Pain - The Commonest of All Symptoms of Illnesses...

Definition
Pain in the Abdomen
Pain in Ankel
Pain in Back
Pain in the Bones
Pain in the Breast
Pain in the Chest
Pain in the Ear
Pain in the Elbow
Pain in the Eye
Pain in the Foot
Pain in the Hand
Pain in the Head
Pain in the Hip

Pain in the Joints
Pain in the Knee
Pain in the Muscle
Pain in the Neck
Pain in the Shoulder
Pain in the Temples
Pain in the Testical
Pain in the Throat
Pain on Bowel Movement
Pain on Menstruation
Pain on Sexual Intercourse
Pain on Urination
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Definition

Pain is the commonest of all symptoms of illnesses. The term 'pain' derives from "poena" in Latin means 'punishment'. Pain, in fact, is an unpleasant sensation feeling. It is either localized, of which the pain is felt in the are of the body in which its cause occurs; or pains are felt in areas remote from the cause, which is also known as referred pain. A stimulus of this kind of pain occurs in disease such as shingles.

Pain is usually caused by strong stimulation of sensory nerve endings by an event or process that is damaging, or is liable to damage, body tissues of any kind.  Nerves carrying pain impulses travelling up the spinal chord and terminate in the brain, and give rise to neurological activity.

Nerve impulses passing to the brain may be blocked by local anaesthetics, by electrical stimulation applied through the skin, by acupunture, and by the inhibitory action of other nerve fibres by releasing blocking substances called endorphins and enkephalins in human body. However, a very persistent (chronic) pain commonly serves as a warning of danger of health status. Prolonged pain is demoralizing and debilitating, and should be controlled as early as possible.

Pain can happen in any part of human body. In fact, it indicates some disorders of the localized organ or systems. A comprehensive overview of the common type of pain is described.

Pain in the Abdomen

This is also referred as tummy pain. And, the possible causes of tummy pain are as follow:

food poisoning

• abdomen hurts when it is pressed
• featuring nausea, vomiting, diarrhoea and loss of appetite
• most common poisoning is due to bacteria Salmonella typhimurium that found in eggs and meats
• most powerful poisoning involves Botulinum toxin released by organism called Clostridium botulinum, and onset of symptoms  is abrupt and occurs from four hours to a week after eating the contaminated food
• patient with botulinum toxin has difficulty to make muscles contract

gastroenteritis

• inflammation of the stomach and intestine, accompanied by fever, diarrhoea and vomiting
• abdomen hurts when you press on it coupled with fever, vomiting and feel ill
• caused by bowel germs such as Escherichia. coli, Salmonella, Giardia lambia, rotaviruses , corona viruses, and other enteroviruses. In most cases is due to poor hygiene in bottle-feeding.
• could be fatal, mostly babies and infants, and usually occurs in tropical and children die from dehydration and malnutrition

appendicitis

• common in adolescents and young adults, but can occur in small children
• symptoms begin with pain in the region of the navel
• painful in  body movement, deep breathing and coughing cause distress
• slight fever, constipation, nausea and occasionally vomiting

dysentery

• blood and mucus in the stools, inflammation, swelling and ulceration of the large intestine and the lower part of the small intestine coupled with abdominal pain, fever, nausea and diarrhoea of increasing frequency up to 20 a day
• inflammation of the bowel resulting from infection either with shigella organism or with the amoeba Enamoeba histolytica

amoebic dysentery

• caused by the ingestion of the cyustic form of the amoeba on fruit and vegetables contaminated by human faeces
• can be spread by male homosexual intercourse or directly from person to person when personal hygiene is poor
• small abscesses occur in the wall of the colon( (large intestine)
• usually treated with drug, metronidazole (Flagyl)

bowel obstruction

• bowel may become twisted, blocked by impacted faeces (especially in the elderly), blocked by an internal tumour, failure of the normal peristalsis
• pain in the abdomen that repeatedly rises to a peak and  then subsides
• gas forms in the intestine and develops distention
• upper obstruction may cause vomiting and is stained with bile
• lower obstruction may cause total constipation

peritonitis

• this is an acute inflammation of the membrane that lines the abdominal cavity and forms the outer coating of the abdominal organs (the peritoneum)
• commonly due to perforation of an inflamed appendix, or of a gastric or duodenal ulcer
• peritonitis causes paralysis of peristalsis and effectively blocks the bowel movement
• severe abdominal pain, board-like rigidity of the abdominal muscles and high fever

pelvic inflammatory disease

• can be due to inflammation of the fallopian tubes (salpingitis), sexually transmitted disease and premenstrual syndrome

stomach and duodenal ulcers

• classified as peptic ulcers
• peptic ulceration causes a burning, boring, gnawing pain high in the abdomen in the angle between the ribs
• pain usually develops 2 hours after a meal
• does not attack on waking but tends to come on around the middle of morning
• the sufferer usually wakes up two or three hours after falling asleep
• caused by the hyperacidity of the stomach juices, stress, severe head injury, drugs such as aspirin and alcohol, and the organism called Helicobacter pylori
• occur in the lining of the stomach, duodenum or at the end of the gullet (oesophagus-reflux of acid from the stomach) due to local loss of the mucous membrane lining, with some penetration into the underlying muscular layer
• cigarette smoking exacerbates the condition
• great majority of gastric and duodenal ulcers heal in four to six weeks
• neglected ulcer may perforate, causing peritonitis with widespread abdominal pain and an abdominal wall that is as hard as a board
• chronic peptic ulceration often persists for life
• common drugs used: antacid, proton pump inhibitor, H2 antagonists

Other causes of abdominal pain may include:

• shingles
• heartburn
• gastritis from alcohol
• acute pancreatitis
• bowel or stomach cancer
• ulcerative colitis

Pain in the Ankel

It is usually due to the stretching or tearing of the ligaments that holds the foot onto the bones of the lower leg. Other causes may due to the effects of old fractures and various forms of arthritis. Tight strapping that pulls the foot up onto the leg may be needed.

