诊断学课件：诊断第一篇-疼痛.ppt

1、疼疼 痛痛pain疼痛是临床常见症状疼痛是临床常见症状疼痛具有保护作用疼痛具有保护作用 疼痛可致生理功能紊乱，甚至休克疼痛可致生理功能紊乱，甚至休克Pain is a common clinical symptomPain has protective effectPain can cause physiological dysfunction,and even shock 发生机制发生机制Mechanism各种刺激（物理或化学性）各种刺激（物理或化学性）Various stimuli(physical or chemical)致痛物质致痛物质 Substance which Substanc

2、e which Induce pain游离神经末梢游离神经末梢 Free nerve endings大脑皮质第一感觉区大脑皮质第一感觉区The first sensory area of cerebral cortex 疼痛疼痛 P Pain传导途径Conduction pathway 致痛物质致痛物质 Substance which Substance which Induce pain乙酰胆碱、乙酰胆碱、5 5羟色胺、组织胺、羟色胺、组织胺、P P物质物质缓激肽及其同类的多肽类缓激肽及其同类的多肽类钾离子、氢离子、酸性产物等钾离子、氢离子、酸性产物等Acetylcholine,5 sero

3、tonin,histamine，P substancePolypeptide bradykinin and its ilkPotassium ion,hydrogen ion,acid product,etc.痛觉传导途径痛觉传导途径 Pain pathway (头面头面)三叉神经三叉神经 三叉神经丘脑束三叉神经丘脑束 (躯干躯干)外周神经外周神经 (内脏内脏)交感神经交感神经 脊髓后根 (气管、食管气管、食管)迷走神经迷走神经大脑皮质第一感觉区大脑皮质第一感觉区 疼痛的类型疼痛的类型 根据发生部位和传导途径根据发生部位和传导途径1 1、躯体性疼痛、躯体性疼痛2 2、内脏痛、内脏痛3 3、深部

4、痛、深部痛 肌肉、肌键、筋膜、关节痛肌肉、肌键、筋膜、关节痛 4 4、放射痛或牵涉痛、放射痛或牵涉痛 放射痛放射痛 radiating painradiating pain指内脏或深部组织的疾病引起的疼痛，可在体表某一部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、发病情况 incidence 2、部位、部位 region 3、的程度与性质、的程度与性质 q

5、uality and severity4、出现的时间和持续的时间、出现的时间和持续的时间 temporal characteristics5、加重、减轻或激发头痛的因素、加重、减轻或激发头痛的因素 Provocative-palliative factors临床特点临床特点 Clinical manifestation头头 痛（痛（headacheheadache）胸胸 痛（痛（chest painchest pain）腹腹 痛（痛（abdominal painabdominal pain）头头 痛痛 HeadacheHeadache发生机制发生机制 mechanism病因病因 causes临

6、床表现临床表现 clinical manifestation伴随症状伴随症状 accompanying symptoms头痛发生机制头痛发生机制1、血管因素：各种原因所致颅内外血管的收缩、扩张、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、脑膜受刺激或牵拉3、具有痛觉的脑神经、具有痛觉的脑神经(V.IX.X)和颈神经受刺激或挤压、牵拉和颈神经受刺激或挤压、牵拉4、头颈部肌肉的收缩、头颈部肌肉的收缩5、五官和颈椎病变引起的头面牵涉痛、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、生化因素和内分泌紊乱7、神经功能紊乱、神经功能紊乱Mechanism of headac

7、heVascular factor:the contraction and expansion of the internal and external blood vessels caused by various reasonsthe stimulation of the brainstimulation or compression,distraction of the brain nerve(V.IX.X)and cervical nerve contraction of head and neck musclereferred pain caused by the facial fe

8、atures and cervical lesions biochemical factors and endocrine disorders nervous function disorder头痛的病因头痛的病因Causes of headache1 1、颅内病变、颅内病变 Intracranial lesions2 2、颅外病变、颅外病变 Extracranial lesions3 3、全身性疾病、全身性疾病 systemic disease：急性感染、心血管疾病、中毒、其他急性感染、心血管疾病、中毒、其他 acute infection,cardiovascular disease,po

9、isoning,and other 4 4、神经官能症：神经衰弱及癔病性头痛、神经官能症：神经衰弱及癔病性头痛neurosis:neurasthenia,hysteria and headache颅内病变颅内病变 Intracranial lesions 1 1、感染：脑膜炎、脑膜脑炎、脑炎、脑脓肿、感染：脑膜炎、脑膜脑炎、脑炎、脑脓肿 2 2、血管病变：蛛网膜下腔出血、脑出血、脑血栓、脑栓塞、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、高血压脑病、脑供血不足、脑血管畸形脑供血不足、脑血管畸形 3 3、占位性病变：颅内肿瘤、寄生虫病、占位性病变：颅内肿瘤、寄生虫病 4 4、颅

