General principles of clinical examination of a patient with pain

The key to a true diagnosis is a complete history and detailed examination. Data from the survey, in conjunction with a review of previous patient records and diagnostic examinations, provide the key to differential diagnosis and treatment. In the medicine of pain, the majority of patients saw a variety of specialists, underwent various diagnostic examinations, and, eventually, appealed to the pain clinic as the last means of salvation. With the advancement of scientific research and the improvement in the training of first-aiders, this trend is beginning to change, and more patients are being referred to specialists in pain departments at earlier stages of the disease, with a more favorable outcome as a result

• Patient survey

Anamnesis of pain: localization of pain, time of onset of attack, intensity, nature, concomitant symptoms, factors aggravating and reducing pain.

It is important to know when and how pain has occurred. The attack of pain should be accurately described (for example, sudden, gradual or impetuous). If the provoking factor is known, the time and circumstances of the onset of a pain attack, then the cause is easier to establish. In cases of injury at work and in car accidents, the condition of patients before and after the injury must be interpreted correctly and documented.

The duration of the pain is very important. If the episode of pain does not last long, like acute pain, treatment should be directed at eliminating the cause. In case of chronic pain, the root cause is usually already eliminated and treatment should focus on optimal therapy.

To determine the intensity of pain, various methods are used. Because the complaints of pain are completely subjective, it can only be compared to the pain of the person he has ever experienced; this can not be compared with the description of another person's pain. Several scales are used to describe the level of pain that is required. The most commonly used scale is the visual-analogue scale (VAS) of the pain intensity. Using this scale, patients should place a marker on a 100 mm continuous line between the meaning "no pain" and "maximum imaginable pain". The mark is evaluated using a standard ruler and recorded as a digital value between 0 and 100. An alternative "pain estimate method" is the use of a verbal digital evaluation scale. The patient immediately determines the number from 0 (no role) to 100 (the most imaginable pain). The verbal digital assessment scale is often used in clinical practice. Another frequently used method is the verbal rank scale, where the intensity is in order from the absence of pain to mild, moderate and strong to maximum tolerable.

The patient's description of the nature of pain is quite useful when considering various types of pain. For example, burning or shooting often describes neuropathic pain, whereas cramping is commonly called nociceptive visceral pain (eg, spasm, stenosis, or blockage). Pain, described as pulsating or knocking, assumes the presence of a vascular component.

It should also be noted the evolution of pain from the onset of an attack. Some types of pain change localization or spread beyond the primary focus of injury or trauma. The direction of the spread of pain gives important clues to the etiology and, ultimately, [diagnosis and treatment of this condition. As a scraper, you can cite a complex regional pain syndrome (CRPS), which can begin in a restricted area. Such as distal limb sections and then spread proximally and in some cases even to the contralateral side.

It is necessary to ask the patient about the presence of concomitant symptoms, including numbness, weakness, intestinal and / or genitourinary disorders, edema, cold sensitivity and / or decreased motor capacity of the limb due to pain.

It is necessary to identify factors that increase pain, since sometimes they reveal the pathophysiological mechanism of pain. Annoying mechanical factors, such as various postures or activities such as sitting, standing, walking, flexing, lifting can help differentiate one cause of pain from another. Biochemical shifts (eg, glucose and electrolyte levels or hormonal imbalances), psychological factors (eg, depression, stress and other emotional problems), and environmental factors (the effect of diets and weather changes, including atmospheric pressure changes) can be important diagnostic keys. It is also necessary to establish factors that alleviate pain. Certain body positions can relieve pain more than others (for example, in most cases of neurogenic lameness, a sitting position is an alleviating factor, while standing or walking increases pain). Pharmacological action and "nerve blockade" help the clinician diagnose and choose the appropriate treatment

The patient should be asked about the previous treatment. Information on analgesic effectiveness, duration of treatment, doses and side effects of medications helps to avoid the recurrence of methods or the use of drugs that have proved ineffective the last time. The list should include all therapies, including physiotherapy, occupational therapy, manual therapy, acupuncture, psychological treatment, and visiting other pain clinics.