Pain in the Back

Back pain is extremely common. Pain condition can be mild and transient, or chronic and disabling. It was estimated an annual loss of 11.5 million working days, and back pain accounts for 6% of general practice consultations It is quite difficult to distinguish causes of the pain. In about 30% patients, no cause will be found. These are the possible causes leading to back pain:

obesity

osteoporosis

• Osteoporosis of the spine may lead to severe back pain due to unsuspected fractures

slipped disc

• Causes pain, numbness and tingling running down your leg as far as the foot, as well as backache, cough and sneeze. It may lead to weakness in muscles activated by the nerve

fibrositis

• inflammation of fibrous tissue that described by muscle pain and tenderness

arthritis

• pain that caused by osteoarthritis and ankylosing spondylitis (inflammation back pain)
• ankylosing spondylitis is the most important cause of inflammatory back pain that presents with back pain and morning stiffness and is typically associated with sacroiliitis on x-ray

The symptoms:

• Pain in the buttocks and radiating down the back of both legs
• Peripheral polyarthritis may also present
• All the joints of the lower limbs are affected
• Heel pain if plantar fascitis occurs
• Iritis (peripheral arthritis and non-articular) occurs in 30% of cases
• The ESR is often raised with abnormality of the lumbar spine and pelvis [a very high ESR suggests myeloma]
• spinal cancer
• It is a boring type of pain
• Not relieved by rest
• Immediate medical attention neede

injudicious lifting

• pain occurs as a resulted of bending the spine instead of the knees in picking up, lifting or carrying something

too much sitting in one position

job involves heavy lifting and carrying

kidney trouble

• infection of the urine drainage system (pyelonephritis) can cause severe back pain with tenderness to touch on one side of the spine
• this pain usually associates with fever, shivering and pain on passing urine

How does the pain in backache happen?

• spasm  of the muscles around the spine
• torn or stretched ligament
• damage of joints between the vertebral bones
• a pressurized spinal nerve roots by a disc between the bones /disc pulp prolapse

As back pain is difficult to find out its causes, a proper diagnostic approach to back pain is required.  Table below highlights some approaches used in diagnosing back pain:

 If none of those causes due to the above diagnostic approach, it is referred as non-specific back pain.

The Investigations to consider in a patient with back pain.

How to manage back pain?

• rest but not on a sagging bed, get support from boards or planks slid under the mattress so that your back is on a really firm support
• practice regular exercise to keep your back muscles in good shape       
• analgesics in the form of balm/gel and tablets
• megadoses of vitamin B1, B6 and B12

Recommended natural approach:

• EnerFlex 40g daily
• Princi B Forte (B1,B6, and B12 preparation) 1-2 tablets daily
• Calcium 600-800mg daily, Magnesium 300-400mg daily
• Vitamin C 500-1000mg daily

Pain in the Bones

Likely caused by bone cancer if pain is a persistent boring type in a constant site. Most bone cancer usually affects young people. The most frequent sites are the lower end of the thigh bone or the upper end of the lower leg bone. Symptoms include pain, tenderness to the touch and swelling. If this happens, immediate medical attention is required and X-ray should be taken at once. An early diagnosis is usually essential if life is to be saved.

Pain in the Breast

Pain in the breast is manifested as mastitis, means inflammation of the breast. It is however, always affects women but may rarely occur in men. This type of pain often an acute condition and rarely be persistent or chronic. However, chronic mastitis is sometimes misinterpreted to a condition of an irregular rubbery consistency and contain painful or tender nodules or cysts. This is not an inflammation and the condition is usually caused by an upset of the balance of the hormones that control menstrual cycle and does not normally require treatment.

The possible causes of pain in the breast due to mastitis:

• spread of infection by way of the blood (usually the affected subject will be obviously very ill)
• acute mumps infection from mumps virus to the breast
• chronic mastitis can be resulted from infection with tuberculosis, syphilis and actinomycosis
• acute mastitis during breast feeding is often involves the bacteria called Staphylococcus aureus, pain is severe tenderness to touch, and is usually  accompanied by high fever, redness and hardening. Breast abscesses sometimes may occur. Generally, breast tenderness and tension are normal features of breast feeding but there should never be pain.

Pain in the Chest

Chest pain is usually a concern to many middle-aged men as it may a signal of heart problem.  

