BIOSOFT HELP FILES

This is a method to quantify tobacco exposure.  To calculate the number of pack years first multiply the number of cigarettes smoked per day by a number of years of smoking.  Then divide the answer by 20.  For example, if a person smoked 10 cigarettes per day for 20 yrs then the number of pack years is 13.5.

Some common types of pain seen in primary care are visceral pain, somatic pain, radicular pain, referred pain, and neuropathic pain.  Somatic pain arises from skin, bone, muscle, ligaments, and joints.  It is sharp, well localized, stabbing or pricking-like, felt at the site of the pathology, Visceral pain is the pain originating from internal organs usually hollow viscera.  The features are vague and not sharp like somatic pain, ill-localized, enhanced autonomic and/or motor reflexes (nausea, vomiting, and diaphoresis of heart attack), usually felt in the midline, pain may or may not be associated with relevant symptoms from the organ, referred pain.  Referred pain is a typical feature of visceral pain.  Examples of visceral referred pain include pain down the arm in cardiac ischemia, shoulder tip pain of gall bladder disease, and referred pain of renal colic.  Visceral hypersensitivity or sensitization (may be important in clinical states like dysmenorrhea, IBS, non-ulcer dyspepsia, non-cardiac chronic chest pain) is the development of visceral hyperalgesia following injury or inflammation of a visceral organ.   Neuropathic pain is characterized by ongoing pain (pain persisting after the neural stimulus stops, continuous or paroxysmal, shooting, shock-like, aching, cramping, crushing, smarting, burning, stabbing), evoked pain (stimulus-evoked pain, usually by mechanical, thermal, chemical, trigger points for mechanical stimuli, cold allodynia, evoked pains are brief, lasting for the period of stimulus application, but sometimes may persist after the cessation of the stimulus, pain may last from minutes to days), sensory deficit in the area of pain (essential criterion for the diagnosis but may not be clinically evident, cold, warmth and pinprick are the commonest deficits),  hyperalgesia (lowering of pain threshold and an increased response to noxious stimuli), allodynia (pain elicit by non-noxious stimuli), hyperpathia (explosive response for pain stimuli). 

(Jensen 2005)

Cognitive biases of helplessness, pessimism, catastrophic fears, somatosensory amplification (See notes), alexithymia (See notes), counter dependency (See notes)

Physiological mechanism Experience (symptom)

Stimulus-independent pain (spontaneous pain)
Development of and (or) increase in spontaneous neural activity)

Pain in response to a stimulus that does not normally produce pain (allodynia)
Reduction in the neural threshold for activation9

Increased pain from a stimulus that normally provokes pain (hyperalgesia)
Increased neural response to repeated, fixed-intensity, C-fibre strength stimulus72

Spread of pain to adjacent, undamaged tissue (secondary hyperalgesia)
Enlargement of neuronal receptive fields9

Spread of pain to distant body regions (remote hyperalgesia)
Injury-induced unmasking of previously ineffective synaptic connections37

Spread of pain to distant body regions (remote hyperalgesia)
Cross-system, viscero–visceral interactions within the central nervous system40

Mirror-image pain (allochiria)
Ipsilateral injury-induced, contralateral peripheral neurite loss49

Katz J, Rosenbloom BN, Fashler S. Chronic Pain, Psychopathology, and DSM-5 Somatic Symptom Disorder. Can J Psychiatry. 2015 Apr;60(4):160-7. doi: 10.1177/070674371506000402. PMID: 26174215; PMCID: PMC4459242.

1)      Stress, fear, anxiety states – other symptoms suggestive of somatic anxiety syndrome seen, recent stress may be seen,

2)      Somatic anxiety syndrome – palpitations as a part of somatic anxiety syndrome

3)      Caffeine, nicotine, cocaine, diet pills -

4)      Anemia – fatigue, dyspnea on exertion, pallor, sweating, pica, limb swelling, evidence of CCF later in the course

5)      Sleep apnea syndrome (See under Medically Unexplained Symptoms)

6)      Suprventricular tachyacardia - Dizziness, anxiety, light headedness, chest pain, palpitations fetl at the neck and chest both, dyspnea, syncope, psychologic distress, polyuria, sudden onset and offset, the usual heart rates are in the range of 160-200 beats pr minutes as opposed to ventricular tachycardias the rate is 120-160 beats per minute, Mx – carotid sinus massage (N), referral for further management.

