What is an Eye Cataract?

Latin: cataracta meaning "waterfall"

Greek: kataraktes and katarrhaktes, from katarassein meaning "to dash down" (kata-, "down"; arassein, "to strike, dash").
As rapidly running water turns white, the term may later have been used metaphorically to describe the similar appearance of mature ocular opacities.

In dialect English a cataract is called a pearl, as in "pearl eye" and "pearl-eyed".

Cross-section illustration of eye, with major structures labeled.

The natural lens

• The natural lens, like the cornea, makes sure that the light rays which enter the eye are refracted.
  
• This results in a sharp image on the retina.
  
• The lens has a diameter of about 9 mm, is 5 mm thick and has a convex front and rear side.

The lens is clear and transparent which enables light to pass through it easily.

Cataract

• In the young, the lens is clear and transparent.
  
• Lens opacity caused by old age or other reasons affects the clarity and the visual acuity. This is a cataract.
• Cataract is the most common cause of vision impairment and blindness in the world.
• Cataract may originate in various different locations in the lens.
• Its onset may be in the middle of the lens, on the side or in other positions.
• Cataract usually starts out in the middle of the lens, in which case it is referred to as nuclear cataract.

Symptoms of cataract

The most common symptoms of cataract are:

• blurred vision (X)
  
• fewer details
• double vision (diplopia)
• sensitivity to light (Photophobia - not scared, med term for sensitive to light) (X)
  
• difficulty reading (X)
• diminished night vision
• changed prescription power for glasses
  

Senile cataract

• Senile cataract is by far the most common type of cataract.
  
• Senile cataract can be compared to getting wrinkles and turning grey.
  
• Due to an aging population, this type of cataract is on the increase.

Cataract caused by a disorder or an accident

Cataract can also occur in young people. In this case, it is usually caused by trauma, for instance when a foreign object gets lodged in the eye or by a blow to the eye. Other causes which may lead to the development of cataract in younger individuals are:

• diabetes;
• a surgical treatment of the eye (vitrectomy)
• long-term exposure to ultraviolet light, sunlight
• long-term use of certain types of medication, such as cortisone
• heavy smoking
• heavy drinking
  

Congenital cataract

In rare cases, cataract can be congenital. Congenital cataract may occur because the mother had rubella during pregnancy. Other problems during pregnancy can also cause cataract. Sometimes congenital cataract is an independent problem, but it can also be part of another syndrome.


http://www.ophtec.com/consumer/en/cataract/what-is-cataract-

Examination of the eye

http://medinfo.ufl.edu/year1/bcs/clist/eye.html

NON PHARMACOLOGICAL MANAGEMENT

Natural non-drug pain control therapies and methods.

Acupuncture (AH-q-punk-sher) is based on the belief that life forces or energy move through the body in specific paths. These paths are called meridians (mer-IH-d-uns). With acupuncture, a needle is put into the meridian that runs to the area where you have pain. This needle blocks the meridian which stops or decreases the pain.

Aromatherapy (uh-ro-muh-THAIR-uh-p) is a way of using good smells to help you relax and decrease pain. Candles, massage oils, scented bubble baths and even baking cookies are all ways that smells are used. Scientists are learning that good smells may change your mood and help you relax. It may also help your brain makes special chemicals like endorphins (n-DOOR-fins). Endorphins are a natural body chemical like morphine that decrease pain.

Biofeedback teaches your body to respond in a different way to the stress of being in pain. Teaching your body to relax helps make the pain less. Caregivers may use a biofeedback machine so that you know right away when your body is relaxed. But, often you may not need any machines. Learn to take your pulse. Then take it while making your mind think about "slowing down" your pulse. This can work with breathing, temperature, and blood pressure too.

Breathing exercises are another physical way to help your body relax. Teaching your body to relax helps make the pain less. Breathing in and out very slowly is all you do. Women have used breathing exercise for many years to decrease the pain of childbirth. A fun way to practice breathing slowly is to blow soap bubbles. You know you are doing a good job when you get very large bubbles. Remember to practice when you are not having pain. This helps it work better when you are having pain.

Distraction (dih-STRAK-shun) teaches you to focus your attention on something other than pain. Try playing cards or games, watching TV, or taking a walk. You can also visit with friends, paint, pet animals, and write out your feelings. Using planned activities helps to manage the boredom that chronic pain and illness can cause. It may also cause you to relax and keep you from thinking about the pain.

Environment (your surroundings) - Being in a quiet place may make it easier for you to deal with the pain. Avoiding bright lights or loud noisy places can also help control your pain. Making sure your home is not too hot or too cold may also decrease pain.

Guided imagery (IH-mij-ree) teaches you to put pictures in your mind that will make the pain less intense. With guided imagery, you learn how to change the way your body senses and responds to pain. Imagine floating in the clouds or remembering favorite place. Guided imagery seems to especially help people with chronic lower back pain.

