Practicing Pain Management: Finding Relief for Your Patients

Pain is a universally understood sign of disease and the most common symptom bringing people to seek medical attention. The International Association for the Study of Pain defines pain as "an unpleasant sensory and emotional experience" associated with actual or potential tissue damage. It is possible to describe different types of pain, and they tend to present differently. The history and physical examination help to identify these differences. Precise and systematic pain assessment is required to make the correct diagnosis and thus establish the most efficacious treatment plan for patients presenting with pain.

The somatosensory system (shown) is the part of the sensory system concerned with the conscious perception of touch, pressure, pain, temperature, position, movement, and vibration arising from the muscles, joints, skin, and fascia. It is a 3-neuron system that relays sensations detected in the periphery and conveys them via pathways through the spinal cord, brainstem, and thalamic relay nuclei to the sensory cortex in the parietal lobe. Impulses are carried from receptors via sensory afferents to the dorsal root ganglia, where the cell bodies of the first-order neurons are located. Their axons then travel through the spinal cord either in an ipsilateral or a contralateral fashion. Second-order neuron cell bodies are located in different anatomical areas depending on the sensation they carry.

The two major categories of pain are nociceptive and neuropathic. This colonoscopy image demonstrates severe colitis that induced visceral nociceptive pain. Nociception is a normal physiologic response to stimuli, initiated by nociceptors that detect mechanical, thermal, or chemical changes. It may be divided into three subtypes. Superficial somatic pain is from cutaneous nociceptors on the skin or superficial tissues. Deep somatic pain is from somatic nociceptors on ligaments, bones, blood vessels, and muscles. Visceral pain is from visceral nociceptors within body organs.

Neuropathic pain is pain induced by damage to the nerves themselves. Herpes zoster (shown) can cause neuropathic pain via growth and inflammation within dermatomal nerves. Hyperpathic symptoms of burning, tingling, or electrical sensations are classic for neuropathic pain. Unfortunately, neuropathic pain is not traditionally responsive to standard pain medications.

Sensitization is an adaptive process in which innocuous stimuli produce an excessive response. Repeated intense stimuli to damaged tissue lower the threshold and frequency of firing of afferent nociceptors. Local inflammatory mediators contribute by recruiting additional nociceptors, which normally remain silent to routine stimuli. For example, patients with bad sunburns will experience severe pain and discomfort to even very light touches because of sensitization of the pain fibers. Sensitization may also be partly responsible in patients with chronic pain syndromes.

This image demonstrates the visceral afferent and modulatory pathways responsible for the pain felt by patients with irritable bowel syndrome. The plus sign denotes pain facilitation and the minus sign denotes pain inhibition. Pain modulation can both enhance and dampen pain signals. Placebo can have a significant analgesic response, and anxiety can magnify the perceived stimuli. Descending signals from the frontal cortex and hypothalamus help modulate the ascending transmission of the pain signal by opiate receptors. (Abbreviations: A6, locus coeruleus; ACC, anterior cingulate cortex; NTS, nucleus tractus solitarius; PAG, periaqueductal gray matter; PFC, prefrontal cortex; RVM, rostra ventral medulla.)

Determining the best treatment course for pain management begins with identification of the intensity and duration of pain. Pain assessment relies largely upon the use of self-report. Both single-dimensional (rating only pain intensity) and multidimensional scales are available. Examples of single-dimensional scales include the Numeric Rating Scale (top) and the Wong-Baker Faces Pain Rating Scale (bottom).^[2]Multidimensional scales, such as the McGill Pain Questionnaire and the Brief Pain Inventory, measure the intensity, the nature and location of the pain, and in some cases, the impact the pain is having on activity or mood. The results obtained from these instruments must be viewed as guides and not absolutes. Image courtesy of the US Department of Veterans Affairs.

Laboratory tests, imaging, and nerve or muscle conduction studies may help identify the root cause of a patient's pain, as well as provide important information about therapeutic planning. For example, the magnetic resonance imaging of a patient with cervical radiculopathy shown here demonstrates a C6-7 disk herniation that is responsible for the patient's pain symptoms. Depending on the extent of the injury, patients may be eligible for injury-specific procedural interventions.