10、脑外伤：脑震荡、脑挫伤、硬膜下血肿、颅内血肿、颅脑外伤：脑震荡、脑挫伤、硬膜下血肿、颅内血肿、脑外伤后遗症脑外伤后遗症 5 5、其他：偏头痛、丛集性头痛、头痛型癫痫、其他：偏头痛、丛集性头痛、头痛型癫痫Intracranial lesionsInfection:meningitis,meningocephalitis,encephalitis,brain abscessVascular disease:Subarachnoid hemorrhage，cerebral hemorrhage,cerebral thrombosis,cerebral embolism,hypertensive en

11、cephalopathy,Cerebral blood deficiency,cerebral vascular malformation Space occupying lesion:intracranial tumor,parasitic disease Head injury:concussion,brain contusion,subdural hematoma,intracranial hematoma,Sequelae of traumatic brain injuryOthers:migraine,cluster headache,headache epilepsy颅外病变颅外病

12、变1、颅骨疾病：颅底凹入症、颅骨肿瘤、颅骨疾病：颅底凹入症、颅骨肿瘤2、颈椎病及其他颈部疾病、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、神经痛：三叉神经痛、舌咽神经及枕神经痛4、眼、耳、鼻和牙疾病所致的头痛、眼、耳、鼻和牙疾病所致的头痛Extracranial lesions1.skull disease:skull base concave disease,skull tumor2.cervical spondylosis and other neck disease3.neuralgia:trigeminal neuralgia,glossopharyngeal ne

13、uralgia and occipital neuralgia4.eyes,ears,nose and teeth disease临床表现临床表现 manifestation1、发病情况、发病情况 incidence 2、部位、部位 region 3、的程度与性质、的程度与性质 quality and severity4、出现的时间和持续的时间、出现的时间和持续的时间 temporal characteristics5、加重、减轻或激发头痛的因素、加重、减轻或激发头痛的因素 Provocative-palliative factorsIncidence急性起病急性起病 伴发热伴发热 感染感染

14、伴意识障碍伴意识障碍 血管疾病血管疾病慢性起病慢性起病 搏动性搏动性 血管性头痛血管性头痛颅内压增高颅内压增高 占位性疾病占位性疾病紧张焦虑紧张焦虑 肌收缩性头痛肌收缩性头痛Acute onset with fever Infection with conscious disturbance Vascular diseaseChronic onset pulsatile vascular headache Intracranial hypertension Space occupying lesion Nervous muscle contraction headache头痛的伴随症状头痛的伴

15、随症状 Accompanying symptoms 1 1、伴剧烈呕吐、伴剧烈呕吐 颅内压增高颅内压增高 2 2、伴眩晕、伴眩晕 小脑肿瘤、椎小脑肿瘤、椎-基底基底A A供血不足供血不足 3 3、伴发热、伴发热 全身感染性疾病或颅内感染全身感染性疾病或颅内感染 4 4、慢性进行性头痛伴精神症状、慢性进行性头痛伴精神症状 颅内肿瘤颅内肿瘤 5 5、慢性头痛突然加剧伴意识障碍、慢性头痛突然加剧伴意识障碍 脑疝脑疝1.With severe vomiting Intracranial hypertension 2.With vertigo Tumor of the cerebellum and Ve

16、rtebral basilar artery insufficiency3.With fever systemic infection or intracranial infection4.Chronic progressive headache with mental symptoms Intracranial tumor5.Chronic headache suddenly intensified with conscious disturbance Cerebral hernia头痛的伴随症状头痛的伴随症状6 6、伴视力障碍、伴视力障碍 青光眼或脑瘤青光眼或脑瘤7 7、伴脑膜刺激症、伴脑

17、膜刺激症 脑膜炎、蛛网膜下腔出血脑膜炎、蛛网膜下腔出血8 8、伴癫痫发作、伴癫痫发作 脑血管畸形、脑内寄生虫病或肿瘤脑血管畸形、脑内寄生虫病或肿瘤9 9、伴一连串密集发作及数月或数年缓解期、伴一连串密集发作及数月或数年缓解期 丛集性头痛丛集性头痛1010、伴重压、紧箍感、伴重压、紧箍感 肌收缩性头痛肌收缩性头痛1111、伴神经功能紊乱、伴神经功能紊乱 神经功能性头痛神经功能性头痛6.with visual impairment glaucoma or brain tumor7.with meningismus meningitis,subarachnoid hemorrhage8.with s