Heat and cold can help decrease pain. Some types of pain improve best using heat while other types of pain improve most with cold. Caregivers will tell you if hot and/or cold packs will help your pain. Also, remember that a long warm bath may help calm you and let your muscles relax. A cool shower on a very hot summer day may do the same thing.

Laughter - It has been said that "10 minutes of belly laughter gives 2 hours of pain-free sleep!" Laughter helps you breathe deeper and your stomach digest (break down) food. It lowers blood pressure and may cause your brain to make endorphins. Laughter can also help change your moods. It helps you relax and let go of stress, anger, fear, depression, and hopelessness. These are all parts of chronic pain.

Massage is often used to help a person become more relaxed. Have someone gently massage your back, shoulders, and neck. Massage can be even more effective if you also use guided imagery, breathing exercises, or music.

Music - It does not matter whether you listen to it, sing, hum or play an instrument. Music increases blood flow to the brain and helps you take in more air. Scientists are learning that it increases energy and helps change your mood. Music also may cause your brain to make special chemicals like endorphins. Endorphins are a natural body chemical like morphine that decrease pain. People who use music often say it decreases their need of medicines for pain and anxiety.

Physical therapy can be helpful with pain that was caused by not moving one part of your body. Stretching the muscles and making them stronger around the injured area can help the pain go away.

Self-hypnosis is a way to change your level of awareness. This means that by focusing your attention you can move away from your pain. You make yourself open to suggestions like ignoring the pain or seeing the pain in a positive way. It is not known exactly how hypnosis helps pain. But, hypnosis can give long-lasting relief of pain without affecting your normal activities. Self-hypnosis gives you better control of your body. You may feel less hopeless and helpless because you are doing something to decrease the pain.

Spinal cord stimulation is a nerve stimulation technique that is similar to TENS. The difference is that in SCS an electrode (a metal wire) is put near the spinal cord during surgery. SCS also uses mild, safe electrical signals to help control pain.
TENS is short for transcutaneous (trans-q-TAIN-e-us) electrical nerve stimulation (stih-mew-LA-shun). A TENS unit is a portable, pocket-sized, battery-powered device which attaches to the skin. The TENS unit uses mild, safe electrical signals to help control pain.

Touch energy therapies come from very old beliefs that life forces or energy move through the body in specific paths. Touch therapies believe disease may cause these paths to become blocked. The therapies use touch to help unblock these paths, and allow the energy to flow normally. Unblocking the paths may help you relax and decrease pain.

Hey people... ignore that figure 1 and all the blue numbers on my last post. I copy paste that section... : )

Reference
http://www.medscape.com/viewarticle/562363_5
psy.ucsd.edu/~dmacleod/159/presentations05/AnaPain.ppt
http://www.anaesthetist.com/icu/pain/Findex.htm#index.htm

Neurotransmitter involved in pain

Neurotransmitter involved in pain

Excitatory:

Inhibitory:

· GABA - mediates gate control in dorsal horn by synapsing on neurons that contain substance P.

- GABA_A Rs- ligand gated ion channel (ionotropic), fast inhibition

- GABA_B Rs- activates G proteins (metabotropic), slow inhibition

Descending Pain Regulation:

· Norepinephrine

· Serotonin

High concentrations of 5-HT and NA containing terminals are found in the spinal cord, especially in the superficial dorsal/posterior horns, where the terminals of small diameter primary afferent fibres make synaptic contact with second-order neurons of the spinal cord. 5-HT and NA in this area of the spinal cord are critically important for modulating pain sensitivity through their presence in the descending pain pathways (Figure 1).^[20] Persistent pain arises from changes in sensitivity within ascending and descending pain pathways in the brain and spinal cord.^[21] Under normal circumstances, descending serotonergic and noradrenergic pathways suppress routine ascending input from the periphery (headache, musculoskeletal pain and abdominal pain) to the brain in such a way that attention can be paid to events occurring outside the body. Dysfunction of the descending inhibitory pathway allows routine inputs to ascend via the spinal cord to the brain where they are interpreted as pain, which explains the painful physical symptoms associated with depression.^[22] Although other neurotransmitters are involved, both 5-HT and NA have been implicated as mediators of endogenous analgesic mechanisms in descending pain pathways. The precise mechanism involved in pathogenesis of persistent pain is not fully understood, but a growing body of evidence indicates that disinhibition and imbalance of 5-HT and NA could contribute to persistent pain mechanisms.^[

· opiates - relieve pain by stimulating mu and delta receptors

Pain gates can also be shut by activating neurons that release endorphins in the PAG

-Periaqueductal gray area (PAG) which presumably mediate the actions of endorphins and enkephalins.

Prognosis of Shingles + Complications :

Prognosis of Shingles + Complications :
 involve appearances of lesions, rashes and blisters on the skin
 go away in about 3 to 5 weeks
 shingles can be life-threatening for people with weakened immune system

Complications :
Postherpetic neuralgia
 severe pain from shingles may last for months, and sometimes years, after the shingles rash has healed.
 PHN occurs from damage to the nerve fibers, caused by the varicella zoster virus.

