诊断学课件：诊断第一篇疼痛

1、疼 痛pain,疼痛是临床常见症状 疼痛具有保护作用 疼痛可致生理功能紊乱，甚至休克 Pain is a common clinical symptom Pain has protective effect Pain can cause physiological dysfunction, and even shock,发生机制Mechanism,各种刺激（物理或化学性） Various stimuli (physical or chemical) 致痛物质 Substance which Induce pain 游离神经末梢 Free nerve endings 大脑皮质第一感觉区The f

2、irst sensory area of cerebral cortex 疼痛 Pain,传导途径Conduction pathway,致痛物质 Substance which Induce pain,乙酰胆碱、5羟色胺、组织胺、P物质 缓激肽及其同类的多肽类 钾离子、氢离子、酸性产物等 Acetylcholine, 5 serotonin, histamine，P substance Polypeptide bradykinin and its ilk Potassium ion, hydrogen ion, acid product, etc.,痛觉传导途径 Pain pathway,(头

3、面)三叉神经 三叉神经丘脑束 (躯干)外周神经 (内脏)交感神经 脊髓后根 (气管、食管)迷走神经,大脑皮质第一感觉区,脊髓丘脑束,疼痛的类型 根据发生部位和传导途径,1、躯体性疼痛 2、内脏痛 3、深部痛 肌肉、肌键、筋膜、关节痛 4、放射痛或牵涉痛,放射痛 radiating pain,指内脏或深部组织的疾病引起的疼痛，可在体表某一部 分也发生痛感或痛觉过敏区 一般认为持续而强烈的内脏疼痛的冲动，经传入纤维使 相应脊髓节段的神经元兴奋并在后角发生联系,1、发病情况 incidence 2、部位 region 3、的程度与性质 quality and severity 4、出现的时间和持续的

4、时间 temporal characteristics 5、加重、减轻或激发头痛的因素 Provocative - palliative factors,临床特点 Clinical manifestation,头 痛（headache） 胸 痛（chest pain） 腹 痛（abdominal pain）,头 痛 Headache,发生机制 mechanism 病因 causes 临床表现 clinical manifestation 伴随症状 accompanying symptoms,头痛发生机制,1、血管因素：各种原因所致颅内外血管的收缩、扩张 2、脑膜受刺激或牵拉 3、具有痛觉的脑神

5、经(V.IX.X)和颈神经受刺激或挤压、牵拉 4、头颈部肌肉的收缩 5、五官和颈椎病变引起的头面牵涉痛 6、生化因素和内分泌紊乱 7、神经功能紊乱,Mechanism of headache,Vascular factor: the contraction and expansion of the internal and external blood vessels caused by various reasons the stimulation of the brain stimulation or compression, distraction of the brain nerve

6、(V.IX.X) and cervical nerve contraction of head and neck muscle referred pain caused by the facial features and cervical lesions biochemical factors and endocrine disorders nervous function disorder,头痛的病因Causes of headache,1、颅内病变 Intracranial lesions 2、颅外病变 Extracranial lesions 3、全身性疾病 systemic dise

7、ase： 急性感染、心血管疾病、中毒、其他 acute infection, cardiovascular disease, poisoning, and other 4、神经官能症：神经衰弱及癔病性头痛 neurosis: neurasthenia, hysteria and headache,颅内病变 Intracranial lesions,1、感染：脑膜炎、脑膜脑炎、脑炎、脑脓肿 2、血管病变：蛛网膜下腔出血、脑出血、脑血栓、脑栓塞、高血压脑病、 脑供血不足、脑血管畸形 3、占位性病变：颅内肿瘤、寄生虫病 4、颅脑外伤：脑震荡、脑挫伤、硬膜下血肿、颅内血肿、 脑外伤后遗症 5、其他：偏

8、头痛、丛集性头痛、头痛型癫痫,Intracranial lesions,Infection: meningitis, meningocephalitis, encephalitis, brain abscess Vascular disease: Subarachnoid hemorrhage，cerebral hemorrhage, cerebral thrombosis, cerebral embolism, hypertensive encephalopathy, Cerebral blood deficiency, cerebral vascular malformation Spac

