2) Sleep apnea syndrome – loud snoring, frequent breathing pauses during sleep, choking or gasping in sleep, waking up sweating during sleep, feeling unrested after a night’s sleep in the morning, daytime drowsiness, headache, dyspnea, snoring, weight gain, obesity, fatigue, rapid weight gain, cognitive deficits (poor memory, decreased mental performance, unable to make decisions with clarity, poor attention), depression, labile hypertension, palpitations, increased frequency of road traffic accidents, higher risk of industrial accidents,
3) Somatic depression syndrome – insomnia, hypersomnia, daytime drowsiness, early morning wake ups, anorexia, hyperphagia, fatigue, poor concentration, poor memory, being slowed down,
4) Somatic anxiety syndrome – dizziness, dyspnea, sweating, derealization (N), depersonalization (N), paresthesiae, palpitations, tremors of body, chills, waves of heat over body, chest tightness,
6) Hypothyroidism - tiredness, weakness, fatigue, weight gain, cold intolerance, dry skin, thinning of hair, hoarseness, constipation, generalized body aches, muscle cramps, mental impairment, psychomotor retardation, depression, menorrhagia, infertility, weight gain, goiter, bradycardia, edema, hoarseness, delayed relaxation of tendon reflexes, slow speech, cool and dry skin, proximal myopathy, elevated TSH levels, low free thyroxine, Tx – thyroxine, 1.7 mcg/kg/day for full replacement, children require higher doses up to 4 mcg/kg/day, older and cardiac patients start with lower doses, repeat TSH 8 weekly until serum values reach normal, then repeat TSH annually
7) Hyperthyroidism – nervousness, fatigue, palpitations, exertional dyspnea, weight loss, heat intolerance, tremor, muscle weakness, oligomenorrhea, sleep disturbance, sweating, diarrhea or frequency of defecation, appetite changes, thyroid enlargement, tachycardia, exophthalmos, hyperreflexia, TSH low, elevated free thyroxine, normal TSH with elevated free thyroxine may be due to a pituitary adenoma. Tx – internal medicine specialist referral
10) Haematological malignancy – fever, fatigue, night sweats, weight loss, generalized pruritus, dyspnea, bruising, bleeding, recurrent infections, bone pain, alcohol-induced pain, abdominal pain, lymphadenopathy, splenomegaly, any combination of any of the above symptoms doe FBC and a blood film
11) Premenstrual tension syndrome – headache, backache, painful menses, breast swelling and tenderness (4 most common symptoms), generalized body swelling, abdominal pain, distension, muscle cramps, weight gain, recurrent cold sores, constipation, diarrhea, carbohydrate craving, noise and light intolerance, acne, all the symptoms start 1 week premenstrual, lasts upto the 3rd day of menses and then disappear, following psychological symptoms too are common in various combinations – somatic anxiety syndrome, panic attacks, somatic depression syndrome, memory deficits like forgetfulness and misplacing things, difficulty in concentration, irritability, usually no disability and interference with day to day functioning, irritability, mood swings, crying spells, Tx – NSAIDS, avoid salt, caffeine, alcohol, good sleep, exercise
12) Premenstrual Dysphoric Disorder – same symptoms as in PMTS but severe in degree, somatic depression syndrome, somatic anxiety syndrome, cognitive symptoms of depression and/or anxiety ++, dysphoria start 1 week premenstrual, lasts upto the 3rd day of menses and then disappear, disability ++ mainly in the occupational and social domains, symptoms for at least 2 consecutive menstrual cycles, Tx – life style interventions like cutting down on caffeine, sodium and refined sugars, vitamin B6 50-100 mg daily, calcium carbonate 1200 mg daily, spironolactone and OCs still being tested, if above interventions do not help and if disability continues other drugs indicated are fluoxetine (20 mg daily) or sertraline, administered either continuosly or intermittently at time of ovulation and stopped with onset of menses, other psychotropics used are alprazolam and clomipramine, it there is no response for psychotropics OCs can be tried but limited data, gonadotropin releasing hormone agonists can be tried as final line of treatment usually as a multidisciplinary approach.