7)      Drug-induced – calcium channel blockers, sympathomimetics, sympathomimetic inhalers and nebulizer solutions

8)      Hyperthyroidism – see under medically unexplained symptoms

9)      Somatic depression syndrome

10)    Palpitations associated with a normal heart rate and rhythm practically exclude heart disease

1)      Hypercholesterolemia

2)      Hypertension

3)      Diabetes

4)      Blackouts or near blackouts with palpitations

5)      Chest pain with palpitations

6)      Dyspnea in palpitations

7)      Past rheumatic fever

8)      Heart murmurs – aortic stenosis, aortic regurgitation, mitral stenosis

9)      Dizziness, anxiety, lightheadedness, chest pain, palpitations felt at the neck and chest both, dyspnea, syncope, psychological distress, polyuria (Supraventricular tachycardia, sudden onset, and offset, )

10)    Elderly, dizziness, bradycardia, tachycardia, alternating bradycardia and tachycardia, fatigue, dyspnea, confusion, chest pain (sick sinus syndrome)

11)    Exclude pulsatile tinnitus and carotid bruit presenting as palpitations

12)    Bradycardia – per se can cause palpitations as it may increase the stroke volume

13)    Palpitations with angina, diaphoresis, presyncope, syncope (underlying heart disease likely)

14)    Palpitations felt at the neck and chest (heart disease likely)

15)    Sensation of heart-stopping, irregular heartbeat, and fluttering (correlated with heart disease)

16)    Palpitations that are frequent, disabling, and symptomatic more urgent evaluation than those that are infrequent and asymptomatic

17)    Associated palpable abnormalitites in the pulse – atrial fibrillation, atrila flutter, bradyarrhythmias

18)    ECG signs – bifascicular heart block, QRS duration > 120 ms, second degree AV block, sinus bradycardia, prolonged QT interval, Q waves, arrhythmogenic right ventricular dysplasia (T inversion in V1-V3, QRS duration > 110 ms in V1-V3)

19)    ECG signs – Brugada pattern – ST elevation in V1-V3, coved appearance of elevated ST segment, T wave inversion, associated with increased risk of ventricular arrythmias, sudden cardiac death (Brugada syndrome), howevere this pattern may also occur in right ventricular infarction, hyperkalemia, drugs,

(Balentine and Eisenhart 2005)

(Balentine and Kassapidis 2006)

(Liu and Sinert 2006)

(Delacretaz 2006)

(Weitz and Weinstock 1995)

1)      CTS – pain and paresthesiae of the median nerve distribution (thumb, index, and middle fingers), paresthesiae particularly nocturnal, symptoms worsen with clenched fists, Tinel’s positive, Phalen’s positive, sensory loss in median nerve distribution, weakness of abductor policies brevis, weakness of opponents policies,

2)      MFPS – See under Myofascial syndromes in the notes or details.

3)      TTS

4)      Radiculopathies

5)      Cubital Tunnel Syndrome – due to entrapment of ulnar nerve at the elbow, point tenderness at the cubital tunnel, pain and paresthesiae in the distribution of the 4^th and 5^th fingers of the hand, sensory loss in the 4^th and 5^th fingers, interossei weakness, Froment’s sign positive (wasting of the 1^st dorsal interosseous muscle and inability to maintain adduction of the thumb so that hyperflexion of the interphalangeal joint occurs while pinching between thumb and the 1^st finger), positive Wartenberg’s sign (inability to abduct the little finger), Tinel’s sign positive (percussion over cubital tunnel causes a shower of paresthesiae in the ulnar distribution), Mx – usually RSI, look for the RSI factors

6)      Pronator Teres Syndrome – activities that require the use of the elbow, forearm supination and grasping, forearm pain, medial aspect of the forearm, point tenderness at the edge of the pronator teres, pain, and paresthesia in the median nerve distribution of the hand, reproduction of symptoms on resisted pronation of the forearm – usually an RSI,

7)      Anterior Interosseous Syndrome – entrapment neuropathy of anterior interosseous nerve branch of the median nerve, pain in the volar aspect of the forearm, weakness of pronator quadratus, flexor policies longus and/or flexor digitus profundus

8)      Posterior Interosseous Syndrome – pain around the elbow joint, pain distal to the lateral epicondyle, tenderness distal to the elbow, weakness of extension of a middle finger, if the entrapment involves sensory branch (which is called radial tunnel syndrome) no weakness nor sensory loss but pain and tenderness at the site of entrapment (this is usually 5-7 cm distal to the  lateral epicondyle), weakness of supination, decreased strength of  ulnar deviation of the wrist,

9)      Hypothenar hammer syndrome – blanching, paresthesiae, pain in the hand, Allen’s test positive

10)    Hyperventilation syndrome – transient paresthesiae of hand and feet, perioral region, lightheadedness, carpopedal spasms, occasionally syncope,

11)    Alcoholic neuropathy – numbness, tingling, burning feet, painful sensations, wekaness of legs, in early and mild cases, when severe and with autonomic involvement muscle cramps, muscle aches, heat intolerance after exercises, impotence, micturition difficulties (incontinence, sensation of incomplete emptying of bladder, hesitancy), constipation, diarrhea, nausea and  vomiting, swallowing difficulty, speech impairment, muscle contractions, muscle atrophy, dyskinesias, symptoms develop gradually, worsen over time, usually bilateral symptoms, lower limb involvement more than upper limb involvement, hyporeflexia, decreased pupillary response to light, Mx -  alcohol cessation and symptomatic management

1)      Vitamin D deficiency – See under Generalized body aches

2)      Vertebrobasilar insufficiency – peioral paresthesiae

(Helliwell 1996)