? Because of this convergence and the fact that the spinal
neurons are most often activated by inputs from the skin,
activity evoked in spinal neurons by input from deep
structures is mislocalized by the patient to a place that is
roughly coextensive with the region of skin innervated by
the same spinal segment
? Coronary ischemic pain usually radiates to medial side
of arm and fingers,which were supplied by 6th~8th
cervical (or T1~T2) over the left side
Referred pain
The convergence-projection hypothesis of
referred pain
Pain modulation
?Brain circuits modulate the activity of the pain-
transmission pathways
?One circuit has links in the hypothalamus,
midbrain,and medulla
?It controls spinal pain-transmission neurons
through a desending pathways
?It is bidirectional
produce analgesia or increase pain
Transmission system for nociceptive messages
Pathophysiology
?Different organs may respond to different stimuli
GI system,sensitive to inflammation,ischemia,spasm
insensitive to cutting
heart,sensitive to acute ischemia
?Integumentary stimuli at lowest level of intensity,
evoke sensations of touch,pressure,warmth and cold
?Noxious stimuli increased to the point
approaching tissue destruction,pain is added
Clinical characteristics
?Character of pain
spastic pain,intermittent
inflammatory,persisting
? Localization of pain,
usually in the diseased part
it may be referred
Clinical characteristics
?Quality and intensity of pain
peptic ulcer,gnawing burning
anginal pain,distress,dull pain whith heavy quality
The following are important,
severity duration frequency
special time of occurrence
Clinical characteristics
?Referred pain
?Aggravating and relieving factors
anginal pain,provoked by exertion,cold,
emotional upset
relieved by rest,nitroglycerine
ulcer pain,relieved by ingestion of food
Headache
?Unpleasant sensations in the regions of cranial
vault,usually reflects as a symptomatic expression
of disease or some minor tension of fatigue
?It may also reflect serious disease intracranially
? 90% of individuals have at least one headache per
year
Etiology
?Intracranial disease
?Extracranial disease
?Systemic disease
?Neurosis
Intracranial disease
?Infection,encephalitis (脑膜炎 )
?Vascular disease,cerebral accident
?Tumor
?Cranial injury,concussion of brain （ 脑震荡 ）
varying combination of headache,dizziness,vertigo,
impaired memory,irritability and difficulty with
concentration
?Others,migraine （ 偏头痛 ）
cluster headache （ 丛集性头痛 ）
Extracranial disease
?Bone disease,osteoarthritis of cervical spine
?Neuralgia,trigeminal neuralgia
（三叉神经痛）
?Disease of head organs,
eye nose ear teeth
Systemic disease
?Systemic infection
?Cardiovascular disease,hypertension
?Intoxication,carbon monoxide
?Heatstroke
?Others,premenstrual tension
chronic disease
Clinical manifestation
?Onset
acute infection,acute onset with fever and
severe headache
cerebral or subarachnoid hemorrhage,acute onset
without fever
brain tumor,chronic persistent
migraine,recurrent
Clinical manifestation
?Localization
diseased part usually referred to ipsilateral side
? Most tension-type headaches are described as
tight,bandlike” pain or as dull deeply located,and
aching pain
Clinical manifestation
?Severity,
Most severe forms,migraine （ 偏头痛 ）
trigeminal neuralgia (三叉神经痛 )
meningeal irritation （ 脑膜刺激 ）
The head pain in brain tumor is of moderate
intensity,headache in vascular disease or infectious
disease is usually striking,
?Occurrence
brain tumor,persistence
Clinical manifestation
?Provocation and relieving
brain tumor,increased during cough
associated with nausea and vomitting
migraine,relieved after ergot（ 麦角 ） derivative
or by sleep
?Associated symptoms
vomiting,increased intracranial pressure
acute headache with mental disturbance,
subarachnoid hemorrhage
Clinical manifestation
?Acute,severe headache with stiff neck but
without fever suggests subarachnoid hemorrhage,
?Persistent headache and fever are often the
manifestations of an acute systemic viral infection,
Diagnostic points
? Detailed history and physical examination are
