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Acute and chronic pain management

Differential Diagnosis Schema 🧠

Acute Pain

  • Musculoskeletal: Trauma, fracture, sprain, acute disc prolapse, tendonitis.
  • Visceral: Appendicitis, cholecystitis, pancreatitis, renal colic, myocardial infarction.
  • Neuropathic: Herpes zoster, nerve compression (e.g., carpal tunnel syndrome), acute radiculopathy.
  • Inflammatory: Rheumatoid arthritis flare, gout, septic arthritis.
  • Post-surgical: Immediate post-operative pain, pain from surgical wound.

Chronic Pain

  • Musculoskeletal: Osteoarthritis, chronic low back pain, fibromyalgia.
  • Neuropathic: Diabetic neuropathy, post-herpetic neuralgia, trigeminal neuralgia.
  • Visceral: Chronic pancreatitis, chronic pelvic pain, irritable bowel syndrome (IBS).
  • Oncological: Cancer pain, bone metastases.
  • Mixed: Complex Regional Pain Syndrome (CRPS), phantom limb pain.

Key Points in History πŸ₯Ό

Pain Characteristics

  • Onset: Sudden (suggests acute process such as trauma, MI) vs. gradual (suggests chronicΒ condition).
  • Location: Focal (e.g., appendicitis, pancreatitis) vs. diffuse (e.g., fibromyalgia, chronic pain syndrome).
  • Duration: Minutes to hours (acute) vs. weeks to years (chronic).
  • Quality: Sharp, stabbing (neuropathic pain) vs. dull, aching (musculoskeletal pain).
  • Radiation: Radiates to back (pancreatitis, AAA) vs. localised (osteoarthritis).
  • Severity: Mild to severe, with or without response to analgesics.

Aggravating/Relieving Factors

  • Movement: Aggravates (musculoskeletal pain) vs. alleviates (visceral pain).
  • Position: Worse lying flat (pancreatitis) vs. better sitting up (pericarditis).
  • Medication: Response to NSAIDs (inflammatory pain) vs. opioids (severe acute or cancer pain).
  • Time of day: Worse in the morning (inflammatory arthritis) vs. no diurnal variation (chronic pain syndromes).

Background

  • Past Medical History: Previous similar episodes (chronic conditions), known comorbidities (e.g., diabetes for neuropathy).
  • Drug History: Analgesics currently or previously used, impact on pain.
  • Family History: Similar pain conditions (genetic predisposition), cancer history (oncological pain).
  • Social History: Occupation (repetitive strain injuries), lifestyle factors (obesity, physical activity).

Possible Investigations 🌑️

Laboratory Tests

  • Full Blood Count (FBC): To identify infection, anaemia.
  • Urea and Electrolytes (U&E): Assess renal function, electrolyte imbalances.
  • C-Reactive Protein (CRP) and Erythrocyte Sedimentation Rate (ESR): Markers of inflammation.
  • Liver Function Tests (LFTs): Assess hepatic causes of pain, medication effects.
  • Amylase/Lipase: Suspected pancreatitis.
  • Blood Glucose/HbA1c: In cases of neuropathic pain, screen for diabetes.

Imaging

  • X-Ray: First-line for suspected fractures, joint pathology.
  • Ultrasound: Useful for soft tissue injuries, biliary pathology.
  • CT Scan: Detailed assessment of abdominal or pelvic pain, trauma.
  • MRI: Soft tissue, spinal cord evaluation, chronic pain syndromes.
  • Nerve Conduction Studies: Neuropathic pain assessment.

Special Tests

  • Lumbar Puncture: Suspected meningitis, subarachnoid haemorrhage.
  • Endoscopy: GI tractΒ pain, unexplained abdominal pain.
  • Electromyography (EMG): Muscle and nerve assessment.

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