The Common Vein Copyright 2008

Jamie Armstrong PA

Ashley Davidoff MD

Red Flags

One of the pearls of using pain scales and descriptors is that they can herald the seriousness of pain. The following characteristic patient complaints may herald a condition a clinician does not want to miss.

Headache: Severe intensity and/or prolonged duration. The phrase “the worst headache of my life” is considered a hallmark for intracranial or subarachnoid bleeding.

Eye Pain: Sudden eye pain in the absence of trauma can signify acute glaucoma, an emergent threat that can lead to blindness.

Chest Pain: As described in the chest pain module, impending or actual myocardial infarction, aortic dissection or pulmonary embolism must be taken seriously when a patient describes their manifestations as chest discomfort. The descriptors can vary for each but onset, pattern and relieving factors may help to discern one of these serious events from more benign causes like gastroesophageal reflux.

Back Pain: Acute back pain may also signify a cardiovascular event for instance in aortic dissection. If accompanied by neurological sequelae like limb parasthesias, decreased motor function or incontinence, the problem may be within the spinal column.

Abdominal Pain: Abdominal pain can be one of the most difficult complaints to evaluate given its relationship to so many organ systems. Visceral pain descriptors like achy, diffuse and  crampy are common in abdominal pain. In addition, location, acuity, intensity and pattern of abdominal pain are good benchmarks to guide the clinician when performing the examination.

Testicular pain: Testicular pain of acute onset may represent mechanical injury to the testes as in the case of testicular torsion or it can be referred from the lower abdominal wall with an incarcerated hernia.

Calf Pain: Calf pain may be thought of as a musculoskeletal problem but may also signify a more life threatening problem like deep vein thrombosis (DVT). Pain descriptors may be helpful in differentiating a vascular from a musculoskeletal source. However, the clinical history may play a more vital role in this scenario.

Neuropathic pain: Neuropathic pain may be described as burning, shooting or tingling pain among other descriptors. When it occurs over the extremities, neuropathic pain is a harbinger of undiagnosed diabetes until proven otherwise.

Muscle pain: Muscular discomfort in the absence of trauma can be a clue to a life-threatening condition like Rhabdomyolysis. This is a syndrome of muscle cell necrosis that can lead to renal failure from the release of myoglobin into the bloodstream. Causes include illicit drug use, trauma and prescription drug toxicity.

Unexplained pain: When a patient is vague and/or inconsistent with explaining pain and there are no obvious findings, consideration should be given to psychogenic pain. It is important to remember that underlying psychological illnesses like depression and bipolar disorder can be life threatening.

The clinical scenarios described above represent important pain syndromes not to be missed given their potentially serious consequences. Remembering them can provide the wisdom to make timely clinical diagnoses and therapeutic decisions.

  Across all patient cohorts, pain is both a necessary evil and a valuable tool that requires medical knowledge, measured inquisitiveness and empathy. As clinicians navigate through the various pain modules of this site and gain practical experience, it will become apparent that pain and its treatment are rarely the same among patients. This imperfection is one of many in medicine but it underscores the artistry necessary to practice the discipline.