always important
? The quality,location,during,and time course of
the headache and the conditions that produce,
exacerbate,or relieve it should be carefully reviewed
? Spinal fluid tests sometimes are needed
? CT scanning is indicated in some cases
Chest pain
Etiology and pathogenesis
?Diseases of chest wall
Herpes zoster costal chondritis chest wall tumor
?Cardiac and blood vessel causes
myocardial ischemia myocarditis pericarditis
?Respiratory diseases
pleuritis pneuminoa pulmonary emboli lung cancar
?Mediastinal diseases mediastinitis
?Gastrointestinal origin
esophageal reflux spasm Mallory-Weiss tear
Clinical manifestations
? Age of onset,
young/middle aged,TB pleuritis pneumothrox
myocarditis
Over 40 years,angina pectoris myocardial infarction
lung cancer
Clinical manifestations
?Localization
herpse zoster,blister along the intercostal nerve
chondritis,with local tenderness of bone
pericarditis,a sharp or aching pain in the procordium
esophageal reflux,midline epigastric discomfort
myocardial infarction,in the left chest
Clinical manifestation
?Quality
intercostal neuralgia,prickling pain and local tenderness
angina,with precordial distress
myocardial infarction,nonlocalized pressure,ache,burning
intensity ranges from severe pain to minimal discomfort
Clinical manifestation
? Pain (or discomfort) due to myocardial ischemia occurs
when the oxygen supply to the heart is deficient in relation
to the oxygen need,
? The most common underlying cause of myocardial ischemia
is obstruction of coronary arteries by atherosclerosis; in the
presence of such obstruction,transient ischemic episodes
are usually precipitated by an increase in oxygem demand
as a result from psychological stress,fever,or large meals
or from compromised oxygen delivery due to anemia,
hypoxia,or hypotension,
Clinical manifestation
?Factors related to chest pain
angina,induced after effort or mental stress
relieved by nitroglycerine
pneumothorax,made worse by breath and
nonproductive cough
Esophageal reflex,induced after meals or supine position
relieved by antacids
antagonist
?Associated symptoms,bronchitis with cough
Lung cancer with bloody sputum
Diagnostic points
? Detailed history,onset quality localization
provocating factors
associated symptoms
? Physical examination,neck lymph nodes
chest examination
? Laboratory check up,sputum
chest X-ray film
Abdominal pain
?Acute abdominal pain
?Chronic abdominal pain
Acute abdominal pain
Etiology and pathogenesis
?Parietal peritoneal inflammation
bacterial contamination chemical irritation
?Acute inflammation of abdominal organs
gastritis enteritis
?Mechanical obstruction of hollow viscera
obstruction of the small or large intestine
Acute abdominal pain
Etiology and pathogenesis
?Vascular disturbances
embolism vascular rupture
?Referred pain
pneumonia coronary occlusion
?Abdominal wall
trauma
?Metabolic and toxic causes
allergic factors
Mechanisms of abdominal pain
? Visceral pain
? Somatic pain
? Referred pain
Visceral pain
? Results from stimulation of autonomic nerves
in the visceral peritoneum which surrounds
internal organs
? The message may be transferred into the spinal
cord via sympathic route
Clinical presentation of visceral
pain
? Pain poorly localized
? Intermittent,crampy or colicky pain
? Accompanied by nausea,vomitting and diaphoresis
Somatic pain
? Stimuli occurs with irritation of parietal peritoneum
? Sensations conducted along peripheral nerves
which can localize pain better
Clinical presentation of somatic
pain
? Precisely localized pain
? Pain described as intense,constant
? With local guarding or rigidity
? Getting worse after coughing or position changes
? May be caused by infection,chemical irritation,or
other inflammatory process
Referred pain
? Pain felt at a distance from its source
? The nerves distribution and visceral organs are
listed in text book (page 37)
Clinical manifestation
?Localization
Tenderness over the diseased organ
Obstruction of small intestine,periumbilical(脐周 ）
supraumbilical（ 脐上 ）