Bacterial skin infection
 Because the shingles rash causes blisters that pop and leave open sores – bacteria infection
 Examples of common bacterial infections that can occur are:
 Impetigo
 Erysipelas
 Folliculitis
Eye pain and infections
 Hutchinson’s sign
 appears on the tip of the nose. It
 indicates that the herpes zoster virus has invaded the nerve in the eye (ophthalmic nerve)
 painful swelling of the eye.
 cause temporary blindness and vision loss.
Motor neuropathy
 paralysis of the muscles affected by the shingles virus.
 Approximately 75% of people with this complication notice a gradual recovery of motor function.
Meningitis
 infection of the fluid surrounding the brain and spinal cord, the cerebrospinal fluid.
 symptoms :
 severe headache
 sensitivity to light
 achy muscles
 fever
Ramsay Hunt Syndrome
 herpes zoster virus spreads to the facial nerve, which causes intense ear pain.
 hearing loss
 Dizziness
 facial paralysis
▪ usually temporary, but not always.

Pharmacological Management of Pain

*Adjuvants can be simple analgesics, steroids, antihistamine, antidepressants, anticonvulsants etc.

3 Step Ladder for Pain Management - introduced by WHO

Step 1 : Mild Pain

• SImple analgesic such as paracetamol and aspirin or NSAID
• Paracetamol do not have anti-inflammatory action but aspirin does and has antipyretic action.
• Both simple analgesic and NSAID have similar mechanism of action that is,they both inhibit COX-2
• Side effect of aspirin: causes stomach ulcers due to the decrease production of protective mucous (due to inhibition of prostacyclin 2 and 3) and increases gastric acid secretion (due to inhibition of prostacyclin 1)
• Aspirin is hydrolysed and removed by kidney

Diclofenac (voltaren) - NSAID

• accumulates in the synovial fluid

• should not be given to patients who have experienced asthma, urticaria, or other

  allergic-type reactions after taking aspirin or other NSAIDs.

• exhibits anti-inflammatory, analgesic, and antipyretic activities in animal models.

Step 2: Mild to Moderate Pain

Weak opioids such as codeine (fyi, codeine is antitussive= cough supressore)

• Codeine less potent analgesic than morphine
• High oral effectiveness
• Used in combination with aspirin
• Rarely causes dependence

Step 3: Moderate to Severe Pain

Strong opioids such as morphine

• Mechanism of action: cause hyperpolarization of nerve cells, inhibition of nerve firing and presynaptic inhibition of transmitter release and inhibition of excitatory transmitters release from nerve terminals carrying nociceptive stimuli
• Usually given IV, subcutenously or IM because first pass metabolism of morphine occurs in the liver but the absorption of morphine from the GIT is slow
• Relieves pain by raising pain threshold at spinal cord level and altering brain's perception of pain
• Side effects : respiratory depression (acute opioid poisoning), vomiting, dysphoria(opposite of euphoria), sedation, constipation, nausea, urinary retention, potential addiction
• Depressant actions of morphine are enhanced by MAO inhibitors, tricyclic anti depressants
• Morphine is conjugated in the liver to glucuronic acid and excreted primarily in the urine
• Duration of action is 4 to 6 hours if administered systemically
• Fentanyl is used if patient is tolerant to opioids because fentanyl has 100-fold analgesic potency of morphine

*Diagnostically important- morphine causes pupil constriction known as pinpoint pupils but many other cases of coma and respiratory depression will produce dilation of pupils.

Methadone

• Well absorbed when administered orally
• Long lasting because accumulates in tissue and binds to protein which are slowly released from
• can cause constipation due to increase in biliary pressure
• can cause physical dependance but milder
• usually use for drug abuses who experiences withdrawal symptoms

SOCRATES mnemonic

Site of pain (exact location) in this case which part of the arm?
Onset-when did the pain start? did it start suddenly or gradually?
Character-Describe the pain. Is it sharp? knife like? gripping? burning? crushing? Radiation-Does the pain spread anywhere? shoulder? jaw? groin?
Association-Does the pain come with any other symptoms?
Timing-Does the pain vary in intensity during the day?
Exacerbating and releving factors-does anything make the pain better or worse?
Severity-Does the pain interupt any activities? sleep?

Good tutorials slides!... i think

http://www.nlm.nih.gov/medlineplus/tutorials/

watch it when you are bored, lonely and depressed.... =)

Tutorial on chicken pox and shingles

http://www.nlm.nih.gov/medlineplus/tutorials/shingles/htm/_no_50_no_0.htm

it's pretty good.. go thru' it!

ONCE AGAIN.....thank you GROUP H... lol

http://www.medicalmnemonics.com/pdf/2002_09_full_unabr_a4.pdf

cool mnemonics!

PCL - 6 Gate controlled theory

Whoever is doing with me, do add on. =) This is what I have done.

Reference: http://health.howstuffworks.com/pain4.htm

NOTE: The large nerve fibres are your A - beta fibres and the small nerve fibres are your C fibres. (remember? Dr. Badariah's lecture today.. Not that I paid attention but yeah I do remember hearing that. Lol.)

