The internist and pain in the hospital setting

Pain is among the most frequent symptoms in medicine and one of the main reasons for patients’ seeking medical care. In the hospital setting, the internist mainly faces acute/recurrent pains, although various chronic pains also emerge in patients hospitalized for different symptoms. The most challenging acute/recurrent pains are of visceral origin and their correct identification is crucial for both diagnostic and therapeutic purposes. Collecting a detailed clinical history, targeted at the pain characteristics, and performing a specific physical examination of the painful area, including manoeuvers for hyperalgesia detection in somatic body wall tissues, represent the fundamental steps towards diagnosis, particularly to distinguish a visceral referred pain from a primary somatic pain. Special care should be taken in the evaluation of elderly, diabetic and hypertensive patients, in whom the pain threshold is raised and acute visceral pain, in particular, is hypo-expressed and/or tends to manifest atypically. As a general rule, pain symptoms should not be cancelled too early with analgesics as they represent a precious element to interpret the clinical picture. In contrast, a pain whose origin has already been identified and is no longer useful for diagnostic purposes should be relieved promptly and effectively, to avoid chronicization and long-term consequences such as a generalized state of pain hypersensitivity from central sensitization processes.