Initial assessment and temporal characteristics
If a patient presents with a pain syndrome, the first and mandatory step is to determine its localization. The physician must clearly identify the primary site of origin of the discomfort before proceeding with further questioning.
After determining the localization, it is necessary to ascertain the temporal parameters of the pain episode. The key characteristics here are:
- Pattern of onset: how exactly the pain appeared — whether it was sudden, developed as an attack (paroxysmal), or increased gradually.
- Duration: how long each pain episode lasts.
- Chronology: the exact time of onset of sensations and the circumstances under which it occurred.
Intensity, radiation, and modifying factors
An important stage of analysis is the assessment of pain intensity. Since this is a subjective sensation, the physician must rely on the patient's own rating of the pain severity.
Next, the pathways of radiation are ascertained — the zones to which the pain spreads (refers) beyond its primary focus.
An integral part of taking the history is searching for modifying factors. The physician finds out:
- Conditions that provoke the onset or contribute to the intensification of pain.
- Factors that alleviate the condition or completely stop the attack. These include adopting a certain body posture, ensuring physical rest, and taking medications.
Relationship with functional load
To conduct a proper differential diagnosis, it is necessary to correlate the pain syndrome with the functional load on a specific organ.
When assessing the cardiovascular system (e.g., to differentiate angina pectoris and cardialgia):
- The provoking factor is most often physical exertion.
- The relieving factor is transitioning to a state of rest or the use of nitroglycerin.
When assessing the gastrointestinal tract (e.g., when suspected stomach ulcer):
- The pain is strictly linked to food intake. Hunger pains are distinguished, as well as early (occurring 30 minutes after eating) and late (after 1.5–2 hours) pains.
- The general dynamics of changes in pain intensity before and after eating are assessed.
Briefly: answers to topical questions
What scales are used to assess pain intensity in internal medicine?
To assess the intensity of the pain syndrome, assessment scales are used:
- Visual Analog Scale (VAS) (Visual Analog Scale, VAS).
- Numeric Rating Scale (NRS) (Numeric Rating Scale): when assessed on a scale from 0 to 10, the patient rates the pain, where 0 is "no pain" and 10 is "maximum pain".
- Verbal Rating Scale (VRS) (Verbal Rating Scale).
NRS and VRS are modifications and analogues of the VAS.
How does cardialgia clinically differ from angina pectoris?
Clinically, cardialgia differs from angina pectoris in localization, character of pain, relationship with physical exertion, and response to medications.
| Sign | Cardialgia | Angina Pectoris |
|---|---|---|
| Localization | Area of the apex of the heart (left nipple) | Retrosternal |
| Character | Stabbing, aching, cutting | Squeezing or pressing |
| Relationship with load | No clear relationship | Attacks during physical exertion |
| Duration | From several seconds to many hours | From 3 to 15 min |
| Effect of nitroglycerin | Ineffective | Pain disappears quickly |
What are the main mechanisms of visceral pain?
The main mechanisms of visceral pain are changes in the tone and volume of internal organs. These include:
- Spasm of hollow organs, such as the intestine or bile ducts.
- Overdistension of hollow organs (including due to obstruction and reflex spasm, leading to increased intraluminal pressure).
- Capsular stretch of parenchymatous organs.
What are the typical zones of radiation in myocardial infarction?
In myocardial infarction, pain spreads beyond the sternum into the upper half of the body. Typical zones of radiation include:
- Left arm and shoulders (more often the left).
- Area under the left scapula.
- Neck.
- Lower jaw (jaws).
- Upper abdomen (characteristic of the abdominal form of infarction).
To quickly memorize the pain detailing parameters, use the acronym OPQRST: Onset, Provocativity/Palliatives, Quality, Region/Radiation, Severity, Time.
Class and exam questions
Which pain parameter needs to be ascertained first?
First and foremost, the exact localization of pain must always be clarified. All subsequent characteristics are analyzed only after establishing the primary focus.
How to differentiate angina pain through patient questioning?
Angina pain is triggered by physical exertion. A key diagnostic sign is relief of pain at rest or after taking nitroglycerin.
What are pain "modifying factors"?
These are conditions affecting the intensity of sensations. They include triggers that worsen the pain as well as alleviating factors: taking medications, body position, or resting.
How is gastric ulcer pain related to food intake?
Pain can be hunger pain, early pain (30 minutes after eating), or late pain (1.5–2 hours after eating). The physician needs to track the dynamics of pain intensity after meals.
What else to study on this topic
- Mechanisms of early and late pain in gastrointestinal pathology
- Differential diagnosis of true angina pectoris and functional cardialgia
- Objectifying subjective pain intensity
- Anatomic pathways of radiation in various internal organ diseases
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