Gate Control Theory of Pain

To explain why thoughts and emotions influence pain perception, Ronald Melzack and Patrick Wall proposed that a gating mechanism exists within the dorsal horn of the spinal cord. Small nerve fibers (pain receptors) and large nerve fibers ("normal" receptors) synapse on projection cells (P), which go up the spinothalamic tract to the brain, and inhibitory interneurons (I) within the dorsal horn.

The interplay among these connections determines when painful stimuli go to the brain:

1. When no input comes in, the inhibitory neuron prevents the projection neuron from sending signals to the brain (gate is closed).
2. Normal somatosensory input happens when there is more large-fiber stimulation (or only large-fiber stimulation). Both the inhibitory neuron and the projection neuron are stimulated, but the inhibitory neuron prevents the projection neuron from sending signals to the brain (gate is closed).
3. Nociception (pain reception) happens when there is more small-fiber stimulation or only small-fiber stimulation. This inactivates the inhibitory neuron, and the projection neuron sends signals to the brain informing it of pain (gate is open).

Descending pathways from the brain close the gate by inhibiting the projector neurons and diminishing pain perception.

This theory doesn't tell us everything about pain perception, but it does explain some things. If you rub or shake your hand after you bang your finger, you stimulate normal somatosensory input to the projector neurons. This opens the gate and reduces the perception of pain.

Treatment for neuropathic pain

Treating the underlying cause
If this is possible, it may help to ease the pain. For example, if you have diabetic neuropathy then good control of the diabetes may help to ease the condition. If you have cancer, if this can be treated then this may ease the pain. Note: the severity of the pain often does not correspond with the seriousness of the underlying condition. For example, postherpetic neuralgia (pain after shingles) can cause a severe pain, even though there is no rash or signs of infection remaining.

Medicines used to treat neuropathic pain

Commonly used ordinary painkillers
You may have already tried 'ordinary' painkillers such as paracetamol or anti-inflammatory painkillers that you can buy from pharmacies. However, these are unlikely to ease neuropathic pain very much in most cases.

Tricyclic antidepressant medicines
An antidepressant medicine in the 'tricyclic' group is a common treatment for neuropathic pain. It is not used here to treat depression. Tricyclic antidepressants ease neuropathic pain separate to their action on depression. It is thought that they work by interfering with the way nerve impulses are transmitted. There are several tricyclic antidepressants, but amitriptyline is the one most commonly used for neuralgic pain. In many cases the pain is stopped, or greatly eased, by amitriptyline. Imipramine and nortriptyline are other tricyclic antidepressants that are sometimes used to treat neuropathic pain.

A tricyclic antidepressant may ease the pain within a few days, but it may take 2-3 weeks. It can take several weeks before you get maximum benefit. Some people give up on their treatment too early. It is best to persevere for at least 4-6 weeks to see how well the antidepressant is working.

Tricyclic antidepressants sometimes cause drowsiness as a side-effect. This often eases in time. To try and avoid drowsiness, a low dose is usually started at first, and then built up gradually if needed. Also, the full daily dose is often taken at night because of the drowsiness side-effect. A dry mouth is another common side-effect. Frequent sips of water may help with a dry mouth. See the leaflet that comes with the medicine packet for a full list of possible side-effects.

Other antidepressant medicines
An antidepressant called venlafaxine has also been shown in research trials to be good at easing neuropathic pain. Venlafaxine is not classed as a tricyclic antidepressant but as a 'serotonin and noradrenaline re-uptake inhibitor (SNRI)'. It may be tried if a tricyclic antidepressant has not worked so well, or has caused problematic side-effects. The range of possible side-effects caused by venlafaxine are different to those caused by tricyclic antidepressants. Another group of antidepressants are called SSRIs (Selective Serotonin Receptor Inhibitors). There is some evidence to suggest that medicines in this group may help to ease neuropathic pain but more research is needed to confirm this.

Anti-epileptic medicines (anticonvulsants)
An anti-epileptic medicine is an alternative to an antidepressant. For example, gabapentin, pregabalin, sodium valproate, and carbamazepine. These medicines are commonly used to treat epilepsy but they have also been found to ease nerve pain. An anti-epileptic medicine can stop nerve impulses causing pains separate to its action on preventing epileptic seizures. As with antidepressants, a low dose is usually started at first and built up gradually, if needed. It may take several weeks for maximum effect as the dose is gradually increased.

Opiates and similar painkillers
Opiates painkillers are the stronger 'traditional' painkillers. For example, codeine, morphine and related drugs. Another painkiller called tramadol is similar but has a distinct method of action that is different to opiate painkillers. Opiates and tramadol tend to be good at treating non-neuropathic pain. They also have a role in treating neuropathic pain, but may be less effective than in treating non-neuropathic pain. Also, there is a risk of problems of drug dependence, impaired mental functioning and other side effects with the long-term use of opiates. In general, opiates and tramadol tend to be used mainly if there are problems or side-effects with using antidepressant or anti-epileptic drugs. A recent research review concluded that tramadol in particular may be a good option for neuropathic pain in certain situations.

