BIOSOFT HELP FILES

1)      Drug-induced water retention – use of NSAIDs, prednisolone, dexamethasone,  estrogen, vasodilators, calcium antagonists,

2)      Premenstrual tension syndrome

3)      Pregnancy

4)      Hypothyroidism –

5)      Idiopathic edema – females, periodic episodes of generalized body swelling, usually accompanied by abdominal distension, orthostatic water retention (as demonstrated by several hours of standing causes body weight to rise by several pounds),

6)      CCF -  dyspnea, orthopnea, paroxysmal nocturnal dyspnea, generalized edema, JVP elevation, heart enlargement, gallop rhythm, basal lung crepts, liver enlargement,

7)      Alcoholic liver disease

1)      Acute water retention of NSAIDs, steroids

2)      Decompensated cirrhosis

3)      Acute nephritic syndrome

4)      Nephrotic syndrome

5)      CCF

6)      Pregnancy – minor symptoms of pregnancy

1)      Generalized aches and pains, malaise (general ill feeling), headache, blurred vision,  sudden onset oliguria (< 400 ml/day), generalized edema manifested as generalized body swelling (facial swelling, periorbital swelling, arms, hand, feet and legs swelling or dependent edema), hypertension, abnormal heart and lung sounds, JVP elevation, enlarged liver, red blood cell casts, dysmorphic red cells, leucocytes, proteinuria, hematuria (blood in the urine appearing as dark, tea-colored, cloudy urine) (microscopic and/or macroscopic), illness onset days-weeks (acute nephritic syndrome), elevated urea and creatinine, (Acute nephritic syndrome)

2)      Massive proteinuria (> 3 g/24 hrs), hypoalbuminemia, generalized edema, hyperlipidemia, lipiduria, hypercoagulability (manifested as peripheral arterial thrombosis, venous thrombosis, renal vein thrombosis, pulmonary embolism) (Nephrotic syndrome)

3)      Ascities, SGPT, and SGOT elevation raised serum bilirubin, abdominal collateral veins, spider angiomas (Liver failure)

1)      Somatic anxiety syndrome

2)      Somatic depression syndrome

3)      Primary Fibromyalgia – generalized body aches, sleep disturbance, fatigue, depression, generalized body aches for more than 3/12, usually on both sides of the body, and both above and below the waist, and also the axial skeleton involvement, tender points at 11 out of 18 according to the American College of Rheumatology criteria (N), however, subsyndromal cases may have about 5 out of 11 classical sites, associated allodynia, hyperalgesia, hypersensitivity, sensitive to smells, sounds, light, odors, pressure and temperature fluctuations, bright lights, noises, touch, and even smells may be converted to pain, flickering lights, staccato or repetitive noise intolerable, Tx – antidepressants, analgesics, exercises, oral interferon, NMDA receptor blockers

4)      Myofascial Pain Syndrome – MFPS – local or regional muscular pain, burning, stabbing, aching, nagging quality, usual sites are neck, mid thorax region, chest wall, elbow, lumbar region, abdominal pain, hip pain, foot pain, pain aggravated by strenuous use of muscle,  passive stretching of the muscle, pressure on the trigger point, placing the muscle in a shortened position for a prolonged period, sustained contraction of the involved muscle, repeated contraction of the involved muscle, cold, damp weather, viral infection, stress, exposure to cold drafts, myofascial pain is reduced by rest, slow, steady, passive, stretching of the involved muscle, moist heat applied over the trigger point, short periods of light activity with movements, specific myofascial therapy, myofascial trigger points usually at abdominis rectus, obliques, levator ani, obturator internus, piriformis, ilopsoas, hip adductors, trigger points are hard, palpable, hypersensitive nodules in the muscles, spot tenderness over the trigger point, taut band and a nodule at the site of pain, trigger point compression elicits local and referred pain which reproduces patient’s usual pain, snapping compression of trigger point elicits a muscle twitch, passive stretch of a muscle with a trigger point painful, muscle may also show painful weakness, satellite trigger points – these are trigger points which develop in the muscles of referral zones or synergistic muscles of the original primary trigger point muscle.  Tx – Trigger point release with spray and stretch, voluntary contraction and release, trigger point pressure release, deep stroking massage, trigger point injection.