The possible causes of chest pain are:

angina pectoris and heart attack

• coronary arteries have become too narrow and the pain is a result of heart muscle trying to work with an inadequate supply of blood oxygen
• the pain may be so mild as to be hardly a pain with uneasiness or pressure in the chest, with breathlessness and belching
• angina pain is always related to exercise and usually comes on after a fixed amount of exertion, such as walking a predictable distance
• angina can be caused by a spasm (a brief period of tightening) of the coronary arteries
• angina can sol result from severe anaemia or from abnormal thickening of the blood
• angina never lasts for more than a few minutes, if the symptom  persists and you feel you are going to die with pain radiates up into the jaw, through to the back and down the left arm, likely a heart attack has occurred (a branch of a coronary artery has probably been blocked completely by blood clotting/coronary thrombosis and the heart muscle actually dies), call an ambulance immediately and tell the operator that it is case of heart attack

heartburn

• a burning pain caused by reflux of stomach acid into the gullet that is felt in the centre or lower part of the chest and can be intense
• it is unrelated to exercise
• usually relates to emotion or dietary indiscretion
• heartburn pain rises slowly to a peak and then subsides after a few minutes
• it may be associated with belching

pleurisy

• it is characterized by stabbing pain brought on by deep breathing
• the pain is sudden and sharp with occurrence at a certain point during breathing in
• pain can be relieved by changing position
• sometimes other sign of chest infections such as fever, cough and sputum may occur

duodenal ulcer

• a chest pain that usually happens in the angle between the lower ribs
• pain usually comes on in the middle of the morning, and is relieved by food
• regular recurrence is characterized by accurate timing, two or three hours after a meal
• the pain often wakes you up at one or two o'clock in the morning

bronchitis

• pain in the chest in association with cough, increasing amount of sputum, breathlessness and wheezing in bronchitis patients
• bronchitis is inflammation of the lining of the air tubes of the lungs (bronchi) and acute bronchitis is generally follows a cold, sore throat, or influenza
• recurrent attack of bronchitis or chronic bronchitis should be taken seriously and properly treated
• smoking is especially dangerous in people with a persistent and productive cough

lung cancer

• always starts on the lining of one of the air tubes (bronchi), and usually with a productive cough and there is often a little blood in the sputum
• one of the commonest forms of cancer that kills for more than half of all male deaths from cancer
• pain develops when cancer cell/tumour growth invades the surrounding lung tissue and the chest wall that causes obstruction and collapse of the part of the lung beyond it
• when tumour attack voice box it causes loss of voice; when spreads to the brain, it causes fits, paralysis and speech problem; when tumour spreads to the bone, it causes bone pain and sometimes even spontaneous fracture
• Chances of survival is slim ranging from few months to 5-years (if surgery is done by removal of the affected lobe or lung -30% chance)

tuberculosis

• it is caused by the germ Mycobacterium tuberculosis (tubercle bacillus)
• symptoms include chest pain, fatigue, loss of appetite and weight, night sweats, and persistent cough
• sputum may be streaked with blood

shingles

• usually has chest and abdominal pain with skin tingling and with painful blisters around the flank

chest wall injuries

secondary cancer affecting the rib

Bornholm disease

• epidemic myalgia caused by coxsackie virus
• charaterized by a sudden attacks of severe pain in the central lower chest and upper abdomen, with headache, fever, sore throat and general upset
• may have repeated occurrence over a period of several weeks
• common in children

How to manage?

• You should always ensure that unexplained chest pain is investigated by medical doctor at once. This is of particularly important as secondary deposits of cancerous tissue in the ribs may also cause chest pain from a primary tumour elsewhere in the body. The most common primary tumour include the breast, womb, colon, or prostate gland.

Pain in the Ear

This is very common in children. The following may cause earache:

middle ear pressure problems

• alteration in the pressure I the middle ear due to failure of the normal pressure equalizing mechanism

middle ear infection or otitis media

• earache is resulted from pressure effects on the ear drum which is forced outwards by the accumulation of pus and watery discharge in the middle ear

external ear infection or otitis externa

• an inflammation in the external ear passage by viruses, bacteria or fungi
• very often caused by injudicious poking with hairpins, matches or paperclips

Pain in the Elbow

Pain in the elbow can be localized or referred from a disorder of the neck part of the spine called cervical spondylosis. Cervical spondylosis is a degeneration of the neck bones that presses the nerves coming out of the spinal cord. Pain is felt as a nerve affected in this area goes to the elbow. Cervical spondylosis can also cause wrist pain. Rheumatoid arthritis and inflammation of the fibrous capsule of the joint (olecranon bursitis) can cause elbow pain.

The common localized elbow pains are tennis elbow and golfer's elbow. Tennis elbow is the inflammation in the region of the bony prominence on the outer side of the elbow from which several forearm muscle tendons arise.

Tennis elbow pain occurs when a trauma is induced due to excessive use of the muscle that extends to the wrist. Symptoms include pain and tenderness in the elbow, on the thumb side, and in the back of the forearm.

Golfer's elbow pain is the inflammation of the corresponding bump of the inner side of the elbow.

How to manage?