Anamnesis of life

• Evaluation of systems.

Evaluation of systems is an integral part of the full assessment of patients with chronic and acute pain. Some systems, directly or indirectly, may be relevant to the symptoms of the patient, others may be important for tactics of managing or treating a morbid condition. An example is a patient with reduced blood coagulability, which can not be injected; or someone with kidney or liver failure, who needs to adjust the dosage of medications.

• Previously transmitted diseases.

Previous health problems should be described, including already resolved conditions. It is necessary to record previous injuries and past or present psychological or behavioral disorders.

• Anamnesis of surgical interventions.

It is necessary to make a list of operations and complications, preferably in chronological order, as some cases of chronic pain are the result of surgical procedures. This information is needed to diagnose and determine the tactics of treatment.

Medical history

Bpac should limit and correct the patient's admission of medicines, as it is necessary to take into account the complications, interactions and side effects of these drugs. The survey should include both painkillers, over-the-counter and mutually exclusive drugs (for example, acetaminophen, aspirin, ibuprofen, and vitamins). It should be noted allergy and to medicines and any other (for example, on latex, food, environmental factors). It is necessary to describe in detail the nature of a specific allergic reaction to each drug or agent.

Social anamnesis

• General social anamnesis.

In the analysis of psychological factors, it is necessary to understand the patient's social status, material support and motivation of behavior. It matters whether the patient is married, whether he has children and work. The level of education, job satisfaction, and attitude to life in general are important. Smoking and a history of alcohol or drug dependence are important in evaluating and developing a treatment strategy. Questions about the way of life, how long it takes to get to work or how much time is spent in front of the TV, favorite leisure activities and hobbies, sports and sleep give the practitioner a more complete picture of the patient.

• Family history

A detailed family history, including the health of the patient's parents, siblings, and descendants, provides important clues for understanding the biological and genetic profile of the patient. It should be noted the presence of rare diseases. A history of chronic pain, alcohol or drug abuse, and disability of family members (including the spouse) should be established. Keys that do not have a direct genetic or biological basis can help detect hereditary mechanisms and co-dependent behavior.

• Professional anamnesis

It is necessary to establish whether the patient has completed higher education and obtained scientific degrees. Pay attention to the specifics of this work and the previous profession. The amount of time spent on each job, the reasons for dismissal, any story about the trial, job satisfaction, but information about whether the patient is working full-time or part-time is important for professional evaluation. It is important to establish whether the patient had a group of disabilities, disability, whether vocational training for people with disabilities

Patient examination

Clinical examination is the main and valuable diagnostic tool. Over the past few decades, advances in medicine and technology and a better understanding of the pathophysiology of pain have greatly improved the methods of assessing the status of various systems, but the shortcomings in accurate diagnosis in most patients referred to the pain clinic emphasize the need for surveys focused on detail and detail.

Types of surveys include both general systemic studies (ten organ systems: musculoskeletal, nervous, cardiovascular, respiratory, ear / throat / nose, visual, genitourinary, circulatory / lymphatic / immune, mental and cutaneous), and one system. In the medicine of pain, the most frequently examined systems are musculoskeletal and nervous

If part of the diagnostic or therapeutic procedures are invasive, the study should show whether the patient does not have risk factors for these manipulations that need to be taken into account. Coagulopathy, an untreated infection, and constitutional neurological dysfunction should be noted before the introduction of the needle or catheter, or before implantation of any device. Particular caution should be exercised when local anesthetics are prescribed to patients with paroxysms of unexplained etiology, conductive anesthesia to patients with low tolerance to vasodilation, or the administration of glucocorticoids to patients with diabetes.

Inspection begins with the evaluation of individual systems and usually moves from head to foot.

General inspection

• Constitutional factors.