9、e occupying lesion: intracranial tumor, parasitic disease Head injury: concussion, brain contusion, subdural hematoma, intracranial hematoma, Sequelae of traumatic brain injury Others: migraine, cluster headache, headache epilepsy,颅外病变,1、颅骨疾病：颅底凹入症、颅骨肿瘤 2、颈椎病及其他颈部疾病 3、神经痛：三叉神经痛、舌咽神经及枕神经痛 4、眼、耳、鼻和牙疾病

10、所致的头痛,Extracranial lesions,1. skull disease: skull base concave disease, skull tumor 2. cervical spondylosis and other neck disease 3. neuralgia: trigeminal neuralgia, glossopharyngeal neuralgia and occipital neuralgia 4. eyes, ears, nose and teeth disease,临床表现 manifestation,1、发病情况 incidence 2、部位 re

11、gion 3、的程度与性质 quality and severity 4、出现的时间和持续的时间 temporal characteristics 5、加重、减轻或激发头痛的因素 Provocative - palliative factors,Incidence,急性起病 伴发热 感染 伴意识障碍 血管疾病 慢性起病 搏动性 血管性头痛 颅内压增高 占位性疾病 紧张焦虑 肌收缩性头痛 Acute onset with fever Infection with conscious disturbance Vascular disease Chronic onset pulsatile vasc

12、ular headache Intracranial hypertension Space occupying lesion Nervous muscle contraction headache,头痛的伴随症状 Accompanying symptoms,1、伴剧烈呕吐 颅内压增高 2、伴眩晕 小脑肿瘤、椎-基底A供血不足 3、伴发热 全身感染性疾病或颅内感染 4、慢性进行性头痛伴精神症状 颅内肿瘤 5、慢性头痛突然加剧伴意识障碍 脑疝,1. With severe vomiting Intracranial hypertension 2. With vertigo Tumor of the

13、 cerebellum and Vertebral basilar artery insufficiency 3. With fever systemic infection or intracranial infection 4. Chronic progressive headache with mental symptoms Intracranial tumor 5. Chronic headache suddenly intensified with conscious disturbance Cerebral hernia,头痛的伴随症状,6、伴视力障碍 青光眼或脑瘤 7、伴脑膜刺激

14、症 脑膜炎、蛛网膜下腔出血 8、伴癫痫发作 脑血管畸形、脑内寄生虫病或肿瘤 9、伴一连串密集发作及数月或数年缓解期 丛集性头痛 10、伴重压、紧箍感 肌收缩性头痛 11、伴神经功能紊乱 神经功能性头痛,6. with visual impairment glaucoma or brain tumor 7. with meningismus meningitis, subarachnoid hemorrhage 8. with seizures cerebral vascular malformations, brain parasitic disease or tumor 9. with a

15、series of intense attacks and remission of months or years cluster headache 10. with heavy press or tight hoop sense muscle contraction headache 11. with nervous function disorder nervous function headache,胸 痛 Chest pain,发生机制 mechanism 病因 causes 临床表现 clinical manifestation 伴随症状 accompanying symptoms

16、,发病机制,发生机制：各种刺激因子如缺氧、炎症、肌张 力改变、癌 肿浸润、组织坏死以及物理、化学因子均可产生痛觉冲动，引起胸痛 感觉神经纤维：肋间神经、支配主动脉的交感神经、支配气管和支气管的迷走神经、膈神经,Mechanism: various stimulating factors such as hypoxia, inflammation, muscle tension changes, tumor infiltration, tissue necrosis and physical and chemical factors can produce a sense of pain Sen

17、sory nerve fibers: intercostal nerve, the sympathetic nerve that control aortic, trachea and the vagus nerve that control the trachea and bronchus and phrenic nerve,胸痛的病因 Causes of chest pain,1、胸壁疾病：疼痛部位明确，局部有压痛 2、心脏与大血管疾病 3、呼吸系统疾病 4、纵隔疾病 5、其他：如食管炎、食管癌、食管裂孔疝、膈下脓肿、脾梗塞等,1, chest wall disease: the pain

18、 is clear with local tenderness 2, heart and big blood vessel disease 3, respiratory system diseases 4, mediastinal disease 5, others: such as esophagitis, esophageal cancer, hiatal hernia, diaphragmatic abscess, spleen infarction, etc.,胸痛的临床表现 manifestation,1、发病情况 incidence 2、部位 region 3、的程度与性质 qua