Medical management of pain proceeds in a stepwise fashion, as shown here (based on the "pain ladder" by the World Health Organization). Acute pain is typically treated with short courses of medication therapy, whereas chronic pain may require long-acting medications or other interventional modalities. For mild to moderate pain, nonnarcotic analgesics are used, such as aspirin, acetaminophen, ibuprofen, naproxen, indomethacin, ketorolac, and celecoxib. For moderate to severe pain, narcotic regimens are typically used, including codeine, oxycodone, morphine, hydromorphone, methadone, meperidine, fentanyl, and tramadol. Combination regimens that contain opioids and nonnarcotic analgesics provide additive pain control. Adjuvant medications therapies include tricyclic antidepressants, antihistamines, and anticholinergics.

The pharmacology of pain control is based on influencing one of several biochemical pathways. Many nonnarcotic analgesics inhibit the cyclooxygenase enzyme, which is responsible for the formation of prostaglandin, prostacyclin, and thromboxane. Opiate medications mimic endogenous opioid peptides. Opioids bind to one of three principle classes of opioid receptors (mu, kappa, delta) to produce centrally mediated analgesia. Tricyclic antidepressants are thought to potentiate the effect of opiates. Image courtesy of Wikimedia Commons.

Patient-controlled analgesia allows patients to self-titrate their intravenous pain medication. It allows for a more consistent administration of analgesia with a reduced duration between when the patient feels pain and when analgesia is administered. It reduces the chances for medication errors, reduces nursing workload, increases patient autonomy, and provides objective data about the amount of medication a patient needs. It is traditionally used for postoperative patients and those with serious oncologic or hematologic diseases. Image courtesy of Wikimedia Commons.

Transdermal patches provide controlled drug delivery with a lower potential for abuse than oral analgesics. Patches can be applied once every 12 to 24 hours. Conditions such as postherpetic neuralgia and chronic cancer pain are routinely treated with transdermal patches. Opiate-infused lollipops (shown) and buccal lozenges are other alternative forms of drug delivery used to treat patients with malignant pain. Image courtesy of Wikimedia Commons.

This patient is undergoing a sural nerve block. Regional blocks with therapeutic injections can provide excellent relief for patients with localized pain and inflammation. Depending on the clinical scenario, therapeutic, sympathetic, diagnostic, prognostic, or prophylactic blocks may be used. Therapeutic injections allow for a return to normal function, preventing the development of compensatory injuries. The exact procedural technique is dependent on the nerve involved, but the general principle involves the direct injection of local anesthetic or corticosteroid into the perineural space.

Depending on operator familiarity and the difficulty of accessing injection sites, image guidance may be used for direct visualization. This computed tomography-guided image demonstrates an injection needle in good position in the outer aspect of the neural foramen. Computed tomography, ultrasound, or fluoroscopic guidance allows for more precise needle placement, thus reducing the amount of injected drug and reducing complications. The procedure is especially useful in patients with distorted native anatomy.

Surgical interventions are limited for patients with discrete deficits who fail conservative management. Depending on the location of pain, patients will typically undergo a stepwise treatment course involving noninterventional management before being eligible for invasive therapy. Surgically implanted devices, such as intrathecal pumps and spinal cord stimulators, are available for use on a case-by-case basis. This image shows the spread of opioids in the cerebrospinal fluid via a spinal injection. The rostral spread of intrathecal opioids is thought to be responsible for unwanted effects such as respiratory depression, pruritus, hypotension, nausea, and vomiting. Image courtesy of Wikimedia Commons.

Spinal cord stimulation (SCS, shown) is approved by the FDA for indications including failed back surgery syndrome, chronic painful peripheral neuropathy, multiple sclerosis, complex regional pain syndromes, ostherpetic neuralgia, post-thoracotomy pain, phantom limb pain, intercostal neuralgia, and certain spinal cord injuries. The neurophysiologic mechanisms of SCS are not completely understood. Experimental evidence supports a beneficial SCS effect at the dorsal horn level, whereby the hyperexcitability of wide-dynamic-range neurons is suppressed. Evidence exists for increased levels of GABA release and serotonin and, perhaps, for reduced levels of some excitatory amino acids, such as glutamate and aspartame. Image courtesy of Wikimedia Commons.