Obstruction of large intestine,infraumbilial area （ 脐下 ）
acute distention of gallbladder,right upper quadrant with
radiation to the right posterior region of the thorax
or the tip of the right scapula （ 肩胛 ）
Clinical manifestation
?Quality and severity
Perforation,severe dull pain over abdomen
Obstruction of hollow abdominal viscera,intermittent
colicky
Intraabdominal vascular disturbances,
sudden and catastrophic in nature
Acute pancreatitis,severe,steady upper,abdominal pain
Clinical manifestation
? Provocation and relief
Acute gastritis and enteritis,eating unfresh or raw foods
vomiting or discharge
Peritoneum inflammation,accentuated by pressure
palpation movement coughing
IBS and constipation,relieved temporarily by bowel
movements
Obstruction,relieved temporarily by vomiting
Ulcer,eating or taking antacids
Clinical manifestation
?Associated manifestations
Fever,inflammation
Jaundice,liver gallbladder pancreatic disease
Hematuria,renal stone
Diarrhea/rectal bleeding,intestinal causes
Differentiation of three colicky
pain
Type Location Other manifestation
Intestinal periumbilical vomiting,nausea
infraumbilical diarrhea,bowel sounds
Biliary right upper jaundice fever
quadrant Murphy’s sign
Renal ipsilateral flank changes in urine test
radiate to genitalia hematuria
groin,scrotum
Diagnostic points
?Pain referred to the abdomen should be
differentiated
?An accurate menstrual history in a female patient
is essential
?Much attention has been paid to the presence or
absence of peristalic sounds,their quality and their
frequency
? PQRST,provocative-palliative factors quality
region severity temporal characteristics
Chronic abdominal pain
Etiology and pathogenesis
? Chronic inflammation of abdominal organs
reflux esophagitis chronic ulcerative colitis
? Peptic ulcer
? Distention of visceral surfaces
? Metabolic and toxic causes uremia
? Infiltration of tumor
? Neurogenic irritable colon neurosis
Clinical manifestation
? Past history
? Localization
? Quality
? Pain and position of the body
Ptosis （下垂） of stomach or kidney,
pain when standing for long time
? Associated symptoms
Chronic infection lymphoma malignant tumor,fever
esophagus stomach billary tree,vomiting
Back pain
? The annual societal cost of back pain in the US
is estimated to be between $ 20 and $ 50 billion
? Back symptoms are the most common cause of
disability in patients under 45 years of age
? 50% of working adults,in one survey,admitted
to having a back injury each year
? Approximately 1% of the U.S,population is
chronically disabled because of back pain
Causes of back pain
? Congenital anomalies of the lumbar spine
spondylolysis
? Trauma
? Sprains and strains
? Vertebral fractures
? Lumbar disk disease
? Others causes of low back pain
spinal stenosis neurogenic claudication
facet joint hypertrophy lumbar adhesive arachnoiditis
Causes of back pain
? Arthritis,spondylosis ankylosing spondylitis
? Other destructive disease,
neoplasm infection osteoporosis osteoclerosis
? Referred pain from visceral disease
low thoracic and upper lumber pain in abdominal disease
lumbar pain with lower abdominal disease sacral pain in
gynecologic and urologic disease
? Postural back pain
? Psychiatric disease
? Unidentified
Clinical manifestation
? Low back pain the diseased part affected most
? Dysfunction the motion restriction
? Abnormality shortened spine
Arthralgia
? Joint pain affects one or more joints
? Caused by many types of injuries or conditions
Common causes of arthralgia
? Autoimmune diseases,rheumatoid arthritis SLE
? Osteoarthritis,bursitis
? Serum negative spinal-arthrosis
? Metabolism and endocrinology,gout
? Infection,Septic arthritis osteomyelitis tendonitis
? Tumor
? Osteo-arthrosis assiciated with joint manifestation
? Degenerative neuropathy
? Trauma,fractures hemarthrosis
? Others,pseudoarthralgia
Clinical manifestation of
arthralgia
? Joint pain
? Joint swelling
? Redness and warmth of diseased joint
? Stiffness of joint or morning stiffness
? Joint deformity
? Motion restriction of the affected joint