• Avoiding the activity for a while plus rest
• Support
• Use of painkillers and anti-inflammatory drugs
• Physiotherapy by the professionals

Pain in the Eye

Eye pain can be due to severe irritation, which does not cause actual pain but the real eye pain of which usually a dull ache felt inside the eye should be taken seriously and investigated. Numerous factors causing eye pain as follow:

foreign body in the eye

• often lodge high under the upper lid and press painfully on the cornea and you will aware of the cause of the pain
•  it can usually be got rid off with the corner of a folder piece of paper or a clean handkerchief, but not to remove a foreign body from the cornea
• see your doctor as soon as possible if condition gets worse off

corneal abrasion

• this is due to the loss of the epithelium layer that covers the many sensitive nerves in the cornea
• extremely painful
• caused by any mechanical trauma via scratching by a baby's finger nail, ultraviolet light radiation (lamp/sunlight), and over-wear of hard contact lenses

other corneal injuries

• usually due to chemical injuries from acid or alkali (dangerous as it causes massive and spreading tissue destruction) splashes
• immediate and prolonged flushing with large volumes of water may help to reverse the condition

corneal ulcer

• very painful as the nerves are stimulated and an ulcer that goes deep may penetrate the cornea
• cold sore or genital herpes virus and herpes simplex (causes the characteristic branching dendritic ulcer with pain, watering and foreign body sensation) is the commonest cause
• can be caused by gonorrhoea, contact lens (organism called Acanthamoeba that grows in contact lens solutions)
• internal inflammation
• sometimes uveitis occurs, an inflammation of the eye's iris and urgent treatment is needed

glaucoma

• chronic simple glaucoma does not cause pain
• acute glaucoma often due to mechanical trauma or disease processes in the eye cause sudden and severe pain and sudden loss of all vision
• the affected eye is acutely painful, intensely red and congested, and very hard and tender to the touch
• in a less severe sub-acute glaucoma, eye-drops and simple operation or outpatient laser procedure may help reverse the condition

Pain in the Face

Usually due to one of the following causes:

sinusitis

• an inflammation (always from infection) of the linings of the bone cavities of the face (the sinuses), characterized by selling, pain in the forehead, cheeks or between the eyes

neuralgia or a disorder of the nerves of the face

• The most severe and distressing form of facial pain is called trigeminal neuralgia due to sudden impulse discharges occur in the sensory nerve of the face-the fifth, or trigeminal, cranial nerve- on one side
• cause is unknown and treatment is difficult
• symptoms include excruciating stabbing pain in the cheek, lips, gums, chin or tongue lasting for only a few seconds to a minute or two, with repeated attacks over several weeks
• affects middle-aged and elderly people
• if sufferers develop resistance with drug (carbamazepine is usually used), an injection to destroy the root of the nerve, or even cutting the nerve surgically may be needed
• surgical procedure will cause permanent numbness of one side of the face

Pain in the Foot

One of the commonest causes of foot pain is bunion as a result of unsuitable footwear, in which the big toe is angled outwards away from the midline of the body. It is medically termed as hallux vagus. Hallux vagus leads to the formation of an inflamed pressure swelling called bursitis. Other possible causes include:

march fracture

• pain that results from a hairline 'march' fracture of one of the long bones of the foot (metatarsal bones) due to excessive trauma in walking

fallen arches

• due to flat foot
• people with fallen arches have hot, stiff, uncomfortable and painful feet, especially on prolonged standing or walking, the elastic 'heel then toe' gait is lost causing walking

rigid toe

• usually due to osteoarthritis and rheumatoid arthritis in which the big toe joint cannot bend backwards properly during walking
• severe pain during walking and joint replacement may be needed

nerve entrapment

• occurs in women 40-50 of age
• a sharp pain in the forefoot that extends forwards to the toes due to nerve being trapped between the long bones of the foot, and fourth space from the big toe side
• if affected nerve becomes thickened surgery may be required

gout

• acute joint disease due to the crystallization of monosodium urate monohydrate deposited around the joints, tendons and other tissues of the body with severe inflammation and tissue damage
• usually affects the joints of the big toe
• the commonest factor is that the kidneys fail to excrete uric acid (a purine and is relatively insoluble in water) fast enough (75-80%), and 20% of gout is caused by excessive production of uric acid
• if untreated, the pain or attack lasts for days or weeks but eventually subsides
• common drugs used: non-steroidal anti-inflammatory drugs (NSAIDs), colchicine and allopurinol. Usage has to be monitored due to their side effects

heel problems

• due to a prominent bony knob on the back of the heel bone causing pressure against the shoes, and rupture of the Achilles tendon in athletes
• pain derives from inflammation of the sheet of tendon under the skin of the sole of the foot

soft tissue problems

Pain in the Hand

Hand pain may be resulted from the following:

fractures of the palm bones (metacarpals)

infection of the soft tissues

carpal tunnel syndrome

• swelling in the region of carpal tunnel that tends to compress the median nerve and interfere with the conduction of nerve impulses of which results in numbness, tingling and sometimes pain in the half of the hand on the thumb side

• may be associated with
• excessive occupational use of the wrist
• overproduction of pituitary gland growth hormone in rheumatoid arthritis causing a thickening of the overlying ligament (through which pass the tendons that flex the finger and wrist)
• premenstrual syndrome
• pregnant women
• women taking oral contraceptives

Pain in the Head

Headache has been recognized as one of the commonest of all symptoms. Most headaches are due to stress and mental tension reflected in long-sustained tightness of muscle in your scalp or neck.

