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1.1: Pain

Table of Contents

Pain is the most common symptom of many diseases. It is an unpleasant sensation or emotional experience associated with actual or potential tissue damage. Any pain of moderate or higher intensity is accompanied by anxiety and the urge to escape or terminate the feeling.

 

Diagnostic Criteria

Self-report is the key to pain assessment. In non- or pre verbal children, facial expression is the most valid indicator of pain; therefore use faces pain scale to assess severity. Pain should be assessed by:

  • Duration
  • Severity, e.g. does the patient wake up because of the pain
  • Site
  • Character, e.g. stabbing, throbbing, crushing, cramp like
  • Persistent or intermittent
  • Relieving or aggravating factors
  • Accompanying symptoms
  • Distribution of pain
  • In children pain can be assessed by child’s crying voice, posture, movement and colour

 

 

1.1.1 Headache

1.1.1.1 Acute Headache

Diagnostic Criteria

  • Secondary to fever and infectious diseases
  • Secondary to local inflammatory cause

For further actions refer to fever, eye, ear and oral sections.

 

Pharmacological Treatment

A: Paracetamol (PO) 1g every 8 hours for at least 3 days OR

A: Ibuprofen (PO) 400mg 8 hourly for at least 3 days

 

Children

A: Paracetamol 15 mg/kg/dose 6 hourly when required to a maximum of 4 doses per 24 hours

If there is no relief to paracetamol give:

A: Ibuprofen (PO) 5–10mg/kg/dose 8 hourly

 

Note: Ibuprofen shall be given with food

 

 

1.1.1.2 Chronic Headache

Diagnostic criteria

  • Migraine
  • Cluster headache
  • Tension headache

 

Pharmacological Treatment: Migraine

In acute attack give analgesics:

A: Paracetamol (PO) 1g immediately then every 4 hours; maximum dose of 4g per day

OR

A: Acetylsalicylic acid 600mg 6 hourly.

AND

C: Metoclopramide (PO) 10mg 8 hourly.

OR

C: Metoclopramide IV 10mg 8 hourly

 

In severe attack give:

C: Ergotamine tartrate 2mg sublingual, 12 hourly. Not to be repeated at intervals less than 4 days.

 

For prevention purposes give:

A: Propranolol (PO) 40–80mg 12 hourly OR

A: Amitriptyline (PO) 10–50mg at night

 

Cluster and tension headaches: Give analgesics as in acute headache (section 1.1.1)

 

1.1.2 Chest Pain

Differential Diagnoses

  • Angina
  • Myocardial infections
  • Reflux Esophagitis
  • Lung infection
  • Pericarditis

 

Non-Pharmacological and Pharmacological Treatments Treat as for main disease as indicated in specific chapters.

 

1.1.3 Abdominal Pain

1.1.3.1 Upper Abdominal Pain

 

Differential Diagnoses Pain related to eating food:

  • Dyspepsia
  • Gastritis

 

Pain related to eating food but persisted for more than three months

  • Peptic ulcers

 

Acute and recurrent pain in upper quadrant

  • Gallbladder diseases
  • Inflammatory bowel syndrome
  • Chronic pancreatitis
  • Diabetic autonomic neuropathy

 

Non-Pharmacological and Pharmacological Treatments Treat as for main diseases

 

1.1 3.2 Lower Abdominal Pain

Diagnostic Criteria

Pain associated with diarrhoea or constipations

  • Intestinal involvement
  • Helminthes

Colicky pain in abdomen without diarrhoea or constipation

  • Colitis

 

Pain just before or during menstruation

  • Dysmenorrhoea
  • Endometriosis

 

Pain over lower abdomen and back associated with excessive white discharge in women

  • Pelvic inflammatory diseases

 

Pain during urination

  • Urinary tract infections (UTI)

 

Non-Pharmacological and Pharmacological Treatments Treat as for main disease as indicated in specific chapters

 

1.1.4 Other Pains

Other pains may include:

  • Generalized body ache
  • Joint pain
  • Pain due to local infections
  • Pains due to injury
  • Eye pains
  • Ear pains

 

Non-Pharmacological and Pharmacological Treatments

For generalized pain give analgesics as in section 1.1.1. Advise the patient to rest and make a follow-up. For joint, infections, injury, eye and ear pains treat as for main disease.

 

CAUTION: Do not use aspirin for abdominal pain or if a patient is vomiting or has nausea and do not use aspirin in children. Patients with peptic ulcers should not be given acetic salicylic acid tablet.

 

Referral:

Refer patients to Regional and Tertiary care for:

  • Children with moderate and acute severe pain
  • No response to oral pain control
  • Uncertain diagnosis
  • All acute abdominal pain accompanied by vomiting and no passing of stool
  • Pain requiring definitive treatment for the underlying disease
  • Pain requiring strong opioids

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