Combinations of medicines
Sometimes both an antidepressant and an anti-epileptic medicine are taken if either alone does not work very well. Sometimes an opiate such as codeine is combined with an antidepressant or an anti-epileptic medicine. As they work in different ways they may compliment each other and have an additive effect on easing pain better than either alone.

Capsaicin cream
This is sometimes used to ease pain if the above medicines do not help, or cannot be used because of problems or side-effects. Capsaicin is thought to work by blocking nerves from sending pain messages. Capsaicin cream is applied 3-4 times a day. It can take up to 10 days for a good pain relieving effect to occur. Capsaicin can cause an intense burning feeling when it is applied. In particular, if it is used less than 3-4 times a day, or if it is applied just after taking a hot bath or shower. However, this side-effect tends to ease off with regular use. Capsaicin cream should not be applied to broken or inflamed skin. Wash your hands immediately after applying capsaicin cream.

Other medicines
Some other medicines are sometimes used on the advice of a specialist in a pain clinic. These may be an option if the above medicines do not help.For example, ketamine injections. Ketamine is normally used as an anaesthetic, but at low doses can have a pain relieving effect. Another example is lidocaine (lignocaine) gel. This is applied to skin with a special 'patch'. It is sometimes used for postherpetic (post shingles) neuralgia (but note, it needs to be put onto non-irritated or healed skin).

Physical treatments
Depending on the site and cause of the pain, a specialist in a pain clinic may advise one or more physical treatments. These include: physiotherapy, acupuncture, nerve blocks with injected local anaesthetics and TENS machines ('Transcutaneous Electrical Nerve Stimulation').

Psychological treatments
Pain can be made worse by stress, anxiety and depression. Also, the perception ('feeling') of pain can vary depending on how we react to our pain and circumstances. Where relevant, treatment for anxiety or depression may help. Also, treatments such as stress management, counselling, cognitive behaviour therapy, and pain management programmes sometimes have a role in helping people with chronic (persistent) neuropathic pain.

http://www.patient.co.uk/health/Neuropathic-Pain.htm

Voltaren

Generic Name: diclofenac (dye-KLOE-fen-ak)

Some information about the drug.

http://www.pharma.us.novartis.com/product/pi/pdf/Voltaren.pdf

http://www.betterhealth.vic.gov.au/bhcv2/bhcmed.nsf/pages/nvcvltal/$File/nvcvltal.pdf

Assessment of pain

HISTORY

The onset of the pain
How long ago did it first start?
Was there any apparent cause for the pain then?
Was the start sudden or gradual?

The severity of the pain
You may be asked to describe this in words or to use a pain scale .
Does the severity vary?
Are there any things that worsen the pain (for example lifting, eating) or that reduce the pain (for example rest, painkillers)?

The quality of the pain
You will be asked to describe the pain in words. For example, pain may be sharp (stabbing), dull (aching), burning, like a tight band, etc.
There may be more than one type of pain, for example a constant dull ache with occasional sharp stabs.

The site of the pain
You will be asked to indicate where the pain is, and you may be asked to draw the site of the pain on a picture.
Sometimes the pain starts in one place and then extends (radiates) somewhere else. An example of this is sciatica, when pain in the back radiates down a leg.
You may have more than one site of pain. If so, you may be asked which is the most troublesome.

Timing
When did the pain start?
Does the pain
remain all the time?
appear every now and then?
come and go quite frequently (for example migraine)?
Is the pain worse at a particular
time of the day or night?
time in the menstrual cycle (for women)?

Are there other associated symptoms?
Associated symptoms will vary according to the site and cause of the pain, but could include a bloating feeling in the abdomen, weakness or numbness in the legs, or alterations in vision. It may also include mood symptoms such as depression. Chronic pain often causes depression, and depression in turn increases the perception of pain.

How is the pain affecting functioning (housework, employment, social life)?
The way the pain affects you will vary according to the site of pain, the underlying cause and you as a person. Different people respond differently to their pain, but the effect the pain is having on your life may alter the approach taken to treat it.


PAIN ASSESSMENT TOOLS

The McGill Pain Questionnaire
Contains a list of descriptive words to choose, to indicate the intensity and character of the pain, with a drawing of a body on which you draw in where the pain affects you.

The Brief Pain Inventory
This questionnaire has a number of scales on which to rate, from one to ten, aspects of the pain, the response to treatment and the effect of the pain on function in everyday activities. There is also a drawing of a body to indicate where the pain is, as in the McGill questionnaire.

The Neuropathic Pain Scale
This questionnaire is particularly designed for people suffering from pain due to nerve disease or damage (neuropathic pain). This type of pain can feel very strange and be difficult to describe. This questionnaire involves rating descriptions of the pain (such as hot or itching) from one to ten


PAIN DIARY
This involves recording, usually for one week, your level of pain (on a pain scale) several times a day, and making notes on activities or other things that seem to worsen the pain, as well as of any medication you take and the effect it has. This can be very helpful in establishing whether there is any particular pattern to the pain, or any triggers that could be avoided.