Transcutaneous electrical nerve stimulation (TENS) units are adjuvant pain control devices that provide pulsatile electric impulses. The proposed mechanisms by which they reduce pain are presynaptic signal inhibition, endogenous pain control, direct inhibition of abnormally excited nerves, and restoration of afferent inputs. TENS units have been used for low back, arthritic, sympathetically mediated, neurogenic, visceral, and postsurgical pain. Although they are widely used and there is a great deal of anecdotal and observation-based evidence, there is a paucity of randomized controlled trials confirming the effectiveness of TENS units. Image courtesy of Wikimedia Commons.

Chronic, refractory pain is best managed with a multidisciplinary team approach that includes psychology, occupational therapy, physical therapy, vocational rehabilitation, and relaxation training. Patients with chronic pain frequently seek complementary and alternative medicine treatment options as well, including acupuncture (shown), dietary supplements, and hypnosis. A 2012 meta-analysis of 29 randomized controlled trials (17,922 patients) found acupuncture to be superior to both sham acupuncture and standard care for the treatment of different types of chronic pain, suggesting that the effects of acupuncture are more than just placebo effect. Image courtesy of Wikimedia Commons.

Meningitis Vs. Meningism

Meningitis is the inflamation of meninges surrounding the brain INFECTIVE in nature. Clinically it shows a triad of Fever-Headache-Neck Rigidity. 
Meningism is inflamation of meninges surrounding the brain but  NOT INFECTIVE in nature. Clinically it shows a triad of Photophobia-Headache-Neck Rigidity.

Unconsciousness= DO NOT

• Do NOT give an unconscious person any food or drink.
• Do NOT leave the person alone.
• Do NOT place a pillow under the head of an unconscious person.
• Do NOT slap an unconscious person's face or splash water on the face to try to revive him.

Myths About Vitiligo Treatment

Three myths about the treatment of vitiligo prevail in the medical profession.

The first myth is that treatment of vitiligo is "impossible." This is clearly not true and the majority of patients can achieve good results.

The second myth is that oral psoralens, which form the basis for some vitiligo treatments are "toxic to the liver." Oral psoralens are not toxic

to the liver.

The third myth is that psoralen + UVA (PUVA) treatments for vitiligo "cause cancer of the skin." When used to treat vitiligo, PUVA therapy requires only a limited number of treatments-approximately 150 in number that has not been shown to cause skin cancer. By comparison, PUVA treatments for psoriasis can be as many as double the number for vitiligo. It has been shown that a small percentage of patients who receive more than 250 PUVA treatments can develop treatable squamous cell cancers of the skin.

Pemphigus Vulgaris Vs Bullous Pemphigoid

Here are two diseases that are easy to confuse: pemphigus vulgaris and bullous pemphigoid. Both diseases are characterized by bullae (big, blister-like skin lesions) and both have “pemphig” in their names (“pemphig-” comes from the Greek pemphix, meaning blister, so that makes sense). So what are the differences between the two?

Pemphigus vulgaris
Here’s the key to differentiating between the two

disorders. “Pemphigus” is used in a very specific way (you’d think it would be used to describe any blistering disorder, but not so!). It is used to describe blistering disorders caused by autoantibodies against some part of the epidermis, which lead to disruption of the intercellular junctions (and hence bullae). Pemphigus vulgaris, not surprisingly, is the most common type of pemphigus (“vulgar-” comes from the Latin vulgaris, meaning the general public). It occurs primarily in adults between the ages of 30 and 60, and is characterized by big, flaccid bullae that burst easily (in most patients, you’ll see more ruptured, scab-covered bullae than intact ones). Patients often present first with oral bullae and ulcerations, and later develop bullae on the skin.

In this disease, patients have autoantibodies against desmogleins, which disrupt the connections between the squamous cells of the epidermis and cause very superficial, intraepidermal, fragile bullae. If you do immunofluorescence on the skin, you’ll see a kind of outlining of each individual epidermal cell (because there are autoantibodies bound to the junctions between the cells). Treatment consists of immunosuppressive agents; prognosis is variable, but many patients have a higher than normal mortality rate.

