1、疼 痛pain,疼痛是臨床常見(jiàn)癥狀 疼痛具有保護(hù)作用 疼痛可致生理功能紊亂，甚至休克 Pain is a common clinical symptom Pain has protective effect Pain can cause physiological dysfunction, and even shock,發(fā)生機(jī)制Mechanism,各種刺激（物理或化學(xué)性） Various stimuli (physical or chemical) 致痛物質(zhì) Substance which Induce pain 游離神經(jīng)末梢 Free nerve endings 大腦皮質(zhì)第一感覺(jué)區(qū)The f

2、irst sensory area of cerebral cortex 疼痛 Pain,傳導(dǎo)途徑Conduction pathway,致痛物質(zhì) Substance which Induce pain,乙酰膽堿、5羥色胺、組織胺、P物質(zhì) 緩激肽及其同類的多肽類 鉀離子、氫離子、酸性產(chǎn)物等 Acetylcholine, 5 serotonin, histamine，P substance Polypeptide bradykinin and its ilk Potassium ion, hydrogen ion, acid product, etc.,痛覺(jué)傳導(dǎo)途徑 Pain pathway,(頭

3、面)三叉神經(jīng) 三叉神經(jīng)丘腦束 (軀干)外周神經(jīng) (內(nèi)臟)交感神經(jīng) 脊髓后根 (氣管、食管)迷走神經(jīng),大腦皮質(zhì)第一感覺(jué)區(qū),脊髓丘腦束,疼痛的類型 根據(jù)發(fā)生部位和傳導(dǎo)途徑,1、軀體性疼痛 2、內(nèi)臟痛 3、深部痛 肌肉、肌鍵、筋膜、關(guān)節(jié)痛 4、放射痛或牽涉痛,放射痛 radiating pain,指內(nèi)臟或深部組織的疾病引起的疼痛，可在體表某一部 分也發(fā)生痛感或痛覺(jué)過(guò)敏區(qū) 一般認(rèn)為持續(xù)而強(qiáng)烈的內(nèi)臟疼痛的沖動(dòng)，經(jīng)傳入纖維使 相應(yīng)脊髓節(jié)段的神經(jīng)元興奮并在后角發(fā)生聯(lián)系,1、發(fā)病情況 incidence 2、部位 region 3、的程度與性質(zhì) quality and severity 4、出現(xiàn)的時(shí)間和持續(xù)的

4、時(shí)間 temporal characteristics 5、加重、減輕或激發(fā)頭痛的因素 Provocative - palliative factors,臨床特點(diǎn) Clinical manifestation,頭 痛（headache） 胸 痛（chest pain） 腹 痛（abdominal pain）,頭 痛 Headache,發(fā)生機(jī)制 mechanism 病因 causes 臨床表現(xiàn) clinical manifestation 伴隨癥狀 accompanying symptoms,頭痛發(fā)生機(jī)制,1、血管因素：各種原因所致顱內(nèi)外血管的收縮、擴(kuò)張 2、腦膜受刺激或牽拉 3、具有痛覺(jué)的腦神

5、經(jīng)(V.IX.X)和頸神經(jīng)受刺激或擠壓、牽拉 4、頭頸部肌肉的收縮 5、五官和頸椎病變引起的頭面牽涉痛 6、生化因素和內(nèi)分泌紊亂 7、神經(jīng)功能紊亂,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,頭痛的病因Causes of headache,1、顱內(nèi)病變 Intracranial lesions 2、顱外病變 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、神經(jīng)官能癥：神經(jīng)衰弱及癔病性頭痛 neurosis: neurasthenia, hysteria and headache,顱內(nèi)病變 Intracranial lesions,1、感染：腦膜炎、腦膜腦炎、腦炎、腦膿腫 2、血管病變：蛛網(wǎng)膜下腔出血、腦出血、腦血栓、腦栓塞、高血壓腦病、 腦供血不足、腦血管畸形 3、占位性病變：顱內(nèi)腫瘤、寄生蟲(chóng)病 4、顱腦外傷：腦震蕩、腦挫傷、硬膜下血腫、顱內(nèi)血腫、 腦外傷后遺癥 5、其他：偏

8、頭痛、叢集性頭痛、頭痛型癲癇,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,顱外病變,1、顱骨疾?。猴B底凹入癥、顱骨腫瘤 2、頸椎病及其他頸部疾病 3、神經(jīng)痛：三叉神經(jīng)痛、舌咽神經(jīng)及枕神經(jīng)痛 4、眼、耳、鼻和牙疾病

10、所致的頭痛,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,臨床表現(xiàn) manifestation,1、發(fā)病情況 incidence 2、部位 re