18、eizures cerebral vascular malformations,brain parasitic disease or tumor9.with a series of intense attacks and remission of months or years cluster headache10.with heavy press or tight hoop sense muscle contraction headache11.with nervous function disorder nervous function headache胸胸 痛痛 Chest painCh

19、est pain发生机制发生机制 mechanism病因病因 causes临床表现临床表现 clinical manifestation伴随症状伴随症状 accompanying symptoms发病机制发病机制发生机制：发生机制：各种刺激因子如缺氧、炎症、肌张各种刺激因子如缺氧、炎症、肌张 力改变、癌力改变、癌 肿浸润、组织坏死以及物理、化学肿浸润、组织坏死以及物理、化学因子均可产生痛觉冲动，引起胸痛因子均可产生痛觉冲动，引起胸痛感觉神经纤维：感觉神经纤维：肋间神经、支配主动脉的交感神肋间神经、支配主动脉的交感神经、支配气管和支气管的迷走神经、膈神经经、支配气管和支气管的迷走神经、膈神经Me

20、chanism: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 Sensory nerve fibers:intercostal nerve,the sympathetic nerve that control aortic,trachea and the vagus nerve that c

21、ontrol the trachea and bronchus and phrenic nerve胸痛的病因胸痛的病因 Causes of chest pain1 1、胸壁疾病：疼痛部位明确，局部有压痛、胸壁疾病：疼痛部位明确，局部有压痛2 2、心脏与大血管疾病、心脏与大血管疾病3 3、呼吸系统疾病、呼吸系统疾病4 4、纵隔疾病、纵隔疾病5 5、其他：如食管炎、食管癌、食管裂孔疝、膈下、其他：如食管炎、食管癌、食管裂孔疝、膈下脓肿、脾梗塞等脓肿、脾梗塞等1,chest wall disease:the pain is clear with local tenderness2,heart and

22、 big blood vessel disease3,respiratory system diseases4,mediastinal disease5,others:such as esophagitis,esophageal cancer,hiatal hernia,diaphragmatic abscess,spleen infarction,etc.胸痛的临床表现胸痛的临床表现 manifestation1、发病情况、发病情况 incidence 2、部位、部位 region 3、的程度与性质、的程度与性质 quality and severity4、出现的时间和持续的时间、出现的时间

23、和持续的时间 temporal characteristics5、加重、减轻或激发头痛的因素、加重、减轻或激发头痛的因素 Provocative-palliative factors发病情况发病情况 incidence青壮年患者青壮年患者 结核性胸膜炎、自发性气胸、心肌结核性胸膜炎、自发性气胸、心肌炎、心肌病风湿性瓣膜病炎、心肌病风湿性瓣膜病40岁以上岁以上 心绞痛、心肌梗死、支气管肺癌心绞痛、心肌梗死、支气管肺癌Young patients tuberculous pleurisy,spontaneous pneumothorax,myocarditis,cardiomyopathy,rhe

24、umatic valvular heart diseaseOver 40 years of age angina,myocardial infarction,bronchial lung cancer胸痛的伴随症状胸痛的伴随症状1 1、伴苍白、大汗、休克、伴苍白、大汗、休克 心肌梗死、主动脉夹层心肌梗死、主动脉夹层2 2、伴有咳嗽或咯血者、伴有咳嗽或咯血者 肺炎、肺结核或肺癌肺炎、肺结核或肺癌3 3、伴呼吸困难者、伴呼吸困难者 大叶性肺炎、自发性气胸、胸腔积液大叶性肺炎、自发性气胸、胸腔积液4 4、吞咽难者、吞咽难者 食道疾病食道疾病1,with pale,sweating,shock myo

25、cardial infarction,aortic dissection2.with cough or hemoptysis Pneumonia,pulmonary tuberculosis or lung cancer3,with breathing difficulties lobar pneumonia,spontaneous pneumothorax,pleural effusion4,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

26、引起，但腹腔外疾病及全身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性疾病也可引起腹腹 痛痛 Abdominal Abdominal painpainAbdominal pain Is a very common symptom,but also the main reason to promote patients for treatment Abdominal pain is caused by abdominal organ diseases,but it can also be caused by diseases out of abdomen and systemi