PAIN SCALES
A pain scale is an attempt to assess the degree of pain you are feeling. You may be asked either to
- describe your pain in words as: no pain, mild, moderate or severe
- say or mark on a line a number from one to ten indicating how severe your pain is.

A scale has been developed for use with children, which has a row of face drawings showing different expressions. The child has to choose the face with an expression closest to how they feel.

However, because pain is subjective, and each person has a different past experience of pain, these scales do not allow one person's score to be compared to another person. They are most useful in monitoring an individual's response to treatment, by showing a change in that person's score over time.

PHYSICAL EXAMINATION
Physical examination may be done either to look for a possible cause for the pain, or to rule out possible serious disease. Sometimes areas other than the painful area will need to be examined. Precisely what form this takes will obviously vary according to the type and site of pain.

TEST AND PROCEDURES - check underlying cause of pain
Blood tests , Computerised tomography (CT scan), Electromyography, Magnetic resonance imaging (MRI scan), Nerve conduction study, Radiography (X-ray)

http://www.paineurope.com/index.php?q=en/book_page/assessment_of_pain

Cholinergic Nerve- Parasymp

>>>>Response ( opposite effects of symp.)

2 types

• nicotinic ( ionotropic , fast) - blocked by tubocurarine

activated by nicotine, NMJ, skeletal muscles

• muscarinic ( metabotropic, slow) - blocked by atropine

heart (decrease heart rate) , GI muscle (contract), blood vessels(indirect, vasodilation), constrict pupil, hypotension

>>>>Removal

• cholinesterase (enzyme)

highly concentrated at NMJ... why? for ACh to function, ACh must be removed immediately

Adrenergic Nerves - Sympathetic

i've got no life so yeah, revising pharmaco...a quick summary on adrenergic nerves...so, read if you want to... =)

Release> Response> Removal

>>>>Release - caused by AMPHETAMINE which acts as indirect adrenergic agonist Function of amphetamine: displaces NA from storage vesicles of adrenergic nerves/ causes more release of more NA (precursor of adrenaline) - amphetamine is a sympathomimetics which means mimics sympathetic effects

>>>Response - alpha (blood vessels) and beta (heart, lungs) -fight or flight response - increase heart rate, bronchodilation , vasoconstriction of skin, vasodilation of muscles, inhibit GIT(both alpha and beta)

>>>Removal- uptake 1 (recaptures) and 2 (taken in by tissues)

Uptake 1 blocked by COCAINE, seratonin, dopamine and NA ( dopamine and NA are precursors of adrenaline)

definitions of different types of pain

Allodynia:means "other pain" and refers to:
Pain caused by stimuli which are not normally painful

Hyperalgesia:an increased sensitivity to pain, which may be caused by damage to nociceptors or peripheral nerves.
Hyperalgesia is often a component of a neuropathic pain syndrome

Hyperpathia:An abnormally exaggerated response to a painful stimulus
evere explosive or persistent pain.
Hyperpathia is often a component of a neuropathic pain syndrome

Idiopathic pain:Occurring without a known cause.
is a diagnosis of pain which is suffered by a patient for longer than 6 months, for which there is no physical cause and no specific mental disorder.

Malignant pain:
pain associated with diseases like cancer caused by the tumour affecting the surrounding tissues, most commonly bone tumours. The pain can be either due to the disease itself or due to the treatment given for cancer like surgery, radiotherapy and chemotherapy. The pain needs to be carefully assessed and appropriately treated

Paresthesia:

abnormal skin sensations (as tingling or tickling or itching or burning) with no apparent long-term physical effect, more generally known as the feeling of pins and needles or of a limb being "asleep" and is usually associated with peripheral nerve damage
It is normally experienced in the extremities (hands, arms, legs, or feet), but can also occur in other parts of the body.
The sensation gradually goes away once the pressure on the nerve is relieved.
Chronic paresthesia indicates a problem with the functioning of nerve cells, or neurons or may arise due to direct damage to the nerves themselves, or neuropathy.

Phantom limb pain:
refers to the severe pain and tingling sensation which continue to be experienced from the perceived existence of the limb which has be amputated. It commonly arises in cases where the amputation is delayed after the initial injury. The perceived limb may be felt to be felt to be lying in an abnormal and uncomfortable position. Damage to nerve endings play an important part in this condition with the resulting erroneous regrowth of nerve tissue triggering abnormal and painful discharge of neurones in the stump, and there is often a change in the way that nerves from the amputated limb connect to neurones within the spinal cord.

Psychogenic pain:
is entirely or mostly related to a psychologic disorder where a person has persistent pain with evidence of psychologic disturbances and but no evidence of a disorder that could cause the pain.
It should be noted that it is very rare for pain to be purely psychogenic and more commonly, the pain has a physical cause but the degree of pain is out of proportion with what most people with a similar disorder experience.