For more details, please visit www.myhealthdriver.com/headache

Pain in the Hip

Hip pain can be caused by the following factors:

Perthes' disease

• usually happens in children aged 4-8 years
• careful medical attention required

Slipped disc

• causing nerve root pressure that is referred to the hip
• back pain may also occur

Osteoarthritis

• inflammation of the tendons or the fibrous capsule surrounding the hip joints

Rheumatoid arthritis

• usually occurs in older people

Fracture of the neck of the thigh bone

• osteoporosis is the commonest factor
• hip replacement may be necessary if the blood supply to the head of the femur is lost

Pain in the Joints

Pain in the joints is part and parcel of rheumatology studies, a branch of medical science of the locomotor system. Rheumatological diseases constitute approximately 20% of the workload of a primary care physician. The major complaints are usually pain and disability, arising not only from the joints, but also from the surrounding soft tissues.

There is several general conditions causing joint pain such as

Osteoarthritis (OA)

• a degenerative joint disorder involving damage to the cartilage-covered bearing surfaces or remodelling of the endsof the bones in the joint (wrist, elbow, shoulder and ankle joint)
• a disease moves slowly from joint to joint and also progresses very slowly within individual joints
• commonest form of arthritis and the cause is unknown although it is commonly associated with injury or deformities
• of the skeleton of the joints particularly the spine, knee and the hip joints.
• inflammation is little but bony spurs often develop at the margins of the affected joints
• symptom usually come on gradually, intermittent pain initially and then becomes more frequent usually in the knees, hips or hands.
• closely related to ageing and by age 65, nearly 80% of people have some objective evidence of the disorder although only a quarter of these have symptoms
• joint may become progressively more limited once the joint capsule becomes thickened and less flexible

How to manage?

• Avoid undue stress or injury to the joints and a change of occupation may be necessary if the underlying cause is due to the nature of occupation
• Medication with NSAIDs or corticosteroids injection
• Losing excess weight is recommended in overweight patients
• Physical therapy: Heat application and exercise

Rheumatoid arthritis (RA)

• RA is a disease of synovium inflammation (inflitration of lymphocytes, plasma cells and macrophages) and proliferation (producing a tumour-like mass called 'pannus') with progressive joint damage
• RA affects at least about 2% of the population world-wide and the usual age of onset is between 30 and 40.
• RA is considered to be an autoimmune disease for the following reasons:
• Autoantibodies are seen as:
• Rheumatoid factor : IgM and IgG may play little part in the pathogenesis of RA
• Antinuclear antibodies
• Antibodies against cytoplasmic antigens in the cytoskeletal structure such as vimentin and keratin
• Immune complexes are common in the snynovial fluid and the circulation  
• Synovial fluid contains locally synthesized immunoglubolins and lymphokines
• Defect in cell-mediated immunity

General Symptoms

Patients often feel tired and unwell. The pain is worse in the mornings on waking, improves as the day goes on the gets worse again in the evenings. Pain at night with disturbed sleep is common. Patients may remain stiff for several hours after waking in active RA. There is a loss of appetite and weight, the development of nodules under the skin, tendon inflammation, bursitis, and often eye inflammation.

Joints

• Affected joints are swollen (soft and made up of effusion and synovial proliferation), often warm, but sometimes red, actively inflamed joints are stiff, painful and tender. In some cases with muscle wasting.

The hips

• Hip joint pain involved in about 50% of patients

The hands and wrists

• 30% of cases involved the distal interphalangeal joints
• There is spindling of the fingers, with swelling in the metacarpophalangeal and wrist joints
• Carpal tunnel syndrome may occur

The feet and ankles

• Deformities similar to those seen in the hands and wrists
• Patients often describe a sensation of walking on marbles

The knees

• Unstable knee joint due to synovial effusions, weakening of the capsule and quadriceps wasting
• Baker's cysts may be formed as the synovial space expands
• Ruptured posterior joint may become inflamed producing pain and swelling in the muscle

The Cervical spine

• Changes in the cervical spine occur in the majority of patients
• Atlanto-axial subluxation occurs in a quarter of hospital patients

Progression and prognosis of joint involvement

• New joints appear to get involved in an additive pattern in most cases
• 10% of patients become seriously disabled
• 40% of patients develop significant disability

Non-articular features

• This involves the soft tissues surrounding joints
• Rheumatoid nodules are found in 20% of cases
• Tenosynovitis may occur affecting the flexor tendons in the palm of the hand, which can cause trigger finger and may contribute to flexion deformities
• Muscle wasting may happen around affected joints, particularly in the hands
• Carpal Tunnel Syndrome is the commonest neurological abnormality in RA patients and the most serious neurological abnormality can result from atlanto-axial subluxation
• Sjogren's syndrome (probably part of a immunological process of rheumatoid disease) affecting the eyes occuring in about 15% of RA cases, which comprises dry eyes (keratoconjunctivitis sicca), a dry mouth (xerostomia) and rheumatoid arthritis
• Felty's Syndrome due palpable lymph nodes, enlarged spleen, skin pigmentation with neutropenia (repeated infections) and weight loss
• Anemia (normochromic normocystic/iron deficiency/haemolytic/hypersplenism-Felty's syndrome) is almost universal in RA due to the activity of the inflammatory process
• Rheumatoid nodules in the lung may occur and can be up to 3cm in diameter
• 30% of cases may have  pericardial rub but endocarditis and myocarditis are rare
• RA is a common cause of amyloidosis affecting the kidneys with presentation of proteinuria that leads to renal failure or to the nephrotic syndrome
• In the presence of Felty's syndrome, the liver may show nodular hyperplasia, which then leads to portal hypertension
• RA patient with Felty's syndrome may also develop vasculitis appears as nail fold lesions in the hands, gangrene of the fingers or toes are quite common
• As a result of increased vascular permeability, ankle edema is common in active RA patients