27、c diseases.胃胃 stomach肝、胆肝、胆 lever and gallbladder盲肠、阑尾盲肠、阑尾 caecum and appendices病变压痛区病变压痛区Tenderness region肾脏肾脏 kidney输尿管输尿管 ureter附件附件 adnexa uteri1、腹腔器官急性炎症腹腔器官急性炎症 acute inflammation of abdominal organs2、空腔脏器阻塞或扩张空腔脏器阻塞或扩张 obstruction or expansion of cavity organ3、脏器扭转或破裂、脏器扭转或破裂 organ torsion o

28、r rupture4、腹膜炎症腹膜炎症 peritonitis5、腹腔内血管阻塞腹腔内血管阻塞 obstruction of abdominal blood vessel6、腹壁疾病腹壁疾病 abdominal wall diseases7、胸腔疾病所致的腹部牵涉性痛胸腔疾病所致的腹部牵涉性痛 abdominal pain caused by chest diseases8、全身性疾病所致的腹痛全身性疾病所致的腹痛 abdominal pain caused by systemic diseases1、腹腔脏器的慢性炎症腹腔脏器的慢性炎症 chronic inflammation of abd

29、ominal organs2、消化道运动障碍消化道运动障碍 digestive tract movement disorders3、胃、十二指肠溃疡胃、十二指肠溃疡 gastric and duodenal ulcer4、腹腔脏器的扭转或梗阻腹腔脏器的扭转或梗阻 the torsion or obstruction ofthe abdominal organs5、脏器包膜的牵张脏器包膜的牵张 stretch of the capsule ofthe internal organs 6、中毒与代谢障碍中毒与代谢障碍 poisoning and metabolic disorders7、肿瘤压迫及

30、浸润肿瘤压迫及浸润 tumor oppression and invasion内脏性腹痛内脏性腹痛 viceral pain躯体性腹痛躯体性腹痛 body pain牵涉痛牵涉痛 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。其疼痛髓。其疼痛特点特点：内脏痛 visceral painVisceral painSignal of stimulation of abdominal organs by sympathetic nerve afferents in the spinal cord

31、.Its pain characteristics:The pain and ambiguous,close to the ventral midlineThe feeling of pain is blurred,spasm,discomfort,blunt painIt is often accompanied by nausea,vomiting,sweating and other plant nerve exciting symptom 定位准确，可在腹部一侧定位准确，可在腹部一侧 痛的程度剧烈而持续痛的程度剧烈而持续 可有局部腹肌强直可有局部腹肌强直 腹痛可因咳嗽、体位变化而加重腹

32、痛可因咳嗽、体位变化而加重躯体痛 body painBody painParietal peritoneum of pain signals afferent to spinal nerve root,reflecting in the corresponding spinal segment dominated the skin region.Its characteristic is:Accurate positioning,can be in the abdomen sideThe degree of pain is intense and sustained.Local abdomin

33、al rigidityThe pain can be aggravated by coughing,postural change临床表现 Clinical manifestation胃、十二指肠疾病、急性胰腺炎，胃、十二指肠疾病、急性胰腺炎，疼痛多在中上腹部疼痛多在中上腹部胆囊炎、胆石症、肝脓肿等胆囊炎、胆石症、肝脓肿等疼痛多在右上腹疼痛多在右上腹急性阑尾炎急性阑尾炎痛在右下腹痛在右下腹Mc BurneyMc Burney点点小肠疾病小肠疾病疼痛多在脐部或脐周疼痛多在脐部或脐周结肠疾病结肠疾病疼痛多在左下腹部疼痛多在左下腹部膀胱炎、盆腔炎及异位妊娠破裂膀胱炎、盆腔炎及异位妊娠破裂疼痛在下腹部

34、疼痛在下腹部急性弥漫性腹膜炎（原发性或继发急性弥漫性腹膜炎（原发性或继发性）、机械性肠梗阻、急性出血性性）、机械性肠梗阻、急性出血性坏死性肠炎、血卟啉病、铅中毒、坏死性肠炎、血卟啉病、铅中毒、腹型过敏性紫癜等腹型过敏性紫癜等疼痛多为弥漫性或疼痛多为弥漫性或部位不定部位不定Stomach,duodenum disease,acute pancreatitis pain more than in the middle of the abdomenCholecystitis,cholelithiasis,hepatic abscessin right upper abdominalAcute app