Pain for Monday's PCL

Types of pain

• Nociceptive Pain arises from the stimulation of specific pain receptors. These receptors can respond to heat, cold, vibration, stretch and chemical stimuli released from damaged cells.
  
  
• Non-Nociceptive Pain arises from within the peripheral and central nervous system. Specific receptors do not exist here, with pain being generated by nerve cell dysfunction.

Somatic Pain (possible cause of Lee Peng's pain)

• Source - tissues such as skin, muscle, joints, bones, and ligaments - often known as musculo-skeletal pain.
  
  
• Receptors activated - specific receptors (nociceptors) for heat, cold, vibration, stretch (muscles), inflammation (e.g. cuts and sprains which cause tissue disruption), and oxygen starvation (ischaemic muscle cramps).
  
  
• Characteristics - often sharp and well localised, and can often be reproduced by touching or moving the area or tissue involved.
  
  
• Useful Medications - may respond to combinations of Paracetamol, Weak Opioids OR Strong Opioids, and NSAIDs

Visceral Pain (d'oh...... )

• Source - internal organs of the main body cavities.
  There are three main cavities -
  - thorax (heart and lungs),
  - abdomen (liver, kidneys, spleen and bowels),
  - pelvis (bladder, womb, and ovaries).
  
  
• Receptors activated - specific receptors (nociceptors) for stretch, inflammation, and oxygen starvation (ischaemia).
  
  
• Characteristics - often poorly localised, and may feel like a vague deep ache, sometimes being cramping or colicky in nature. It frequently produces referred pain to the back, with pelvic pain referring pain to the lower back,
  abdominal pain referring pain to the mid-back,
  and thoracic pain referring pain to the upper back.
  
  
• Useful medications - usually very responsive to Weak Opioids and Strong Opioids.

Nerve Pain (likely to be the cause of Lee Peng's Pain, old age?)

• Source - from within the nervous system itself - also known as pinched nerve, trapped nerve. The pain may originate from the peripheral nervous system (the nerves between the tissues and the spinal cord), or from the central nervous system (the nerves between the spinal cord and the brain)
  
  
• Causes - may be due to any one of the following processes
• Nerve Degeneration - multiple sclerosis (hardening), stroke, brain haemorrhage, oxygen starvation
• Nerve Pressure - trapped nerve
• Nerve Inflammation - torn or slipped disc
• Nerve Infection - shingles and other viral infections
  
  
• Receptors activated - the nervous system does not have specific receptors for pain (non nocicpetive). Instead, when a nerve becomes injured by one of the processes named above, it becomes electrically unstable, firing off signals in a completely inappropriate, random, and disordered fashion.
  
  
• Characteristics - These signals are then interpreted by the brain as pain, and can be associated with signs of nerve malfunction such as hypersensitivity (touch, vibration, hot and cold), tingling, numbness, and weakness.
  There is often referred pain to an area where that nerve would normally supply e.g. sciatica from a slipped disc irritating the L5 spinal nerve produces pain down the leg to the outside shin and big toe i.e. the normal territory in the leg supplied by the L5 spinal nerve. Spinal nerve root pain is also often associated with intense itching in the distribution of a particular dermatome. People often describe nerve pain is often described as lancinating, shooting, burning, and hypersensitive.
  
  
• Useful Medications - only partially sensitive to paracetamol, NSAIDs, Opioids. More sensitive to Anti-depressants, Anti-convulsants, Anti-arrhythmics, and NMDA Antagonists. Topical Capsaicin, may be helpful
  
  

Sympathetic Pain ( unlikely, because no changes in skin)

• Source - due to possible over-activity sympathetic nervous system, and central / peripheral nervous system mechanisms. The sympathetic nervous system controls blood flow to tissues such as skin and muscle, sweating by the skin, and the speed and responsiveness of the peripheral nervous system.
  
  
• Causes - occurs more commonly after fractures and soft tissue injuries of the arms and legs, and these injuries may lead to Complex Regional Pain Syndrome (CRPS). CRPS is a chronic progressive disease characterized by severe pain, swelling and changes in the skin and was previously known as Reflex Sympathetic Dystrophy (RSD).
  
  
• Receptors activated - like nerve pain there are no specific pain receptors (non nociceptive). Similar process to nerve pain.
  
  
• Characteristics - presents as extreme hypersensitivity in the skin around the injury and also peripherally in the limb (allodynia),
  and is associated with abnormalities of sweating and temperature control in the area.
  The limb is usually so painful, that the sufferer refuses to use it, causing secondary problems after a period of time with muscle wasting, joint contractures, and osteoporosis of the bones. It is possible that the syndrome is initiated by trauma to small peripheral nerves close to the injury.
  
  
• Useful medications - many of the features of sympathetic pain are similar to those of nerve pain, and therefore nerve pain medications may be useful (Anti-depressants, Anti-convulsants, and Anti-arrhythmics).
  Drugs which lower blood pressure by causing vasodilatation (nifedipine) may also be useful when used in combination.
  Treatment should include appropriate multi-modal medications, sympathetic nerve blocks, and intensive rehabilitation combining occupational and physiotherapy.