Rheumatic fever

• Does not seriously affect the joint and disability and always follows a throat infection by the Group A haemolytic streptococcus bacteria
• It is important as it damages the heart
• The commonest and most serious effect is scarring of the valves with stenosis (narrowing) or leakage (incompetence) and sometimes heart valve replacement may be necessary
• It may affect nervous system with features uncontrollable, jerky movements of the limbs and body accompanied by emotional upset

Gout

• acute joint disease due to the crystallization of monosodium urate monohydrate deposited around the joints, tendons and other tissues of the body with severe inflammation and tissue damage
• usually affects the joints of the big toe
• the commonest factor is that the kidneys fail to excrete uric acid (a purine and is relatively insoluble in water) fast enough (75-80%), and 20% of gout is caused by excessive production of uric acid  (normal uric acid levels for males: 3.5- 7.2mg/dL, females: 2.6-6.0mg/dL)
• if untreated, the pain or attack lasts for days or weeks but eventually subsides
• common drugs used: non-steroidal anti-inflammatory drugs (NSAIDs), colchicine and allopurinol. Usage has to be monitored due to their side effects

Systemic Lupus Erythematosus (SLE)

Systemic lupus erythematosus (SLE) is the commonest autoimmune disease involving the connective tissue disorders. It is characterized by the presence of serum of antibodies against nuclear components (ANA). Patient presents with arthralgia and rashes as the commonest clinical features. Cerebral and renal disease are the most serious problems among SLE patients.

SLE affects about 0.1% of the population worldwide. It is about nine times as common in women than men. Prevalence is peak between people aged between 20 and 40. The cause of SLE is unknown but the following factors are believed to play a part:

Immunological abnormalities

• A defect of suppressor T cell function that prevents production of autoantibodies

Viral aetiology

• SLE patients have lymphocytotoxic antibodies following some viral infections

Genetic factors

• Associated with changes near the HLA gene region have an increased risk of developing SLE

Sex

• More common in women than men

Drugs

• Certain drugs produce an SLE-like syndrome: hydralazine and procainamide as they may act by altering double-stranded DNA

Clinical features of systemic lupus erythematosus (SLE)

General

• Fever in up to 80% of cases

Depression and tiredness

• Skin Disorders
• 80% of cases
• Photosensitivity in 33% of the cases leading to exacerbations of the disease
• Butterfly rash on the cheeks of the face and across the bridge of the nose
• Vasculitis lesions on the finger tips and around the nail folds
• Purpura
• Urticaria

Chest Disorders

• 2/3 of the cases have lung involvement diseases
• Recurrent of pleurisy and pleural effusions (exudates)
• Restrictive lung defect

Joints Pain

• More than 90% of patients present symptoms resemble rheumatoid arthritis
• Swelling of joint
• Aseptic bone necrosis due to corticosteroid therapy may be seen

Nervous System Disorders

• 60% of cases
• Mild depression
• Epilepsy
• Cerebellar ataxia
• Aseptic meningitis
• Cranial nerve lesions due to vasculitis or immune complex deposition
• Peripheral neuropathy

Heart

• 40% of cases
• Pericarditis is common
• Some cases of  endocarditis involving mitral valve may occur but is very rare

Gastrointestinal Disorders

• Abdominal pain
• Nausea
• Vomiting
• Anorexia
• Diarrhoea

Renal Diseases

• 30-50% of cases
• Proteinuria (1g per 24-hour) is common
• Immune complex deposits in their kidneys
• Hypertension may occur as a result from progression to either the nephrotic syndrome or renal failure

Myopathy

• Myalgia is common
• Myositis also occurs

Blood Disorders

ESR is raised

• Autoimmune haemolytic anaemia, usually with normochromic normocytic
• Rheumatoid factor is positive in 50% of cases
• Immunoglobulins are raised (usually IgG and IgM)

Eyes Disorders

• Retinal lesions
• Blindness is uncommon
• Sjogren's syndrome  (such as dried eyes, dried mouth) may be see

Common drugs used to manage SLE

• NSAIDs in patients with mild disease and arthralgia
• The anti-malarial drug, chloroquine (150mg daily)
• Immunosuppressive drugs (Azathioprine 2mgper kg body weight daily is most used) with steroids

Pain in the Knee

Knee pain is usually felt in the knee with long-term swelling. However, localized pain suggests a torn cartilage or a torn ligament due a history of injury. If the knee is so unstable that you are liable to fall down, you might have a dislocated kneecap. Some of the causes of knee pain as follow:

• Osgood-Schlatter disease (probably due to interference with the blood supply of the region) that affects mostly boys during puberty due to the bulky group of muscles on the front of the thigh run down together with tendon is inserted into a bony lump on the front of the main bone of the lower leg (the tibia)

• Secondary bone cancer (usually affects the young adult) occurring as a remote spread from a primary cancer in another organ (osteogenic sarcoma) that usually appears at the lower end of the thigh bone (the femur) just above the knee; bone pain usually at night without obvious reason.