Bullous pemphigoid
This disease is called pemphigoid rather than pemphigus, because it looks like pemphigus but really isn’t! Pemphigus is characterized by autoantibodies against the connections between epidermal cells. In bullous pemphigoid, patients have autoantibodies – but they are against the basement membrane of the epidermis, not against epidermal cell junctions. This means that the bullae are actually subepidermal, so they are less fragile than those of pemphigus vulgaris (if you see a patient with bullous pemphigoid, you’ll see lots of intact, tense bullae, rather than a bunch of ruptured bullae covered with scabs). The immunofluorescence pattern is correspondingly different – you’ll see just a line at the base of the epidermis (rather than the lace-like outlining of epidermal cells you see in pemphigus vulgaris).

Patients with bullous pemphigoid are generally elderly, and the clinical presentation varies a lot (but usually it doesn’t start in the mouth, like pemphigus vulgaris). It’s a less serious disease, usually, since the bullae often don’t rupture (so there’s less chance of infection and scarring).

So if you can remember that pemphigus is a disease that has intraepidermal antibodies, then you can keep the clinical presentation and immunofluorescence pattern of the two diseases straight.

Hemoptysis

Common causes of hemoptysis include the following:
• Acute infections (e.g., exacerbations of COPD).
• Bronchiectasis: can be responsible for massive hemoptysis.
• Bronchial carcinoma: secondary deposits and benign tumors can also lead to hemoptysis but are less common.

• Pulmonary tuberculosis: a common cause worldwide.
• Pulmonary embolus with infarction.
• Left ventricular failure can lead to the production of pink, frothy sputum.
• Mitral stenosis.
• Other infections, such as lobar pneumonia ("rusty" sputum) or, less commonly, lung abscess.
• Trauma (e.g., contusions to the chest, inhalation of foreign bodies, or after intubation).
Rare causes of hemoptysis include the following:
• Bleeding diatheses.
• Vasculitis (e.g., Goodpasture's syndrome and Wegener's granulomatosis).
• Diffuse interstitial fibrosis.
• Idiopathic pulmonary hemosiderosis.
• Arteriovenous malformations (Osler-Weber-Rendu disease [hereditary hemorrhagic telangiectasia], a favorite in exams but rare in practice).
• Eisenmenger's syndrome.
• Sarcoidosis and amyloidosis.
• Primary pulmonary hypertension.
• Cystic fibrosis.
• Invasive aspergillosis.
Note that in up to 15% of cases no cause for hemoptysis is found.

15 Cancer Symptoms Men Ignore

Experts say that men could benefit greatly by being alert to certain cancer symptoms that require a trip to the doctor’s office sooner rather than later. But when it comes to scheduling doctor visits, men are notorious foot-draggers. In fact, some men, would never go to the doctor if it weren't for the women in their life.

Leonard Lichtenfeld, MD, is deputy chief medical officer for the national office of the American Cancer Society. According to Lichtenfeld, men often need to be pushed by women to get screened for cancer. That’s unfortunate. Routine preventive care can find cancer and other diseases in their early stages. When cancer is found early, there are more options for treatment. That means there are also better chances for a cure.

Some cancer symptoms in men are specific. They involve certain body parts and may point directly to the possibility of cancer. Other symptoms, though, are vague. For instance, pain that affects many body parts could have many explanations. It may or may not be a sign of cancer. But you can't rule cancer out without seeing a doctor.

Cancer Symptom in Men No. 1: Breast Mass

If you’re like most men, you’ve probably never considered the possibility of having breast cancer. Although it’s not common, it is possible. "Any new mass in the breast area of a man needs to be checked out by a physician," Lichtenfeld says.

In addition, the American Cancer Society identifies several other worrisome signs involving the breast that men as well as women should take note of. They include:

• Skin dimpling or puckering
• Nipple retraction
• Redness or scaling of the nipple or breast skin
• Nipple discharge

When you consult your physician about any of these signs, expect him to take a careful history and do a physical exam. Then, depending on the findings, the doctor may order a mammogram, a biopsy, or other tests.

Cancer Symptom in Men No. 2: Pain

As they age, people often complain of increasing aches and pains. But pain, as vague as it may be, can be an early symptom of some cancers. Most pain complaints, though, are not from cancer.

Any pain that persists, according to the American Cancer Society, should be checked out by your physician. The doctor should take a careful history, get more details, and then decide whether further testing is necessary. If it's not cancer, you will still benefit from the visit to the office. That’s because the doctor can work with you to find out what's causing the pain and determine the proper treatment.