SOURCE: http://www.painclinic.org

History and further information and physical examination to make a diagnosis
-WWQQAAB
-Blood test to check for infection

Factors that affect perception of pain

Refer to Dr. Amudha's notes.....

1)Physical -Insomnia, exhaustion, loss of independence,Poor previous management

2)Psychological-Depression, anger, anxiety

3) Social-Financial, legal, interpersonal relationships

4)Cultural-Negative cultural attitudes to disease/painLanguage barriers

5)Spiritual-Meaninglessness, guilt, regrets, unresolvedspiritual questions

• Chronic stress increases both the perception of pain and disability.
• isolation and inactivity increase it and foster self-preoccupation

Cognitive factors have an impact on pain in several ways.

• First, the adverse quality of pain is modified by its interpretation. Such “catastrophic” interpretation of pain as in,“My nerves are being crushed,” or “I may become paralyzed,” impede coping. The situation is not helped by physicians who attribute pain to such pathology when this may not be true. Take, for instance, the very common experience of back pain, which is the leading cause of disability and absenteeism from the workplace. Specific causes of back pain, such as infections, tumors, osteoporosis, spondyloarthopathies and trauma, represent a minority of pain syndromes. Conversion of acute back pain to chronic may be in part iatrogenic, meaning it is at least in part made worse by the doctor who is trying to treat the pain.
• Belief in personal helplessness fosters pain and disability; on the other hand, a sense of self-efficacy promotes efforts to cope. Thus, perceptions of helplessness lead to depression, resignation and passivity, which, in turn, increase disability and pain. Self-efficacy, the opposite of helplessness, is correlated with successful rehabilitation in fibromyalgia, for instance.
• “locus of control” refers to one’s sense of the origins of events. The perception that events are a consequence of the individual own behavior (internal locus of control) is associated with better mood and function. Those with an external locus of control tend to see events as contingent on other people or “fate.” People with chronic pain who have an external locus of control report depression and anxiety, feel helpless to deal with their pain and often rely on maladaptive coping strategies, such as excessive rest and eating. Decreased perception of self-control may explain much of the relationship between depression and pain
  
  
• Anxiety seems to intensify such symptoms as myalgias and neuropathic pain. Anxiety can be the major reason for failure of rehabilitation. Phobic processes have been implicated on a cycle of unnecessary self-protection, leading to deconditioning. When people became afraid to move, disability and dysfunction can result as much from unwarranted fear as from the pain itself.

SOURCE: http://www.spineuniverse.com/displayarticle.php/article3348.html

Examination of the Ear

Hey people...... Just a brief summary of the ear exam!

Testing the Eight Cranial (Acoustic) Nerve

Two components

• Cochlear - afferent fibres subserving hearing , organ of Corti
• Vestibular - afferent fibres subserving balance, begin in utricle and semicircular canals and joins with auditory fibres of facial canal

History

• Noticed by patient or relatives?
• Unilateral hearing loss more common - nerve lesion?
• Gradual or sudden onset?
• History of deafness? Occupational ? Recreational? Exposure to loud noise?
• History of trauma or recurrent ear infections?

Examination

• Look at patient's ear, if patient is wearing hearing aid, remove it.
• Examine pinna :-

-look for scars behind ears

-pull on pinna gently, if tender = external ear disease/temporomandibular joint

-feel for nodes, if present = disease of external auditory meatus (canal)

• Inspect external auditory meatus (canal)

- Canal angulates, thus, to see eardrum, pull the auricle(earlobe) up and backwards before inserting otoscope ( oto = ear)

- Normal eardrum = PEARLY GREY and CONCAVE

- Look for wax or other obstructions and inspect eardrum for inflammation

A Quick Simple Test to test hearing

• Cover opposite auditory meatus with 1 finger, moving this finger as a distraction while you whisper a number in the other ear
• Use same numbers for both ears.
• For high tone, use 68 and low tone, use 100
• Whisper towards the end of expiration to standardize volume and 60cm from ear
• Examiner's larynx should not vibrate if whispering is soft enough

If partial deafness is suspected, Rinne's and Weber's Tests

Rinne's Test : it compares the patients ability to hear a tone conducted via air and bone - the mastoid process.

• normal ear, air conduction (AC) is better than bone conduction (BC) = Rinne Positive
• conductive hearing loss, bone conduction is better than air = Rinne Negative

Weber's Test: it compares bone conduction in both ears. It is most valuable in distinguishing between a true and false Rinne's negative test. It is frequently done post-operatively, to check that the ear is active.

If the sound lateralizes (is louder on one side than the other), it suggests the following:

• an ipsilateral(same side) conductive hearing loss
• a contralateral(opposite site) sensorineural (caused by lesion/disease of inner ear/auditory nerve) hearing loss.

Extra info on weber's test:

http://hemakumar.fastlink.in/pdfs/webertest.pdf