Pain in the Muscles

Muscle pain (myalgia) somehow is relatively common and has many causes such as:

Muscle cramps

• involving a single or a group of muscles that suddenly goes into a state of powerful sustained contraction followed by severe pain, which persists until the contraction eases off
• main contributor is due to excess salt loss from sweating
• night cramps involving the calf muscles and symptom is usually harmless
• Swimmer's cramps affect the abdominal or the limb muscles
• Writer's cramp as the muscles involved in holding the pen or pencil go into a state of spasm so that writing cannot be continued

Muscle spasms

• Similar to muscle cramp but with explained underlying causes
• It is an abnormal state of sustained contraction of a muscle and usually involves nerve connections disorder
• Tetany (an underaction of the parathyroid glands) is a characteristic form of muscle spasm resulting from low levels of blood calcium affecting the hands and feet (producing a claw-like effect with extension of the nearer joints and bending of the others), facial muscles, the larynx, or even the spinal muscles

Pain during exertion (intermittent claudication)

• A sudden pain in the leg muscles, usually in the calf and associated with temporary inability to walk
• Caused by an inadequate blood supply to the muscles from narrowing disease of the arteries (atherosclerosis)
• Pain-causing substances are due to the build-up of waste products in  the muscles
• Recent evidence suggests that the condition can be improved by deliberately 'walking through claudication' by walking for an hour every day before the pain comes on

Muscle compartment syndrome

• A muscle disorder of increased pressure within a compartment of the body
• Usually affects the forearm or the lower leg that results in compression of the veins followed by the arteries and eventually the muscles are deprived of their blood supply and become useless, shrunken and replaced by fibrous tissue
• Similar condition may be seen in athletes whose muscles are developed so quickly that they outgrow the space available

Polymyalgia rheumatica

• Muscle pain with stiffness in the shoulders, neck, back and arms
• Stiffness is often present on waking (may be so severe that the affected person can hardly get out of bed) or after prolonged sitting
• Is now known to be associated with another serious condition called giant cell arteritis may put patients at risk of suffering sudden blindness
• Affecting more women than men, almost as three times as often as men

Muscle Inflammation

• Defined as myositis- inflammation of muscle
• Usually occurs as a result of infection by viruses, or by other germs causing actual death of muscle

Pain in the Neck

Cervical spondylosis is the commonest disorder of the bones of the neck. Pain in the neck is a degenerative condition of the spine, in the neck region, with backward outgrowth of bone causing narrowing of the canal, which contains the spinal cord. Spinal cord or the emerging spinal nerve roots is compressed causing neurological damage. Slipped disc may also occur in the neck causing pain, stiffness and pain that radiate down either or both arms or through the back.

Symptoms include stiffiness, neck pain, weakness and atrophy in the arm muscles and scissors-like walking disorder.

Pain in the Shoulder

Pain is usually due to muscle or tendon problems or to pain referred from elsewhere.

Common causes of shoulder pain:

• Cervical spondylosis with softening and flattening of the neck vertebrae and pressure on the emerging nerve roots
• Coronary artery disease that causes angina pectoris or the pain of a heart attack referred to the shoulder, usually the left shoulder
• A lung cancer might lead to referred pain in the shoulder
• A liver abscess may refer pain to the right shoulder as it irritates the underside of the diaphragm
• Tendinitis due to the deposition of calcium hydroxyapatite around the tendons
• Frozen shoulder or adhesive capsulitis due to the capsule of the joint stiffens (a form of tendonitis) and may persist for few months

Pain in the Temples

Headache involves the temples with pain associated with exquisite tenderness on pressure and with visible red streaks. This type of pain indicates inflammation, with swelling tenderness and possible blockage involving arteries in the scalp and brain (temporal arteritis or giant cell arteritis). If it affects the main artery of the eye, blindness may occur and urgent medical treatment is required.

Pain in the Testical

This pain is common to young boys as the testicles are very sensitive to injury and even a minor blow to the area. However, the symptom is harmless. In adult males, pain is associated with inflammation from mumps orchitis, and as a rule, only one testicle is affected. Total sterility from this cause is rare. In addition, three quarters of cancers of the testicle are painless and are detected only by noticing a swelling or lump and should be reported at once.

Pain in the Throat

Pain in the throat is associated with sore throat, or pharyngitis, usually caused by viruses or bacteria. Pharyngitis is sometimes serious, with high fever, general upset, swelling (oedema) of soft palate or larynx. It may also cause hard swelling of the soft tissues in the floor of the mouth - Ludwig's angina.

Tonsilitis or inflammation and swollen of the tonsils is another type of pain associated with streptococcal bacteria. Symptoms include sore throat, pain on swallowing, headache, fever and a feeling of unwellness, constipation and earache. The lymph nodes are enlarged and tender. Tonsilitis usually responds well to antibiotic treatment, but severe case may justify surgical removal of the tonsils.

The most serious cause of pain in the throat is diphtheria with the symptoms of sore throat, fever, headache, and difficulty in swallowing and enlarged lymph nodes in the neck. Increased health awareness on the danger of toxin of diphtheria immunization, the cases is rare in developed countries. The released toxin may get into the bloodstream may cause serious damage to the heart, the nervous system causing permanent muscle weakness or the kidneys.

Pain in the Wrist

Wrist pain is often caused by referred pain to any part particularly the elbow and the wrist. Wrist pain may be caused by osteoarthritis, rheumatoid arthritis, tuberculosis or by inflammation (tenosynovitis) in the sheaths of some of the many narrow tendons the pass across both the front and the back of the wrist.