5)      Hypothyroidism

6)      Depression

7)      GAD

8)      SFD

9)      Steroid withdrawal syndrome

10)    Alcoholic myopathy – acute onset generalized body aches, alcohol binging episodes, muscle swelling

11)    Chronic fatigue syndrome

12)    Hypermobility syndrome – Mx – patient education, activity modification, muscle strengthening program

13)    Somatoform Pain disorders

14)    Hypochondriasis

15)    Infections – Fasiocoliasis, amebiasis, giardia, chronic candida yeast infection (particularly in those given multiple courses of antibiotics for UTI, sinusitis, otitis media, sore throat)

16)    Drugs - statins

17)    Osteomalacia

18)    Hypokalemia

1)      Persistent unexplained bone pain (FBC, X-ray, urea, electrolytes, liver and bone profile, PSA, ESR, CRP)

2)      Increasing, unexplained or persistent bone pain OR tenderness, particularly at rest

3)      Elderly, proximal muscle pain and weakness, malaise, weight loss, headache, raised ESR (exclude polymyalgia rheumatica)

4)      Temporal headaches and/or jaw claudication (temporal arteritis)

5)      Weight loss, malaise, anorexia, fever (connective tissue diseases)

6)      Hypercalcemia (metabolic, endocrine or malignant diseases)

7)      Elevated alkaline phosphatase (metabolic, endocrine or malignant diseases)

8)      Hyperuricemia (metabolic, endocrine or malignant diseases)

9)      Hypokalemia (metabolic, endocrine or malignant diseases)

10)    Diffuse bone pain predominantly in the hip girdle, bone tenderness (use moderate force on sternum or anterior tibia with thumb and if it elicits tenderness suggestive of osteomalacia), muscle weakness, particularly proximal muscle weakness with Tredelenburg gait, easy fatiguability, pathological fractures, perioral paresthesiae, acroparesthesiae, carpopedal spasms (Osteomalacia – confirm by low serum Vit D, varying levels of serum Ca and P )

11)    Family history of hemochromatosis, fatigue, weakness, weight loss, abdominal pain, joint pain, mild elevations of aminotransferase levels, asymptomatic hepatomegaly (See under MMSCs for hemochromatosis)

12)    Alcohol abuse, muscle overexertion, muscle compression, HMgCoA reductase inhibitors, cyclosporine, itraconazole, erythromycin, colchicine, zidovudine,  corticosteroids, muscle pain, tenderness, swelling, bruising, weakness, tea-colored urine, fever, malaise, nausea, vomiting, acute confusional state, complications like acute renal failure, DIC, hyperkalemia, hypocalcemia, cardiac arrest, (Rhabdomyolysis)

13)    Hypalgesia, paresthesia, dysesthesia in the limbs and trunk (painful electric shock-like sensations down the spine on neck flexion, painful leg spasms), particularly with a sensory level, loss of vibration sense, loss of positional sense, associated cerebellar signs (ataxia, intention tremor, ataxic gait), eye signs (irregular areas of visual loss in 1 eye, loss of color intensity, eye pain made worse with eye movements, these symptoms initially recurrent but later progressive, nystagmus, INO or MLF syndrome which causes diplopia on lateral gaze), spinal cord signs (manifested as incontinence, impotence, impairment of gait, incontinence initially in sleep and during sexual intercourse, recurrent episodes of retention of urine, finally total loss of control, psychosexual dysfunction include erectile dysfunction, loss of sexual desire, premature or retrograde ejaculation) (Multiple sclerosis) 

1)      Persistent bone pain (FBC)

2)      Unexplained bone pain (FBC)

(NCC-PC Referral Guidelines for Suspected Cancer  in Adults and Children)

(Singer et.al. 1995)

(Alvarez and Rockwell 2002)

(Froese 2001)

(Sauret and Marinides 2002)

(Kaufman 2007)

(CDC – Sexually Transmitted Diseases Treatment Guidelines 2006)