The weight, weight and basic indices of the body (blood pressure, heart rate, respiratory rate, body temperature, and pain intensity) should be measured and recorded. Pay attention to appearance, development, deformation, nutrition and care of the body surface. It is necessary to carefully study the devices brought by the patient. From patients who abuse alcohol or smokers, a specific smell may emerge. Watching a patient who does not know that they are looking at him, you can find inconsistencies, unnoticed during the survey.

• Painful behavior.

Pay attention to facial expressions, color and grimaces. Features of speech show the presence of emotional factors, as well as alcohol or drug intoxication. Some patients try to convince the doctor that they suffer from very severe pain, confirming their oral complaints with groans, wailing, convulsive movements, clutching at the painful area, unduly stressing the antalgic gait or posture, or straining the muscle groups. Unfortunately, this complicates the objective examination.

• Skin covers.

Assess color, temperature, rash and swelling of soft tissues. Changes in trophic skin, nails and hair are often observed in complex regional pain syndrome. In patients with diabetes, vascular pathology and peripheral neuropathy, one should look for lesions that may be the cause of chronic bacteremia requiring treatment before implantation of metal structures (eg, spinal cord stimulant or infusion pump apparatus).

System inspection

• The cardiovascular system.

Systolic murmur with dissemination indicates aortic stenosis, and the patient may have a decreased tolerance to hypovolemia and tachycardia that accompany rapid vasodilation (eg, after application of spinal local anesthetics and blockade of the sympathetic or solar plexus). A patient with arrhythmia can have atrial fibrillation, and he can take anticoagulants. It is necessary to check pulsation of arteries (diabetes, complex regional pain syndrome and upper chest aperture syndrome), filling of veins, presence of varicose extensions and capillary mesh. Vascular lameness should be distinguished from neurogenic lameness in patients. Who were diagnosed with stenosis of the spinal canal in the lumbar region. The increase in the number of invasive cardiac procedures, such as coronary artery bypass grafting, increased the number of young patients receiving antiplatelet agents.

• Pulmonary system.

The lung examination can detect respiratory noises, such as wet wheezing, which can serve as a sign of congestive heart failure and a decrease in the heart reserve. High wheezing dry wheezing may indicate chronic obstructive pulmonary disease. Care should be taken with blockages in the chest area due to the risk of pneumothorax.

• Musculo-skeletal system.

Inspection of the musculoskeletal system includes assessment of walking and posture. Deformations and asymmetries are estimated. After collecting an anamnesis, the doctor usually already has an idea of the part of the body in which the symptoms of the lesion arose. Otherwise, a short examination of the clinically relevant area is required. Positive tests are the basis for further and more thorough examination of the affected segment. Palpation of soft tissues, bone structures, inactive and mobile joints can reveal the temperature difference, the presence of puffiness, fluid accumulation, crevices, crackling, clicks and soreness. Functional comparison of the right and left sides, measurement of normal spinal bends and provocation of typical symptoms by manipulation can help in determining the mechanism and localization of the pathological process. Measurement of the amplitude of movements helps to identify the hyper- and hypo-mobility of the joints. Checking the active movements determines the flexibility, strength of the muscles and the willingness of the patient to cooperate. Passive movements, on the other hand, in case of correct execution, allow to reveal the presence of pain, to determine the amplitude, and volume. Most difficulties arise when examining patients with persistent pain, because they tend to respond to most manipulations positively, thus making the test specificity low.

• Special tests.

Rise of the straightened lower limb (Laceg symptom): determines the mobility of the dura mater and the dural sac at the level of L4-S2. Sensitivity of this test in the diagnosis of herniated discs 0.6-0.97, specificity 0.1-0.6.

Stretch nerve tension, starting from 15 to 30 degrees, is evaluated in the supine position. This leads to the tension of the roots of the nerves from L4 to S2 and the dura mater. Normally, the amplitude is limited by the tension of the hamstrings at a level of 60 to 120 degrees. A rise of more than 60 degrees causes movement in the sacroiliac joint and therefore can be painful in the presence of dysfunction of this articulation.