Cancer Symptom in Men No. 3: Changes in the Testicles

Testicular cancer occurs most often in men aged 20 to 39. The American Cancer Society recommends that men get a testicular exam by a doctor as part of a routine cancer-related checkup. Some doctors also suggest a monthly self-exam.Evan Y. Yu , MD, is assistant professor of medicine at the University of Washington and assistant member of the Fred Hutchinson Cancer Research Center in Seattle. Yu tells WebMD that being aware of troublesome testicular symptoms between examinations is wise. "Any change in the size of the testicles, such as growth or shrinkage," Yu says, “should be a concern.”

In addition, any swelling, lump, or feeling of heaviness in the scrotum should not be ignored. Some testicular cancers occur very quickly. So early detection is especially crucial.  "If you feel a hard lump of coal [in your testicle], get it checked right away," Yu says. 

Your doctor should do a testicular exam and an overall assessment of your health. If cancer is suspected, blood tests may be ordered. You may also undergo an ultrasound examination of your scrotum, and your doctor may decide to do a biopsy. A biopsy may require the removal of the entire testicle.

Cancer Symptom in Men No. 4: Changes in the Lymph Nodes

If you notice a lump or swelling in the lymph nodes under your armpit or in your neck -- or anywhere else -- it could be a reason for concern, says Hannah Linden, MD. Linden is a medical oncologist and an associate professor of medicine at the University of Washington School of Medicine. She is also a joint associate member of the Fred Hutchinson Cancer Research Center in Seattle. "If you have a lymph node that gets progressively larger, and it's been longer than a month, see a doctor," she says.

Your doctor should examine you and determine any associated issues that could explain the lymph node enlargement, such as infection. If there is no infection, a doctor will typically order a biopsy.

Cancer Symptom in Men No. 5: Fever

If you've got an unexplained fever, it may indicate cancer. Fever, though, might also be a sign of pneumonia or some other illness or infection that needs treatment.

Most cancers will cause fever at some point. Often, fever occurs after the cancer has spread from its original site and invaded another part of the body. Fever can also be caused by blood cancers such as lymphoma or leukemia, according to the American Cancer Society. 

It’s best not to ignore a fever that can’t be explained. Check with your doctor to find out what might be causing the fever and to determine its proper treatment.

Cancer Symptom in Men No. 6: Weight Loss Without Trying

Unexpected weight loss is a concern, Lichtenfeld says. "Most of us don't lose weight easily." He's talking about more than simply a few pounds from a stepped up exercise program or to eating less because of a busy schedule. If a man loses more than 10% of his body weight in a time period of 3 to 6 months, it’s time to see the doctor, he says.

Your doctor should do a general physical exam, ask you questions about your diet and exercise, and ask about other symptoms. Based on that information, the doctor will decide what other tests are needed.

Cancer Symptom in Men No. 7: Gnawing Abdominal Pain and Depression

“Any man (or woman) who's got a pain in the abdomen and is feeling depressed needs a checkup,” says Lichtenfeld. Experts have found a link between depression and pancreatic cancer. Other symptoms of pancreas cancer may include jaundice, a change in stool color -- often gray -- a darkening of the urine. Itching over the whole body may also occur.

Expect your doctor to do a careful physical exam and take a history. The doctor should order tests such as an ultrasound, a CT scan or both, as well as other laboratory tests.

Cancer Symptom in Men No. 8: Fatigue

Fatigue is another vague symptom that could point to cancer in men. But many other problems could cause fatigue as well. Like fever, fatigue can set in after the cancer has grown. But according to the American Cancer Society, it may also happen early in cancers such as leukemia, colon cancer, or stomach cancer.

If you often feel extremely tired and you don’t get better with rest, check with your doctor. The doctor should evaluate the fatigue along with any other symptoms in order to determine its cause and the proper treatment.

Cancer Symptom in Men No. 9: Persistent Cough

Coughs are expected, of course, with colds, the flu, and allergies. They are also sometimes a side effect of a medication. But a very prolonged cough -- defined as lasting more than three or four weeks -- or a change in a cough should not be ignored, says Ranit Mishori, MD, assistant professor and director of the family medicine clerkship at Georgetown University School of Medicine in Washington, D.C. Those cough patterns warrant a visit to the doctor. They could be a symptom of cancer, or they could indicate some other problem such as chronic bronchitis or acid reflux.