13) Menopause – hot flashes, skin flushes, night sweats, sweating episodes, insomnia, mood swings, anxiety, depression, irregular menstrual periods, spotting between periods, vaginal dryness, dyspareunia, decreased sex drive, vaginitis, UTIs, Tx – light dressings, avoid alcohol, caffeine, spicy foods, deep breathing exercises during an attack of hot flashes, other relaxations techniques (yoga, tai chi, meditation), soy-based foods, continue sexual activity, perform Kegel exercises daily (vaginal and pelvic muscles are toned up), water-based creams during sexual intercourse, to reduce disabling hot flushes start HRT short term, fluoxetine, paroxetine, venlafaxine, clonidine
15) Addison’s disease – fatigue, weakness, pigmentation of skin, pigmentation of mucous membranes, weight loss, anorexia, nausea, vomiting, hypotension, abdominal pain, salt craving, diarrhea, constipation, syncope, vitiligo
16) Autonomic Dysfunction Syndromes – postural dizziness, recurrent syncope, falls, orthostatic hypotension (OH) (decrease in SBP of > 20 OR DBP > 10 on standing from a supine position), (differential diagnosis of OH is volume depletion, baro reflex dysfunction, autonomic insufficiency, venodilatory antihypertensives like alpha blockers and alpha-beta blockers ) chronic orthostatic hypotension symptoms (fatigue, visual blurring, headache, neckache, dyspnea, drop attacks, cognitive slowing), impotence, erectile dysfunction, retention of urine, urine incontinence, poor urinary stream, nocturia, diarrhea, constipation, fecal incontinence, gastroparesis, pupilary immobility, dry skin with impaired sweating, snoring, sleep apnea, tachycardia, painless myocardial ischemia, impaired cardiovascular responses for exercise and stress, palpitations (ventricular arrhythmias due to cardiac autonomic neuropathy CAN – bedside tests for CAN (N)), Mx – Fluid intake of 2-2.5 L/day, salt intake of at least 10 mg/day, salt rich fluids like tomato juice, sports drinks, canned soups, gradual transition from supine to standing particularly morning wake up when the orthostatic tolerance is at the lowest, raising the head of the bed by 10-20* to prevent night BP elevation, rapid ingestion of 500 ml of water within 2 minutes shortly bedore orthostatic stress (this creates a pressor response within 5 minutes which lasts for 1 hr), fluorohydrocortisone, midodrine HCL, ephedrine 25-50 mg tid, compression stockings, leg crossing, squatting, muscle pumping help maintain BP, compression stockings, abdominal binders, isotonic exercises for leg muscles, bethanechol 5-50 mg for bladder atonia, intermittent self catheterization for chronic recurrent urinary retention, Sildenafil 50 mg/use, OR Tadalafil 10 mg/use OR Vardenafil 5-10 mg/use for erectile dysfunction, GIT dysmotility symptoms Metoclopramide 5-10 mg 30 min before meals, Erythromycin 250-500 mg immediately after a meal, Domperidone 10 mg before meals, Loperamide for diarrhea, stool softeners and laxative for constipation,
17) Family history of hemochromatosis, fatigue, weakness, weight loss, abdominal pain, joint pain, mild elevations of aminotransferase levels, asymptomatic hepatomegaly, late in the course cirrhosis, hepatocellular carcinoma, diabetes, hypogonadotropic hypogonadism, impotence, hypothyroidism, arrhythmias, heart failure, destructive arthritis, increased transferrin saturation levels (fasting saturation levels above 45% or 35% in premenopausal women), high serum ferritin levels, Mx – Phlebotomy treatment of choice as it prevents iron overload, prevents end-organ damage, halts the progress of end-organ damage if present
18) Uraemia – Fatigue, decreased mental acuity, seizures, anorexia, nausea, decreased sense of taste and smell, cramps, restless legs, sleep disturbances, coma, amenorrhea, sexual dysfunction, reduced body temperature, bone disease due to phosphate retention, hyperparathyroidism, Vit D deficiency, reduced resting energy expenditure, insulin resistance, increased protein muscle catabolism, serositis, itching, hiccups, anemia, peripheral neuropathy,
19) Pregnancy – minor symptoms of pregnancy, nausea, vomiting, fatigue, heartburn (frequent small meals, avoid frequent bending, antacids with aluminum hydroxides), ptyalism, gingivitis, increased vaginal discharge (usually asymptomatic unless accompanied by moniliasis which needs treatment ), leg cramps (calf and peroneal muscles, usually nocte, usually in the second and third trimesters, Tx – massage, stretching, calcium), paresthesiae (usually in the hand, CTS and/or shoulder drooping associated with pregnancy, Tx with diuretics), backache, urinary symptoms of frequency and/or stress incontinence, lower leg and vulval varicosities (avoid prolonged standing, encourage active exercises, leg elevation while sitting and lying down), constipation (bowel training, diet rich in fruits, green leafy vegetables, bran), hemorrhoids (manage constipation, soothing agents, local anesthetics)
20) Primary fibromyalgia – GBA, chronic muscle pain, muscle spasms, muscle tightness, leg cramps, moderate to severe fatigue, decreased energy, insomnia, waking up unrefreshing, early morning stiffness, stiffness after inactivity, difficulty remembering, concentrating, performing simple mental tasks, abdominal pain, bloating, nausea, constipation alternating with diarrhea (IBS), tension or migraine headaches, jaw, and facial tenderness (TMJ dysfunction), sensitivity to 1 or more of following (odors, noise, light, medications, foods, cold), feeling anxious, depressed, numbness or tingling in the face, arms, hands, legs, feet, increase in urinary frequency or urgency (irritable bladder), reduced exercise tolerance, myalgia after exertion, feeling of swelling without actual swelling in the hands and feet, painful menstrual periods, dizziness,
21) Myofascial pain syndrome – local pain (regionalized but poorly localized pain at the joints and muscles), referred pain, tightness, tenderness, popping, clicking, stiffness, limitation of movements, autonomic phenomena, local twitch responses in the affected muscle, muscle weakness without atrophy, trigger points (are seen at characteristic sites for a given muscle) which cause referred pain in characteristic areas for muscle restricted range of motion, visible or palpable LTR to local stimulation, sensory disturbances,
22) Hyperventilation syndrome – both acute and chronic subtypes. See under dyspnea for details