt with. Bkuyn GW. a note on recurring headache that may be pain-driven. The anterior part consists of a scries of cylindrical vertebral bodies connected to one another by the intervertebral disks and held tightly together by the anterior and posterior longitudinal ligaments.spinous process. New York. it produces preauricular pain that is associated with chewing food. moreover.Kevin Science. 15-1). psoas. Brain Cogn 21:181. but fever would be a rare associated Icaturc. in general. Saunders. 5th ed. Thus pain about the head as the result of somatic disease or trauma may reawaken an otherwise quiescent migrainous mechanism. external portions of the posterior annulus fibrosus. 10th ed. Temporomandibular. Extensive diagnostic batteries are most often unrevealing.: Headache. including the facet joints.) Moskowi MA I In' parts of |hi' back that |m»sscss the greatest frivilom of movement. arises from the spinal nerve prior to its division into an anterior and posterior ramus. Right: Lateral view of two articulated lumbar vertebrae. The posterior primary ramus of the spinal nerve further divides into medial and lateral branches. TP = transverse process. 1993 ----. /9H5. IVF — intervertebral foramen. twisting. IF = inferior articular facet. vol 48: Iti'iidarlir Amsterdam. 1990 ------. medullary portion of the vertebral body may be destroyed by tumor. Prog Drug RES 34:209. 1993 RL: Identification and treatment of cerebral aneurysms after sentinel headache. Oli-sen J: Symptomatic and nonsymptomaiic headaches in a general population. the cranial arteries by palpation. a not unreasonable sequence of events. The physician should be cautious about assigning depression as the cause of recurring headache.: Lumbar puncture headache:. referred. 1992 RASKIN NH: Pharmacology of migraine. The sinuvertebral nerve. 1990 ----. 1986 Mechanism and Management of Headache. Headache 33:18.puncture is mandatory. 1993 JR: Headache to worry about. 1993 KL. headache disorders may be activated by the pain attending otological or endodontic surgical procedures. Neurology 42:481. the headaches tend to sfop after a few years so that structured analgesic support can enable these teenagers to move through secondary school and enter college. Similarly. I. 1993 PJ. The posterior elements are joined to adjacent vertebrae by two small facetal synovial joints which allow a modest degree of motion between any two segments but in aggregate produce a rather extensive range (Fig. dura of the nerve root sleeve. The relationship of head pain to depression is not straightforward. The vertebral and paravertebral structures are innervated by branches of the segmental spinal nerves that exit the neural foramina at each spinal level. DB: Visual field effects of classical migraine. Studies of large populations of depressed patients do not reveal headache prevalence rates that are different from the general population. SC = spinal canal. and other movements. FIGURE 15-1 Left: Superior view of a stripped lumbar vertebra. and that arising from secondary (protective) muscular spasm. Lancet 1:15. voluntary and reflex contractions of the sacrospinalis.: Headaches related to sexual activity. In addition to (he voluntary motion* required lor bending. Finally. By the time they reach the late teens. one should consider the investigation of cardiovascular and renal status by blood pressure and urine examination. eyes by fundoscopy. headache-prone patients may observe that headaches are more frequent and severe in the presence of a painful temporomandibular joint problem. There is always the possibility of a first attack of migraine. BORGES . gluteal. arc the lumbar and cervical regions.chancc coincidence of migraine with both bipolar (manic depressive) and unipolar depressive disorders. Together these nerves supply the posterior parts of the spine. The latter structures arc 15 BACK AND NECK PAIN HENRY J. support. 1989 OLESEN J: Cerebral and extracranial circulatory disturbances in migraine: Pathophysiological implications. and ligaments arc often exquisitely painful. Bickekstakf Blau Boles Couch Dechant Clissold Goadshy Edvinsson Goadsiiy Gundlacii Hakdebo Hughes Jensen Johns Lance JW: ER: Basilar artery migraine. The posterior part consists of more delicate elements that extend from the vertebral body as pedicles and broaden posteriorly to form laminae.

although of deep. The mechanisms arc principally disttMliou. An important exception to this is pain caused by an aortic aneurysm. Pain of this type. Also. stretching. or “root. and may be modified by the activity of the involved viscus. (hat from the lower lumbar and sacral segments js referred to the gluteal regions. In other words. which is of aid in identifying the site of the abnormality.” pain has sonic of the characteristics of referred pain but differs in its greater intensity. maneuvers that alter local pain have a similar effect on referred pain. Pain due to diseases of the upper pari of Ihc lumbar spine is usually referred to th<f anterior aspects of the thighs and legs." pain. the referred pain parallels in intensity the local pain in the back. does not improve with recumbency. or “root. eliciting a lancinating quality. calves. though not with such precision and immediacy as in radicular. sneeze. posterior thighs. Firm pressure or percussion on superficial structures in the region involved usually evokes tenderness. it has been suggested that in patients with spinal stenosis the “lumbar claudication" pattern may be due to a relative ischemia associated with compression. irritation. circumscription to the territory of a root. Referred pain may be confused with pain from visceral disease. Referred pain is of two types: that projected from the spine into regions lying within the area of the lumbar and upper sacral dermatomes and that projected from the pelvic and abdominal viscera to the spine. this may not be apparent if a deep structure of the back is (he site ol disease. Certain movements or postures that alter (he position of the injured tissues aggravate the pain. Reflex splinting of the spine segments by paravertebral muscles is frequently noted and may produce deformity or postural abnormality. aching quality and rather diffuse. varying considerably with position oi^activity^JEhc pain may hr sharp ordull and although often diffuse is always felt in or near the affected part of the spine. and sometimes feet.CHAPTER 10 QUANTITATIVE ASPECTS OF CLINICAL REASONING innervated by afferent fibers of the posterior primary rami and ihc sinu vertebral nerve. most often central to the intervertebral foramen. Nearly always the radiation of pain is from a central position near the spine to some part of the lower extremity. In addition. Radicular. various maneuvers which increase the irritation of the root or stretch it may greatly intensify the pain. and compression of a spinal root. and strain are characteristic evocative maneuvers. visccral pain is usually unaffcctcd by movement of the spine. Local pain is often described as steady but may be intermittent. Cough. but since they njay also jar or move the spine. A slowly enlarging aortic aneurysm may erode the anterolateral spine and produce discomfort that changes with movement or recumbency. and the factors which excite il (Table 15-1). Although the pain itself is often dull or aching. Although painful . they may aggravate local pain as well/Forward bending with the knees extended 43 . but the latter is usually described as “deep” and tends to radiate from the abdomen through to the back. In general. distal radiation.states are often accompanied by swelling of the affected tissues. tends at times to be superficially projected.