? Friction
neurons are most often activated by inputs from the skin,
activity evoked in spinal neurons by input from deep
structures is mislocalized by the patient to a place that is
roughly coextensive with the region of skin innervated by
the same spinal segment
? Coronary ischemic pain usually radiates to medial side
of arm and fingers,which were supplied by 6th~8th
cervical (or T1~T2) over the left side
Referred pain
The convergence-projection hypothesis of
referred pain
Pain modulation
?Brain circuits modulate the activity of the pain-
transmission pathways
?One circuit has links in the hypothalamus,
midbrain,and medulla
?It controls spinal pain-transmission neurons
through a desending pathways
?It is bidirectional
produce analgesia or increase pain
Transmission system for nociceptive messages
Pathophysiology
?Different organs may respond to different stimuli
GI system,sensitive to inflammation,ischemia,spasm
insensitive to cutting
heart,sensitive to acute ischemia
?Integumentary stimuli at lowest level of intensity,
evoke sensations of touch,pressure,warmth and cold
?Noxious stimuli increased to the point
approaching tissue destruction,pain is added
Clinical characteristics
?Character of pain
spastic pain,intermittent
inflammatory,persisting
? Localization of pain,
usually in the diseased part
it may be referred
Clinical characteristics
?Quality and intensity of pain
peptic ulcer,gnawing burning
anginal pain,distress,dull pain whith heavy quality
The following are important,
severity duration frequency
special time of occurrence
Clinical characteristics
?Referred pain
?Aggravating and relieving factors
anginal pain,provoked by exertion,cold,
emotional upset
relieved by rest,nitroglycerine
ulcer pain,relieved by ingestion of food
Headache
?Unpleasant sensations in the regions of cranial
vault,usually reflects as a symptomatic expression
of disease or some minor tension of fatigue
?It may also reflect serious disease intracranially
? 90% of individuals have at least one headache per
year
Etiology
?Intracranial disease
?Extracranial disease
?Systemic disease
?Neurosis
Intracranial disease
?Infection,encephalitis (脑膜炎 )
?Vascular disease,cerebral accident
?Tumor
?Cranial injury,concussion of brain （ 脑震荡 ）
varying combination of headache,dizziness,vertigo,
impaired memory,irritability and difficulty with
concentration
?Others,migraine （ 偏头痛 ）
cluster headache （ 丛集性头痛 ）
Extracranial disease
?Bone disease,osteoarthritis of cervical spine
?Neuralgia,trigeminal neuralgia
（三叉神经痛）
?Disease of head organs,
eye nose ear teeth
Systemic disease
?Systemic infection
?Cardiovascular disease,hypertension
?Intoxication,carbon monoxide
?Heatstroke
?Others,premenstrual tension
chronic disease
Clinical manifestation
?Onset
acute infection,acute onset with fever and
severe headache
cerebral or subarachnoid hemorrhage,acute onset
without fever
brain tumor,chronic persistent
migraine,recurrent
Clinical manifestation
?Localization
diseased part usually referred to ipsilateral side
? Most tension-type headaches are described as
tight,bandlike” pain or as dull deeply located,and
aching pain
Clinical manifestation
?Severity,
Most severe forms,migraine （ 偏头痛 ）
trigeminal neuralgia (三叉神经痛 )
meningeal irritation （ 脑膜刺激 ）
The head pain in brain tumor is of moderate
intensity,headache in vascular disease or infectious
disease is usually striking,
?Occurrence
brain tumor,persistence
Clinical manifestation
?Provocation and relieving
brain tumor,increased during cough
associated with nausea and vomitting
migraine,relieved after ergot（ 麦角 ） derivative
or by sleep
?Associated symptoms
vomiting,increased intracranial pressure
acute headache with mental disturbance,
subarachnoid hemorrhage
Clinical manifestation
?Acute,severe headache with stiff neck but
without fever suggests subarachnoid hemorrhage,
?Persistent headache and fever are often the
manifestations of an acute systemic viral infection,
Diagnostic points
? Detailed history and physical examination are
always important