35、endicitisBurney Mc point in the right lower abdomenthe small intestine diseasesumbilical cordColon disease in the left lower abdomenCystitis,pelvic inflammatory disease and ectopic pregnancy rupturein the lower abdomen Acute diffuse peritonitis(primary or secondary),mechanical intestinal obstruction

36、,acute bleeding necrotizing enteritis,porphyria,lead poisoning,abdominal type Henoch Schonlein purpuramore diffuse or Location uncertainty1.The sudden epigastric severe knifelike pain,burning pain often caused by gastric or duodenal ulcer perforation2.Epigastric persistent severe pain or paroxysmal

37、aggravation should consider acute gastritis,acute pancreatitis3.Gastrointestinal spasm,gallstones or urinary stones often paroxysmal colic,is very severe,resulting in patients with anxiety绞痛的鉴别诊断绞痛的鉴别诊断 Differential diagnosis of colic肠绞痛肠绞痛 多位于脐周、下腹部多位于脐周、下腹部 常伴有恶心、呕吐常伴有恶心、呕吐 、腹泻或、腹泻或 便秘、肠鸣音增加等便秘、肠鸣

38、音增加等胆绞痛胆绞痛 位于右上腹，放射至位于右上腹，放射至 常有黄疸、发热、肝可触及常有黄疸、发热、肝可触及 右背与右肩胛右背与右肩胛 或墨菲征阳性或墨菲征阳性肾绞痛肾绞痛 位于腰部，并从肋腹位于腰部，并从肋腹 常有尿频、尿急、小便含蛋白常有尿频、尿急、小便含蛋白 向下放射，达于腹股向下放射，达于腹股 质质 、红细胞等、红细胞等 沟、外生殖器及大腿沟、外生殖器及大腿 内侧内侧 疼痛类别疼痛类别 疼痛的部位疼痛的部位 其他特点其他特点Differential diagnosis of colic pain category region other features pain category

39、region other features Intestinal colicAround the umbilical cord,the lower abdomenOften accompanied by nausea,vomiting,diarrhea orConstipation,bowel sounds increase etc.Gallbladder colicLocated in the right upper quadrant,right back and radiating to the right scapularJaundice,fever,liver can be touch

40、edKidney colicLocated in the waist,and from the rib,down to the groin,external genital and inner thighfrequent micturition,urine urgency,urine protein,urine red blood cells,etc.4.Paroxysmal drilling pain down to xiphoid often caused by biliary ascariasis 5.Persistent,extensive abdominal pain with ab

41、dominal wall muscle tension or plate stiffness,suggesting acute diffuse peritonitis 6.Dull pain is often visceral pain by gastrointestinal tension changes or mild inflammation 7.Distending pain often caused by stretch of organ capsuleCholecystitis or gallstones often have a history of greasy food be

42、fore the attack.Before the onset of acute pancreatitis,there is often a history of binge drinking.Part of mechanical intestinal obstruction associated with abdominal surgeryThe abdomen pain caused by violence with shock may be liver or spleen rupture1.Postprandial pain may be due to bile duct or pan

43、creatic diseases,stomach cancer or indigestion2.Hunger pain with periodic and rhythmic onset often in gastric and duodenal ulcer3.Abdominal pain of endometriosis uterina associated with menstrual cycle.4.Rupture of the follicle often in the menstrual period5.Pain of gastric mucosa prolapse patients

44、can relieve at the left side lying position6.In patients with duodenal obstruction,pain and vomitiong can relieve at knee-chest posture or prone position7.Pain of patients with pancreatic body cancer increase obviously at supine position,and reduce at the forward position or prone position8.In eflux

45、 esophagitis patients,burning pain increase at the flexion position,and reduce at erect positon 伴随症状 Accompanying symptoms1.Accompanied by fever and chills Acute cholecystitis,liver abscess,abdominal abscess,etc.2.With jaundice Liver and gallbladder diseases,acute hemolytic anemia3.With vomiting eso

46、phageal and gastrointestinal diseases.Vomiting and gastrointestinal tract obstruction4.With regurgitation,belching gastric or duodenal ulcer orgastritis5.With diarrhea Digestive and absorptive disorders or intestinal inflammation,ulcers,or tumors6.With blood urine Urinary system diseases(such as urinary stones)Accompanying symptoms 病因病因复杂复杂引起引起疼痛疼痛机制机制各异各异认真了解病史认真了解病史作出正作出正确的诊断确的诊断联系病理联系病理生理改变生理改变进行全面的体格进行全面的体格检查和必要的辅检查和必要的辅助检查（包括化验助检查（包括化验检查与器械检查）检查与器械检查）综合分析综合分析