11、gion 3、的程度與性質(zhì) quality and severity 4、出現(xiàn)的時(shí)間和持續(xù)的時(shí)間 temporal characteristics 5、加重、減輕或激發(fā)頭痛的因素 Provocative - palliative factors,Incidence,急性起病 伴發(fā)熱 感染 伴意識(shí)障礙 血管疾病 慢性起病 搏動(dòng)性 血管性頭痛 顱內(nèi)壓增高 占位性疾病 緊張焦慮 肌收縮性頭痛 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,頭痛的伴隨癥狀 Accompanying symptoms,1、伴劇烈嘔吐 顱內(nèi)壓增高 2、伴眩暈 小腦腫瘤、椎-基底A供血不足 3、伴發(fā)熱 全身感染性疾病或顱內(nèi)感染 4、慢性進(jìn)行性頭痛伴精神癥狀 顱內(nèi)腫瘤 5、慢性頭痛突然加劇伴意識(shí)障礙 腦疝,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,頭痛的伴隨癥狀,6、伴視力障礙 青光眼或腦瘤 7、伴腦膜刺激

14、癥 腦膜炎、蛛網(wǎng)膜下腔出血 8、伴癲癇發(fā)作 腦血管畸形、腦內(nèi)寄生蟲(chóng)病或腫瘤 9、伴一連串密集發(fā)作及數(shù)月或數(shù)年緩解期 叢集性頭痛 10、伴重壓、緊箍感 肌收縮性頭痛 11、伴神經(jīng)功能紊亂 神經(jīng)功能性頭痛,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,發(fā)生機(jī)制 mechanism 病因 causes 臨床表現(xiàn) clinical manifestation 伴隨癥狀 accompanying symptoms

16、,發(fā)病機(jī)制,發(fā)生機(jī)制：各種刺激因子如缺氧、炎癥、肌張 力改變、癌 腫浸潤(rùn)、組織壞死以及物理、化學(xué)因子均可產(chǎn)生痛覺(jué)沖動(dòng)，引起胸痛 感覺(jué)神經(jīng)纖維：肋間神經(jīng)、支配主動(dòng)脈的交感神經(jīng)、支配氣管和支氣管的迷走神經(jīng)、膈神經(jīng),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?。禾弁床课幻鞔_，局部有壓痛 2、心臟與大血管疾病 3、呼吸系統(tǒng)疾病 4、縱隔疾病 5、其他：如食管炎、食管癌、食管裂孔疝、膈下膿腫、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.,胸痛的臨床表現(xiàn) manifestation,1、發(fā)病情況 incidence 2、部位 region 3、的程度與性質(zhì) qua

19、lity and severity 4、出現(xiàn)的時(shí)間和持續(xù)的時(shí)間 temporal characteristics 5、加重、減輕或激發(fā)頭痛的因素 Provocative - palliative factors,發(fā)病情況 incidence,青壯年患者 結(jié)核性胸膜炎、自發(fā)性氣胸、心肌炎、心肌病風(fēng)濕性瓣膜病 40歲以上 心絞痛、心肌梗死、支氣管肺癌 Young patients tuberculous pleurisy, spontaneous pneumothorax, myocarditis, cardiomyopathy, rheumatic valvular heart disease

20、Over 40 years of age angina, myocardial infarction, bronchial lung cancer,胸痛的伴隨癥狀,1、伴蒼白、大汗、休克 心肌梗死、主動(dòng)脈夾層 2、伴有咳嗽或咯血者 肺炎、肺結(jié)核或肺癌 3、伴呼吸困難者 大葉性肺炎、自發(fā)性氣胸、胸腔積液 4、吞咽難者 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,是臨床極其常見(jiàn)的癥狀，也是促使病人就診的主要原因 腹痛多數(shù)由腹部臟器疾病所引起，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、膽 lever and gallbladder,盲腸、闌尾 caecum and appendices,病變壓痛區(qū) Tenderness region,腎臟 kidney,輸尿管 ureter,附件 adnexa uteri,1、腹腔器官急性炎癥 acute inflam

23、mation of abdominal organs 2、空腔臟器阻塞或擴(kuò)張 obstruction or expansion of cavity organ 3、臟器扭轉(zhuǎn)或破裂 organ torsion or rupture 4、腹膜炎癥 peritonitis,急性腹痛 acute abdominal pain,5、腹腔內(nèi)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牽涉性痛 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、腹腔臟器的慢性炎癥 chronic inflammation of abdominal organs 2、消化道運(yùn)動(dòng)障礙 digestive tract movement disorders 3、胃、十二指腸潰瘍 gastric and duodenal ulcer 4、腹腔臟器的扭轉(zhuǎn)或梗阻 the torsion or obstruction of the abdominal organs,慢性腹痛Chronic abdominal pain,5、臟器包膜的牽張 stretch of t