? The quality,location,during,and time course of
the headache and the conditions that produce,
exacerbate,or relieve it should be carefully reviewed
? Spinal fluid tests sometimes are needed
? CT scanning is indicated in some cases
Chest pain
Etiology and pathogenesis
?Diseases of chest wall
Herpes zoster costal chondritis chest wall tumor
?Cardiac and blood vessel causes
myocardial ischemia myocarditis pericarditis
?Respiratory diseases
pleuritis pneuminoa pulmonary emboli lung cancar
?Mediastinal diseases mediastinitis
?Gastrointestinal origin
esophageal reflux spasm Mallory-Weiss tear
Clinical manifestations
? Age of onset,
young/middle aged,TB pleuritis pneumothrox
myocarditis
Over 40 years,angina pectoris myocardial infarction
lung cancer
Clinical manifestations
?Localization
herpse zoster,blister along the intercostal nerve
chondritis,with local tenderness of bone
pericarditis,a sharp or aching pain in the procordium
esophageal reflux,midline epigastric discomfort
myocardial infarction,in the left chest
Clinical manifestation
?Quality
intercostal neuralgia,prickling pain and local tenderness
angina,with precordial distress
myocardial infarction,nonlocalized pressure,ache,burning
intensity ranges from severe pain to minimal discomfort
Clinical manifestation
? Pain (or discomfort) due to myocardial ischemia occurs
when the oxygen supply to the heart is deficient in relation
to the oxygen need,
? The most common underlying cause of myocardial ischemia
is obstruction of coronary arteries by atherosclerosis; in the
presence of such obstruction,transient ischemic episodes
are usually precipitated by an increase in oxygem demand
as a result from psychological stress,fever,or large meals
or from compromised oxygen delivery due to anemia,
hypoxia,or hypotension,
Clinical manifestation
?Factors related to chest pain
angina,induced after effort or mental stress
relieved by nitroglycerine
pneumothorax,made worse by breath and
nonproductive cough
Esophageal reflex,induced after meals or supine position
relieved by antacids
antagonist
?Associated symptoms,bronchitis with cough
Lung cancer with bloody sputum
Diagnostic points
? Detailed history,onset quality localization
provocating factors
associated symptoms
? Physical examination,neck lymph nodes
chest examination
? Laboratory check up,sputum
chest X-ray film
Abdominal pain
?Acute abdominal pain
?Chronic abdominal pain
Acute abdominal pain
Etiology and pathogenesis
?Parietal peritoneal inflammation
bacterial contamination chemical irritation
?Acute inflammation of abdominal organs
gastritis enteritis
?Mechanical obstruction of hollow viscera
obstruction of the small or large intestine
Acute abdominal pain
Etiology and pathogenesis
?Vascular disturbances
embolism vascular rupture
?Referred pain
pneumonia coronary occlusion
?Abdominal wall
trauma
?Metabolic and toxic causes
allergic factors
Mechanisms of abdominal pain
? Visceral pain
? Somatic pain
? Referred pain
Visceral pain
? Results from stimulation of autonomic nerves
in the visceral peritoneum which surrounds
internal organs
? The message may be transferred into the spinal
cord via sympathic route
Clinical presentation of visceral
pain
? Pain poorly localized
? Intermittent,crampy or colicky pain
? Accompanied by nausea,vomitting and diaphoresis
Somatic pain
? Stimuli occurs with irritation of parietal peritoneum
? Sensations conducted along peripheral nerves
which can localize pain better
Clinical presentation of somatic
pain
? Precisely localized pain
? Pain described as intense,constant
? With local guarding or rigidity
? Getting worse after coughing or position changes
? May be caused by infection,chemical irritation,or
other inflammatory process
Referred pain
? Pain felt at a distance from its source
? The nerves distribution and visceral organs are
listed in text book (page 37)
Clinical manifestation
?Localization
Tenderness over the diseased organ
Obstruction of small intestine,periumbilical(脐周 ）
supraumbilical（ 脐上 ）
