PAIN

Chapter 29


imagePAIN




INTRODUCTION


As mentioned in Chapter 28, I have changed the order of the traditional 10 questions and I assign the first question to pain, but this is not to say that one should always start by asking about pain. The order of questioning should be flexible.


In this chapter I will discuss pain and its diagnostic points in general. Pain in various areas of the body is discussed under the relevant questions; for example, the diagnosis of chest pain will be found under the questions related to “Chest and abdomen”.




WHEN WE ASK


Obviously we need to ask about pain in great detail when this is the chief complaint. However, even if the patient comes to us for a condition that does not involve pain (e.g. asthma), we should always ask whether the person experiences pain in any part of the body. On the one hand, this may uncover a condition that the patient did not report spontaneously and, on the other hand, an analysis of the character, location and timing of pain may help us to confirm the original diagnosis; indeed, in some cases an analysis of the pain may also add a new dimension to our original diagnosis. For example, a woman may present with a chief complaint of mental depression which we diagnose as being caused by Liver-Qi stagnation; before concluding the interrogation we should ask whether she experiences any pain in any part of the body. If the patient tells us that she suffers from abdominal pain and distension, this would clearly confirm the diagnosis of Liver-Qi stagnation. To carry the example further, if she also suffers from severe period pains, with dark, clotted menstrual blood, this clearly tells us that there is not only Liver-Qi stagnation but also Liver-Blood stasis. Since the Liver-Blood stasis is shown purely by the menstrual pain (e.g. the tongue is not Purple) we would not have known about it if we had not asked about pain.



HOW WE ASK


When asking about pain, we should ask systematically about the following four aspects:









Location of pain

The first obvious question is about the location of the pain. It is important in this respect not to accept automatically the patient’s description of the location of the pain. Patients often have their own way of describing a certain location, a common one being “stomach” when they mean lower abdomen. When the pain is in the abdomen it is particularly important to establish exactly where it is, according to the abdominal areas that are described in Chapter 16, by asking the patient to point to its location. This is even more important in children whose terminology is obviously limited and who often refer to “tummy ache”.


In channel problems, it is also important to enquire exactly about the location of the pain in order to identify the channel or channels involved. For example, if a patient complains of shoulder pain, we should enquire clearly whether the pain is in the front of (Lung channel), the centre (Large Intestine channel) or the back of the shoulder (Small Intestine channel). However, in channel problems, the identification of the exact location of the pain must be done also with the help of palpation.



Nature of pain

After asking about the location, we should then ask about the nature of the pain. First let the patient describe it spontaneously; do not suggest any special terms. A potential difficulty here is the terminology used by the patient, which will obviously be different from that used in China. With experience, we learn how to “translate” Western expressions into the Chinese equivalent. For example, “bloating” indicates “distension”, “feeling like a weight on the chest” indicates “feeling of oppression”, “feeling like being pulled down” in the abdomen indicates a “bearing-down” feeling, and so on. After letting patients describe the nature of the pain, if it is still necessary, we can then ask about the nature of the pain according to the traditional Chinese terminology, which, often, Western patients recognize as a very accurate description of their pain. For example, in cases of abdominal pain, when we ask, “Is the pain accompanied by a feeling of heaviness?” many patients confirm that that is exactly how it feels.




Factors affecting pain

Finally, we should ask about the reaction to pressure or temperature. When asking about the reaction of pain to pressure, it is important to formulate the questions in a way that Western patients can understand. Rather than asking, “Is the pain better or worse with pressure?” (as one might do with a Chinese patient), we should ask something like, “Does the pain feel better if you rub it or press it, or do you actually dislike its being touched?”


When asking about reaction of the pain to temperature, we should also do it in a way that is readily understandable to Western patients. For example, if a patient complains of joint pain, we should ask whether it feels worse when the weather is cold and rainy. We should also enquire whether the application of heat or cold ameliorates or aggravates the pain.


Chinese medicine offers a detailed classification of pain according to five parameters:








NATURE OF PAIN


In general, a pain or ache that is mild in nature indicates Deficiency, whereas a sharp, severe pain is due to Fullness. It should be noted that a mild pain is usually dull and that a “dull” pain may also be intense. For example, a headache from Blood deficiency will be mild in its intensity and dull in nature; however, an occipital headache from invasion of external Cold may be dull in its nature but very intense. Thus when a patient complains of a “dull” headache, we should clarify whether this is mild (suggesting Deficiency) or intense (suggesting Fullness).


The pain from Fullness is due to the obstruction of the channels by a pathogenic factor. Possible factors are listed in Box 29.1.



BOX 29.1   PATHOGENIC FACTORS CAUSING FULL TYPES OF PAIN



Related posts:

  1. OBSERVATION OF THE GENITALIA
  2. MENSTRUAL SYMPTOMS
  3. DIGESTIVE SYSTEM AND TASTE
  4. MENTAL AND EMOTIONAL SYMPTOMS

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Apr 15, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on PAIN

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