Your doctor should take a careful history, examine your throat, listen to your lungs, determine their function with a spirometry test, and, if you are a smoker, order X-rays. Once the reason for the coughing is identified, the doctor will work with you to determine a treatment plan.

Cancer Symptom in Men No. 10: Difficulty Swallowing

Some men may report trouble swallowing but then ignore it, Lichtenfeld says. "Over time, they change their diet to a more liquid diet. They start to drink more soup." But swallowing difficulties, he says, may be a sign of a GI cancer, such as cancer of the esophagus.

Let your doctor know if you are having trouble swallowing. Your doctor should take a careful history and possibly order a chest X-ray and a barium swallow. The doctor may also send you to a specialist for an upper GI endoscopy to examine your esophagus and upper GI tract.

Cancer Symptom in Men No. 11: Changes in the Skin

You should be alert to not only changes in moles -- a well-known sign of potential skin cancer -- but also changes in skin pigmentation, says Mary Daly, MD. Daly is an oncologist and head of the department of clinical genetics at the Fox Chase Cancer Center in Philadelphia.

Daly also says that suddenly developing bleeding on your skin or excessive scaling are reasons to check with your doctor. It's difficult to say how long is too long to observe skin changes, but most experts say not to wait longer than several weeks.

To find out what’s causing the skin changes, your doctor should take a careful history and perform a careful physical exam. The doctor may also order a biopsy to rule out cancer.

Cancer Symptom in Men No. 12: Blood Where It Shouldn't Be

“Anytime you see blood coming from a body part where you've never seen it before, see a doctor,” Lichtenfeld says. "If you start coughing up blood, spitting up blood, have blood in the bowel or in the urine, it’s time for a doctor visit.”

Mishori says it’s a mistake to assume blood in the stool is simply from a hemorrhoid. "It could be colon cancer," he says.

Your doctor should ask you questions about your symptoms. The doctor may also order tests such as a colonoscopy. This is an examination of the colon using a long flexible tube with a camera on one end. The purpose of a colonoscopy is to identify any signs of cancer or precancer or identify any other causes of the bleeding.

Cancer Symptom in Men No. 13: Mouth Changes

If you smoke or chew tobacco, you need to be especially alert for any white patches inside your mouth or white spots on your tongue. Those changes may indicate leukoplakia, a pre-cancerous area that can occur with ongoing irritation. This condition can progress to oral cancer.

You should report the changes to your doctor or dentist. The dentist or doctor should take a careful history, examine the changes, and then decide what other tests might be needed.

Cancer Symptom in Men No. 14: Urinary Problems

As men age, urinary problems become more frequent, says Yu. Those problems include the following:

• The urge to urinate more often,especially at night
• A sense of urgency
• A feeling of not completely emptying the bladder
• An inability to start the urine stream
• Urine leaking when laughing or coughing
• A weakening of the urine stream

"Every man will develop these problems as he gets older," Yu says. "But once you notice these symptoms, you should seek medical attention." That's especially true if the symptoms get worse.

Your doctor should do a digital rectal exam, which will tell him whether the prostate gland is enlarged or has nodules on it. The prostate gland often enlarges as a man ages. It’s most often caused by a noncancerous condition called benign prostatic hyperplasia or BPH. 

Your doctor may discuss doing a blood test to check the level of prostate-specific antigen or PSA. PSA is a protein produced by the prostate gland, and the test is used to help determine the possibility of prostate cancer. 

If the doctor notices abnormalities in the prostate or if the PSA is higher than it should be, your doctor may refer you to a urologist and perhaps order a biopsy. Prostate cancer may be present even with a normal PSA level.

Cancer Symptom in Men No. 15: Indigestion

Many men, especially as they get older, think "heart attack" when they get bad indigestion. But persistent indigestion may point to cancer of the esophagus, throat, or stomach. Persistent or worsening indigestion should be reported to your doctor.

Your doctor should take a careful history and ask questions about the indigestion episodes. Based on the history and your answers to the questions, the doctor will decide what tests are needed.