Another wrist pain is called De Quervain's disease of which is an inflammation and thickening of the sheath of a tendon that extends the thumb. This type of pain is common in women aged 30 to 50. It is usually due to excessive local trauma as form wringing out washing or overenthusiatic use of secateurs in pruning roses.

Pain on Bowel Movement

Key causes of pain on bowel include anal fissure and anal fistula and piles/haemorrhoids. Anal fissure is characterized a tear in inner lining of the canal of the anus often caused by hard faeces. Meanwhile, anal fistula is due to abnormal connection or passage between the inside of the anal canal and the outer skin near the anus.

Pain on Menstruation

Menstruation pain is termed as dysmenorrhoea scientifically. Almost all women who have not had babies experience it. It can be so painful that in effect, dysmenorrhoea is a kind of mini-labour. Dysmenorrhoea is due to uterine ischemia resulting from excessive myometrial contraction. Endometrial blood flow is decreased during these contractions.

The pain occurs either just before (24-48 hours prior to menstruation) or at the beginning of the period. It is coupled with cramping, rhythmical pain in the lower abdomen and back that lasts for a few hours, but sometimes to a whole day. For the serious one, the pain may last throughout the entire menstrual period. To some extend, it is so bad that some women are temporarily unable to work or carry on with their normal daily routine.

As for other symptoms, there may also be nausea, backache, headache, faintness, vomiting and diarrhoea, cramping and colicky pain in the bowels.

Dysmenorrhoea may be either primary or secondary. Primary dysmenorrhoea is defined as painful menstrual cramps occurring in the absence of a pelvic abnormality, while secondary dysmenorrhoea is usually associated with a pelvic disorder such as endometriosis, pelvic inflammatory disease, or submucous leiomyomas.

It has been found that abnormal prostaglandin levels are responsible for primary dysmenorrhoea than with secondary dysmenorrhoea. Primary dysmenorrhoea is one of the commonest gynecological disorders, affecting about 50% of women and causing an estimated 140 million lost working hours each year in the United States.

How to Manage?

• NSAIDs drug during onset (if possible, try to avoid as they may cause gastrointestinal ulceration), the most widely used: mefenamic acid

Natural/Dietary Approach:

• EnerFlex® 40g per day
• Vitamin B6 50mg , 2 tablets twice a day
• Dong Quai Capsules, 2-4 a day
• Essential Fatty acids such as Evening Primrose Oil and Starflower oil Capsules, 500mg capsules: 2 capsules twice a day
• Calcium 800-1000mg, Magnesium 300-400mg per day
• Vitamin C 500mg per day

Pain on Sexual Intercourse

Pain on sexual intercourse felt by a woman is medically termed as dyspareunia. It is often caused by a powerful vagina spasm (vaginismus) of psychological origin (fear of sex) so severe that even finger can barely be admitted. Key causes as follow:

• a thick, persistent (imperforate) hymen
• any inflammation of external genital area (vulvitis)
• inflamed mucus-secreting glands (bartholinitis)
• inflammation in the urine tube
• inflamed vagina
• old episiotamy scars
• dryness of the vagina, due to estrogen deficiency after the menopause
• a congenital central vaginal partition, septate, or double vagina

Pain on Urination

Cystitis or inflammation of the urinary bladder caused by infection (Chlamydia trachomatis,Trichomonas vaginalis, Haemophilus vaginalis, Candida albicans) by far the commonest cause of pain on urination. Women are prone to this disorder than men. The key is the shortness of the tube from the bladder to the exterior (the urethra) and there is burning or scalding pain on passing urine but frequently in small quantities. There is unduly frequent desire to visit the toilet, and even involuntarily letting out a small squirt of urine when coughing or laughing. This condition termed as stress incontinence. Cystitis in men is usually associated with infection and inflammation of the prostate gland (prostatitis).

Occasionally, blood may present in the urine and affected people often have to wake up during the night.

How to manage?

• Drink lots of fluid to 'flush out' the urinary system
• Try to empty the bladder after urination or double urination
• To pee after sexual intercourse
• Avoid nylon underwear and vaginal deodorant
• Use vaginal estrogen creams in menopausal with cystitis

Recent Updates

VIOXX® Recall: What You Need to Know

Merck & Co., Inc. announced that it is voluntarily pulling its arthritis and acute pain medication VIOXX® from the market after clinical trials found that long-term use (more than 18 months) increased the risk of cardiovascular concerns such as heart attack and stroke. VIOXX , a COX-2 inhibitor, was introduced in 1999 and has been a blockbuster medication, with over $2.5 billion in sales in 2003 alone.

“Acting Food and Drug Administration (FDA) Commissioner Dr. Lester M. Crawford stated that FDA will closely monitor other drugs in this class for similar side effects. "All of the NSAID drugs have risks when taken chronically, especially of gastrointestinal bleeding, but also liver and kidney toxicity. They should only be used continuously under the supervision of a physician."

What is the Food and Drug Administration doing about this? The FDA issued a public health advisory concerning the use of VIOXX . Get more information about the FDA's advice about VIOXX.

FDA Consumer Information: Vioxx

FDA statement on the voluntary withdrawal of Vioxx , including questions and answers about the drug.

www.fda.gov/cder/drug/infopage/ vioxx /default.htm