19、lity and severity 4、出现的时间和持续的时间 temporal characteristics 5、加重、减轻或激发头痛的因素 Provocative - palliative factors,发病情况 incidence,青壮年患者 结核性胸膜炎、自发性气胸、心肌炎、心肌病风湿性瓣膜病 40岁以上 心绞痛、心肌梗死、支气管肺癌 Young patients tuberculous pleurisy, spontaneous pneumothorax, myocarditis, cardiomyopathy, rheumatic valvular heart disease

20、Over 40 years of age angina, myocardial infarction, bronchial lung cancer,胸痛的伴随症状,1、伴苍白、大汗、休克 心肌梗死、主动脉夹层 2、伴有咳嗽或咯血者 肺炎、肺结核或肺癌 3、伴呼吸困难者 大叶性肺炎、自发性气胸、胸腔积液 4、吞咽难者 食道疾病,1, with pale, sweating, shock myocardial infarction, aortic dissection 2. with cough or hemoptysis Pneumonia, pulmonary tuberculosis or

21、lung cancer 3, with breathing difficulties lobar pneumonia, spontaneous pneumothorax, pleural effusion 4, swallowing difficult esophageal disease,是临床极其常见的症状，也是促使病人就诊的主要原因 腹痛多数由腹部脏器疾病所引起，但腹腔外疾病及全身性疾病也可引起,腹 痛 Abdominal pain,Abdominal pain,Is a very common symptom, but also the main reason to promote p

22、atients for treatment Abdominal pain is caused by abdominal organ diseases, but it can also be caused by diseases out of abdomen and systemic diseases.,胃 stomach,肝、胆 lever and gallbladder,盲肠、阑尾 caecum and appendices,病变压痛区 Tenderness region,肾脏 kidney,输尿管 ureter,附件 adnexa uteri,1、腹腔器官急性炎症 acute inflam

23、mation of abdominal organs 2、空腔脏器阻塞或扩张 obstruction or expansion of cavity organ 3、脏器扭转或破裂 organ torsion or rupture 4、腹膜炎症 peritonitis,急性腹痛 acute abdominal pain,5、腹腔内血管阻塞 obstruction of abdominal blood vessel 6、腹壁疾病 abdominal wall diseases 7、胸腔疾病所致的腹部牵涉性痛 abdominal pain caused by chest diseases 8、全身性

24、疾病所致的腹痛 abdominal pain caused by systemic diseases,1、腹腔脏器的慢性炎症 chronic inflammation of abdominal organs 2、消化道运动障碍 digestive tract movement disorders 3、胃、十二指肠溃疡 gastric and duodenal ulcer 4、腹腔脏器的扭转或梗阻 the torsion or obstruction of the abdominal organs,慢性腹痛Chronic abdominal pain,5、脏器包膜的牵张 stretch of t

25、he capsule of the internal organs 6、中毒与代谢障碍 poisoning and metabolic disorders 7、肿瘤压迫及浸润 tumor oppression and invasion,内脏性腹痛 viceral pain 躯体性腹痛 body pain 牵涉痛 referred pain,发生机制 MECHANISM,是腹内某一器官受到刺激，信号经交感神经通路传入脊髓。其疼痛特点： 疼痛部位含混，接近腹中线 疼痛感觉模糊，多为痉挛、不适、钝灼痛 常伴恶心、呕吐、出汗等其他植物神经 兴奋症状,内脏痛 visceral pain,Visceral

26、 pain,Signal of stimulation of abdominal organs by sympathetic nerve afferents in the spinal cord. Its pain characteristics: The pain and ambiguous, close to the ventral midline The feeling of pain is blurred, spasm, discomfort, blunt pain It is often accompanied by nausea, vomiting, sweating and ot

27、her plant nerve exciting symptom,是来自腹膜壁层的痛觉信号，经体神经传至脊神经根，反映到相应脊髓节段所支配的皮肤。其特点是： 定位准确，可在腹部一侧 痛的程度剧烈而持续 可有局部腹肌强直 腹痛可因咳嗽、体位变化而加重,躯体痛 body pain,Body pain,Parietal peritoneum of pain signals afferent to spinal nerve root, reflecting in the corresponding spinal segment dominated the skin region. Its charac

28、teristic is: Accurate positioning, can be in the abdomen side The degree of pain is intense and sustained. Local abdominal rigidity The pain can be aggravated by coughing, postural change,1、腹痛部位 region of abdominal pain 一般腹痛部位多为病变所在部位 often the region of the lesion,临床表现 Clinical manifestation,2、腹痛性质