The main tests of the sacroiliac joint, causing pain in the gluteal region: (these tests are conducted to find out when the pain in the buttock occurs):

• in the patient's position, the cuff on his back with his arms crossed, push the iliac bones outwards and downwards. If there is pain and buttocks, repeat the test with the forearm of the patient under the lumbar spine to stabilize the lumbar vertebrae.
• the patient lies on the diseased side, the investigator forcefully presses the iliac bone in the direction of the median line, stretching the sacral ligaments.
• the patient lies on his stomach, press the center of the sacrum in the center direction.
• Patrick's test (pain due to ligament tension) - flexion, abduction, and rotation of the hipbone to the outside of the hip joint while simultaneously pressing the anterior superior ostium of the ilium of the contralateral side, which leads to tension of the anterior sacroiliac ligament.
• forced lateral rotation of the hip for bent at the knee joint by 90 ° in the patient's position lying on the back.

Assessment of the flexibility of the spine: flexion, extension, slopes to the side and rotation can be limited and / or painful due to the pathology of arcuate joints, discs, muscles and ligaments.

Reception of Adson: Adson's reception is used to confirm the syndrome of the upper aperture of the chest. The doctor determines the change in the filling of the pulse on the radial artery in a patient standing with arms apart. Turning the head ipsilateral during inspiration can cause compression of the vessels with an anterior staircase. When a modified admission Adson, the patient's head turns in the contralateral direction. Changing the pulse involves compression by the middle staircase muscle. Some experts consider both methods to be unreliable, since they can be positive in 50% of healthy people.

Tynel's test consists in percussion of the carpal tunnel. In case of a positive result, paresthesia appears distal to the place of percussion. It can be carried out at any other site (for example, the channel of the ulnar or tarsal nerves), where it is assumed that the nerve is contracted. The test of Fahlen is positive in case of carpal tunnel syndrome in case of sensation of numbness in less than 1 minute after passive wrist flexion

Neurological examination

• Assessment of the motor system begins with the evaluation of muscle mass, muscle tone, the presence of spasm.

Muscle strength is measured in the upper and lower limbs. Weakness can be due to the patient's reluctance to cooperate, fear of pain, insufficient effort, reflex suppression of motor impulses in the affected limb due to pain, or organic damage. Additional information can be obtained by examining the deep tendon reflexes, clonus, and pathological reflexes, such as the Babinsky reflex. Evaluation of coordination and higher motor skills can help in identifying associated dysfunctions.

The preservation of the functions of the cranial nerves is checked by examining the fields of vision, eye movements, pupils, the sensitivity of the shaft, the symmetry and strength of the facial muscles, hearing (for example, using a tuning fork, whispering, or finger rubbing), spontaneous and reflex (palpitations, language.

Sensitivity is determined by light touch (ab-fiber), needle prick (A8-fiber), and hot and cold stimulus (A8 and C-fibers). Tactile sensitivity can be measured quantitatively with Frey's hair. With neuropathic pain, the following symptoms are often observed: hyperesthesia, dysesthesia, allodynia, hyperpathy, temporary summation (a gradual increase in the sensation of pain with repeated exposure to the sharp end of the needle In an interval of more than 3 seconds).

Assessment of the state of intelligence is part of the neuropsychological examination. You should assess the level of mental abilities, orientation in space and time, speech, mood, affect, attention, thinking. A useful method of evaluation is a brief scale for assessing mental status (Mini-Mental Status Exam). Orientation in place and time, praxis, attention, account, memory and speech are tested. Each correct answer is given 1 point. The maximum number of points is 30. Cognitive disorders can be assumed with a score of less than 24 points.

Anamnesis and objective examination are the basis for assessing pain and treatment, are prerequisites for effective pain therapy. They are individual for each patient, which is due to the complexity of the problem of pain and the patient's condition.

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