1)      Gonococcal infection – IP 3-14 days, painful, mucopurulent discharge, Dx – Gram stain of discharge shows intracellular diplococci, other tests available are culture, nucleic acid hybridization test, nucleic acid amplification test, Tx – Cefixime 400 mg PO single dose OR Ceftriaxone 125 mg IM OR Ciprofloxacin 500 mg PO OR ofloxacin 400 mg PO (effective against chlamydia), Levofloxacin 250 mg orally single dose (effective against chlamydia), syphilis and HIV serology, partner tracing and treating, counselling, all patients treated for gonorrhea must also be tested and evaluated for Chlamydia, syphilis, HIV, if any specific tests are not done for Chlamydia then all gonococcal infections must also be treated with drugs effective against Chlamydia as well,

2)      Male patient urethritis – purulent, mucopurulent discharge, dysuria, pruritus, Ix – Gram stain microscopy (more than 5 WBC/oil immersion field, if no discharge then do a Gram stain on the sediment of the first void urine, Gram negative Intracellular Dipplcocci establish the GC infection, if it is negative treat for C. trachomatis if STD risk factors are positive, if not other etiological factors like Ureaplasma ueralyticum, Mycoplasma genitalium, T. vaginalis, HSV, adenoviral infections ), culture (urethral swabs), nucleic acid hybridization tests (uretrhal swabs), nucleic acid amplification test (urine, higher sensitivity), Mx – Gonococcal treatment see above, reginmens for Chlamydial infections are Azithromycin 1 g orally one dose OR Doxycyline 100 mg bid orally for 7 days OR Erythromycin base  500 mg orally 4 times daily for 7 days OR Ofloxacin 300 mg orally bid for 7 days OR Levofloxacin 500 mg orally once daily for 7 days,  revaluaiton after 3 days if no improvement, symptoms alone without lab evidence of infection does not require treatment, avoid sexual intercourse until 7 days after therpy AND partner adequately treated, screen for HIV, syphilis, partner referral for evaluation and treatment, persistent symptoms, discomfort,  irritative voiding syndrome after 3 months exclude chronic prostatitis and pelvic pain syndromes.

3)      Female cervicitis – vaginal discharge, intermestrual bleeding, purulent or mucopurulent endocervical discharge visible on speculum exam  or endocervical swab specimen, sustained endocervical bleeding easily induced by a gentle passage of a cotton swab through the cervical os, more than 10 WBC per high power field on microscopic exam of vaginal secretions (this is commonly associated with gonococcal and/or chlamydial infections, absence excludes cervicitis of infective origin), intracellular gram negative diplococci (low specificity), NAAT for N gonorrhoea and C. trachomatis, usually caused by N. gonorrhoea, C. trachomatis, mycoplasma genitalium, bacterial vaginosis, persistent abnormality in the vaginal flora, douching, chemical irritants, cervical ectopy (consider non-intfectious causes in persistent and treatment resistant cases), Tx – presumptive therapy in cases of high STD risk (age < 25 yrs, new sex partner, multiple sex partner, unprotected sex) with Azithromycin 1 g orally single dose (particularly in pregnancy) OR Doxycyline 100 mg orally bid for 7 days, in cases of chlamydial infections Erythromycin (500 mg orlly 4 times daily for 7 days), Ofloxacin (300mg orally twice daily for 7 days) or Levofloxacin (500 mg orally once daily for 7 days) also considered, sexual abstinence for 7 days after treatment started, exclude PID, sex partner treatment (if sexual contact within 60 days of symptom initiation) if gonococcal, chlmydia or tricho infections diagnosed, screen for HIV, syphilis.

4)      Chlamydial infection – IP 1-3 weeks, purulent or mucoid genital discharge,

5)      Trichomonas infection –

6)      Senile vaginitis

7)      Genital Herpes – see under Genital Ulcers

1)      Anterior urethritis – males, dysuria, purulent discharge per urethra, tender glans penis, - Tx - Erythromycin

2)      Prepubertal vaginitis – foul smelling, pruritic vaginal discharge in a prepubertal female, - Tx erythromycin

3)      Chronic balanitis – genital scratching, discharge, adhesive prepuce, white paste of smegma, underlying phimosis (stenosed prepuce cannot be retracted over the glans, complaints of foreskin ballooning with urination), Mx – clean with antibiotic cream gently