Obstruction of large intestine,infraumbilial area （ 脐下 ）
acute distention of gallbladder,right upper quadrant with
radiation to the right posterior region of the thorax
or the tip of the right scapula （ 肩胛 ）
Clinical manifestation
?Quality and severity
Perforation,severe dull pain over abdomen
Obstruction of hollow abdominal viscera,intermittent
colicky
Intraabdominal vascular disturbances,
sudden and catastrophic in nature
Acute pancreatitis,severe,steady upper,abdominal pain
Clinical manifestation
? Provocation and relief
Acute gastritis and enteritis,eating unfresh or raw foods
vomiting or discharge
Peritoneum inflammation,accentuated by pressure
palpation movement coughing
IBS and constipation,relieved temporarily by bowel
movements
Obstruction,relieved temporarily by vomiting
Ulcer,eating or taking antacids
Clinical manifestation
?Associated manifestations
Fever,inflammation
Jaundice,liver gallbladder pancreatic disease
Hematuria,renal stone
Diarrhea/rectal bleeding,intestinal causes
Differentiation of three colicky
pain
Type Location Other manifestation
Intestinal periumbilical vomiting,nausea
infraumbilical diarrhea,bowel sounds
Biliary right upper jaundice fever
quadrant Murphy’s sign
Renal ipsilateral flank changes in urine test
radiate to genitalia hematuria
groin,scrotum
Diagnostic points
?Pain referred to the abdomen should be
differentiated
?An accurate menstrual history in a female patient
is essential
?Much attention has been paid to the presence or
absence of peristalic sounds,their quality and their
frequency
? PQRST,provocative-palliative factors quality
region severity temporal characteristics
Chronic abdominal pain
Etiology and pathogenesis
? Chronic inflammation of abdominal organs
reflux esophagitis chronic ulcerative colitis
? Peptic ulcer
? Distention of visceral surfaces
? Metabolic and toxic causes uremia
? Infiltration of tumor
? Neurogenic irritable colon neurosis
Clinical manifestation
? Past history
? Localization
? Quality
? Pain and position of the body
Ptosis （下垂） of stomach or kidney,
pain when standing for long time
? Associated symptoms
Chronic infection lymphoma malignant tumor,fever
esophagus stomach billary tree,vomiting
Back pain
? The annual societal cost of back pain in the US
is estimated to be between $ 20 and $ 50 billion
? Back symptoms are the most common cause of
disability in patients under 45 years of age
? 50% of working adults,in one survey,admitted
to having a back injury each year
? Approximately 1% of the U.S,population is
chronically disabled because of back pain
Causes of back pain
? Congenital anomalies of the lumbar spine
spondylolysis
? Trauma
? Sprains and strains
? Vertebral fractures
? Lumbar disk disease
? Others causes of low back pain
spinal stenosis neurogenic claudication
facet joint hypertrophy lumbar adhesive arachnoiditis
Causes of back pain
? Arthritis,spondylosis ankylosing spondylitis
? Other destructive disease,
neoplasm infection osteoporosis osteoclerosis
? Referred pain from visceral disease
low thoracic and upper lumber pain in abdominal disease
lumbar pain with lower abdominal disease sacral pain in
gynecologic and urologic disease
? Postural back pain
? Psychiatric disease
? Unidentified
Clinical manifestation
? Low back pain the diseased part affected most
? Dysfunction the motion restriction
? Abnormality shortened spine
Arthralgia
? Joint pain affects one or more joints
? Caused by many types of injuries or conditions
Common causes of arthralgia
? Autoimmune diseases,rheumatoid arthritis SLE
? Osteoarthritis,bursitis
? Serum negative spinal-arthrosis
? Metabolism and endocrinology,gout
? Infection,Septic arthritis osteomyelitis tendonitis
? Tumor
? Osteo-arthrosis assiciated with joint manifestation
? Degenerative neuropathy
? Trauma,fractures hemarthrosis
? Others,pseudoarthralgia
Clinical manifestation of
arthralgia
? Joint pain
? Joint swelling
? Redness and warmth of diseased joint
? Stiffness of joint or morning stiffness
? Joint deformity
? Motion restriction of the affected joint
? Friction