29、和程度 Quality and severity,腹痛的性质和程度与病变性质密切相关 The nature and degree of abdominal pain are closely related to the nature of the disease.,1、突发的中上腹剧烈刀割样痛、烧灼样痛，多为胃、十二指肠溃疡穿孔 2、中上腹持续性剧痛或阵发性加剧应考虑急性胃炎、急性胰腺炎 3、胃肠痉挛，胆石症或泌尿系结石常为阵发性绞痛，相当剧烈，致使患者辗转不安,1. The sudden epigastric severe knifelike pain, burning pain often

30、 caused by gastric or duodenal ulcer perforation 2. Epigastric persistent severe pain or paroxysmal aggravation should consider acute gastritis, acute pancreatitis 3. Gastrointestinal spasm, gallstones or urinary stones often paroxysmal colic, is very severe, resulting in patients with anxiety,绞痛的鉴别

31、诊断 Differential diagnosis of colic,肠绞痛 多位于脐周、下腹部 常伴有恶心、呕吐 、腹泻或 便秘、肠鸣音增加等 胆绞痛 位于右上腹，放射至 常有黄疸、发热、肝可触及 右背与右肩胛 或墨菲征阳性 肾绞痛 位于腰部，并从肋腹 常有尿频、尿急、小便含蛋白 向下放射，达于腹股 质 、红细胞等 沟、外生殖器及大腿 内侧,疼痛类别 疼痛的部位 其他特点,Differential diagnosis of colic,pain category region other features,4、阵发性剑突下钻顶样疼痛是胆道蛔虫症的典型表现 5、持续性、广泛性剧烈腹痛伴腹壁肌紧

32、张或 板样强直，提示为急性弥漫性腹膜炎 6、隐痛或钝痛多为内脏性疼痛，多由胃肠张力变化或轻度炎症引起 7、胀痛可能为实质脏器的包膜牵张所致,4. Paroxysmal drilling pain down to xiphoid often caused by biliary ascariasis 5. Persistent, extensive abdominal pain with abdominal wall muscle tension or plate stiffness, suggesting acute diffuse peritonitis 6. Dull pain is oft

33、en visceral pain by gastrointestinal tension changes or mild inflammation 7. Distending pain often caused by stretch of organ capsule,胆囊炎或胆石症发作前常有进油腻食物历史 急性胰腺炎发作前则有酗酒、暴饮暴食史 部分机械性肠梗阻与腹部手术有关 腹部受暴力作用引起的剧痛并有休克者，可能是肝、脾破裂所致,3、诱发因素 Inducing factor,Cholecystitis or gallstones often have a history of greasy

34、food before the attack. Before the onset of acute pancreatitis, there is often a history of binge drinking. Part of mechanical intestinal obstruction associated with abdominal surgery The abdomen pain caused by violence with shock may be liver or spleen rupture,3、Inducing factor,餐后痛可能由于胆胰疾病、胃部肿瘤或消化不

35、良所致 饥饿痛发作呈周期性、节律性者见于胃窦、十二指肠溃疡 子宫内膜异位者腹痛与月经周期有关 卵泡破裂者发作在月经间期,4、发作时间及与体位的关系Attack time and relationship with body position,Attack time and relationship with body position,1. Postprandial pain may be due to bile duct or pancreatic diseases, stomach cancer or indigestion 2. Hunger pain with periodic and

36、 rhythmic onset often in gastric and duodenal ulcer 3. Abdominal pain of endometriosis uterina associated with menstrual cycle. 4. Rupture of the follicle often in the menstrual period,胃粘膜脱垂病人左侧卧位可使疼痛减轻 十二指肠壅滞症患者膝胸或俯卧位可使腹痛及呕吐等症状缓解 胰体癌患者仰卧位时疼痛明显，而前倾位或俯卧位时减轻 反流性食管炎病人烧灼痛在躯体前屈时显，而直立位时减轻,5. Pain of gastr

37、ic mucosa prolapse patients can relieve at the left side lying position 6. In patients with duodenal obstruction, pain and vomitiong can relieve at knee-chest posture or prone position 7. Pain of patients with pancreatic body cancer increase obviously at supine position, and reduce at the forward position or prone position 8. In eflux esophagitis patients, burning pain increase at the flexion position, and red