25、he capsule of the internal organs 6、中毒與代謝障礙 poisoning and metabolic disorders 7、腫瘤壓迫及浸潤(rùn) tumor oppression and invasion,內(nèi)臟性腹痛 viceral pain 軀體性腹痛 body pain 牽涉痛 referred pain,發(fā)生機(jī)制 MECHANISM,是腹內(nèi)某一器官受到刺激，信號(hào)經(jīng)交感神經(jīng)通路傳入脊髓。其疼痛特點(diǎn)： 疼痛部位含混，接近腹中線 疼痛感覺(jué)模糊，多為痙攣、不適、鈍灼痛 常伴惡心、嘔吐、出汗等其他植物神經(jīng) 興奮癥狀,內(nèi)臟痛 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,是來(lái)自腹膜壁層的痛覺(jué)信號(hào)，經(jīng)體神經(jīng)傳至脊神經(jīng)根，反映到相應(yīng)脊髓節(jié)段所支配的皮膚。其特點(diǎn)是： 定位準(zhǔn)確，可在腹部一側(cè) 痛的程度劇烈而持續(xù) 可有局部腹肌強(qiáng)直 腹痛可因咳嗽、體位變化而加重,軀體痛 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 一般腹痛部位多為病變所在部位 often the region of the lesion,臨床表現(xiàn) Clinical manifestation,2、腹痛性質(zhì)

29、和程度 Quality and severity,腹痛的性質(zhì)和程度與病變性質(zhì)密切相關(guān) The nature and degree of abdominal pain are closely related to the nature of the disease.,1、突發(fā)的中上腹劇烈刀割樣痛、燒灼樣痛，多為胃、十二指腸潰瘍穿孔 2、中上腹持續(xù)性劇痛或陣發(fā)性加劇應(yīng)考慮急性胃炎、急性胰腺炎 3、胃腸痙攣，膽石癥或泌尿系結(jié)石常為陣發(fā)性絞痛，相當(dāng)劇烈，致使患者輾轉(zhuǎn)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,絞痛的鑒別

31、診斷 Differential diagnosis of colic,腸絞痛 多位于臍周、下腹部 常伴有惡心、嘔吐 、腹瀉或 便秘、腸鳴音增加等 膽絞痛 位于右上腹，放射至 常有黃疸、發(fā)熱、肝可觸及 右背與右肩胛 或墨菲征陽(yáng)性 腎絞痛 位于腰部，并從肋腹 常有尿頻、尿急、小便含蛋白 向下放射，達(dá)于腹股 質(zhì) 、紅細(xì)胞等 溝、外生殖器及大腿 內(nèi)側(cè),疼痛類別 疼痛的部位 其他特點(diǎn),Differential diagnosis of colic,pain category region other features,4、陣發(fā)性劍突下鉆頂樣疼痛是膽道蛔蟲(chóng)癥的典型表現(xiàn) 5、持續(xù)性、廣泛性劇烈腹痛伴腹壁肌緊

32、張或 板樣強(qiáng)直，提示為急性彌漫性腹膜炎 6、隱痛或鈍痛多為內(nèi)臟性疼痛，多由胃腸張力變化或輕度炎癥引起 7、脹痛可能為實(shí)質(zhì)臟器的包膜牽張所致,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,膽囊炎或膽石癥發(fā)作前常有進(jìn)油膩食物歷史 急性胰腺炎發(fā)作前則有酗酒、暴飲暴食史 部分機(jī)械性腸梗阻與腹部手術(shù)有關(guān) 腹部受暴力作用引起的劇痛并有休克者，可能是肝、脾破裂所致,3、誘發(fā)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,餐后痛可能由于膽胰疾病、胃部腫瘤或消化不

35、良所致 饑餓痛發(fā)作呈周期性、節(jié)律性者見(jiàn)于胃竇、十二指腸潰瘍 子宮內(nèi)膜異位者腹痛與月經(jīng)周期有關(guān) 卵泡破裂者發(fā)作在月經(jīng)間期,4、發(fā)作時(shí)間及與體位的關(guān)系A(chǔ)ttack 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,胃粘膜脫垂病人左側(cè)臥位可使疼痛減輕 十二指腸壅滯癥患者膝胸或俯臥位可使腹痛及嘔吐等癥狀緩解 胰體癌患者仰臥位時(shí)疼痛明顯，而前傾位或俯臥位時(shí)減輕 反流性食管炎病人燒灼痛在軀體前屈時(shí)顯，而直立位時(shí)減輕,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