Physical Exam Key Points




Somatic pain Visceral pain

Neuropathic pain


Physiologic dependence

Psychological dependence or addiction

Nociceptive pain from skin, bones, joints, ligaments, and muscle Pain from nerve endings in viscera responding mostly to stretch; often referred to other areas of body Pain from nerve injury, compression, or disease; in central or peripheral nervous system

Decreased analgesic effect, or need to increase opioid dosage to maintain same analgesic effect Tolerance develops at different rates and is dependent on drug, dosage, frequency, and duration

Need to continue medication administration to prevent signs or symptoms of physical withdrawal Compulsive drug use characterized by continued drug craving and need to use opioids for effects other than pain relief

1. Vital signs. Tachycardia and tachypnea may occur with pain, or they may indicate other diseases such as infection.

2. Hydration status. Dehydration precipitates pain in sickle cell disease.

3. Chest. Listen for crackles and observe for cyanosis or other signs of infection. Consider the chest as a source of pain, particularly in patients with sickle cell disease (acute chest syndrome, pneumonia).

4. Abdomen. Evaluate as a source of pain. Examine for tenderness, guarding, or rigidity.

5. Neurologic exam. Observe mental status, and assess ease with which patient can be distracted from the pain.

6. Extremities. Look for localized tenderness, decreased range of motion, deformities, areas of erythema, warmth, and swelling.

Laboratory Data. Consider infection; obtain CBC with differential, C-reactive protein, ESR, blood culture, and urinalysis, if febrile.

Radiographic and Other Studies. Studies are based on the location, quality, and intensity of pain. In a patient with sickle cell disease, consider obtaining a chest X-ray if acute chest syndrome is suspected or plain X-rays of extremities if warranted. Focal abdominal pain often warrants an ultrasound.

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