BIOSOFT HELP FILES

Exaggerating the negative experiences.  Eg. I could not get enough marks for the chemistry paper.  I am an academic failure.

MEDICALLY UNEXPLAINED SYMPTOMS

OR

Multiple MultiSystem Symptom Combinations (MMSSCs)

Properties are many symptoms, symptoms referable to many body systems,

Identify common patterns of diseases with many somatic symptoms

1)      Stress Response Syndrome – (Physical symptoms ) – fatigue, nausea, headaches, generalized body aches, (Psychological symptoms) – disturbed sleep, nightmares, restlessness, excessive alertness, easily startled, (Cognitive symptoms) poor concentration, poor attention, poor memory, visual images of the event, intrusive thoughts, disorientation, confusion, (Emotional symptoms) fear, numbness and detachment, avoidance, depression, guilt, oversensitivity, anxiety, panic, withdrawal, tearfulness,

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,

5)      Somatoform disorders – SD, UDSFD, SPD, HCDS, MUS

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

8)      Cushing’s syndrome - Central obesity, moon facies, buffalo hump, plethoric complexion, thin skin, abdominal striae, ecchymotic patches, proximal myopathy, hyperglycemia

9)      Othe endocrinopathies

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 3^rd 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 3^rd 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

14)    Systemic lupus erythematosus – tiredness, myalgia, lymphadenopathy, joint pain, tendonitis, photosensitivity, various rashes, hair loss, pleuritic chest pain, Pericarditis, migraine, TIAs, epilepsy, depression, cognitive deficits, anemia, leucopenia, thrombocytopenia, phlebitis, miscarriages, fatigue, malaise, fever, weight loss, generalized body aches, polyarthritis, malar rash, photosensitivity, oral ulcers, alopecia, anemia, leucopenia, lymphopenia,. cognitive deficits, pleurisy, proteinuria, ANA seen (SLE)

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

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

(Grady-Weliky 2003)

(Singer et.al. 1995)

(Jean Louis 2007)

(Gibbons and Freeman 2006)

(Pietrangelo 2004)

(Meyer and Hostetter 2007)

(Webmd.com)

(Newton 2005)

(Australian Psychological Society 2008)

(Singer et.al. 1995)

(WHO 2003)

(Gerstein 2007)

(Barrett 2005)

(Asherson 2007)

(Searight, Burke, Rottnek 2000)

(Inouye et.al. 2006)

(Adelman and Daly 2005)

(APA DSM-IV 1994)

1)      Benign forgetfulness or normal aging – difficult to recall some types of information like names of persons

2)      Mild Cognitive Impairment – MCI – this is more severe than memory loss of normal aging and subset of persons with MCI will show progressive deline in the memory and ultimately may develop AD.

3)      Stress

4)      Anxiety states

5)      Somatic anxiety states

6)      Somatic depression syndrome

7)      Depression

8)      Hypothyroidism –

9)      Apathetic hyperthyroidism – hyperthyroidism presenting with features of hypothyroidism like fatigue, psychomotor retardation, depression, weight gain

10)    Dementia – Impairment in memory when associated with deficits in at least 1 other area of higher cognitive functioning like judgment, abstract thinking, complex task performance, agnosia, apraxia, visuospatial awareness, personality change in the context of above deficits,  early signs and symptoms – getting lost in conversations, word-finding difficulty (anomia), left-right disorientation, aphasia, inability to copy drawing, early memory loss, cognitive problems in multiple domains, difficulty in learning and retaining new information, difficulty in finding one’s way in familiar surroundings, getting lost in familiar surroundings, aimless wandering, personality change into passive, suspicious, aggressive, confirm the diagnosis by Mini-Mental State Exam, routine laboratory investigations to exclude reversible causes of dementia (FBS, TSH, Electrolytes, S. Calcium, S. Glucose, S. B12 Levels), MRI if following criteria present (age < 60 yrs, rapid onset and decline in cognitive deficits, recent head trauma, localized neurological signs an symptoms, gait disturbance, urinary incontinence early in the history),

11)    Multi-infarct dementia – memory deficit, anomia, limb apraxia (abnormal skilled movements of hand), difficulty in the calculation, gait dysfunction, urinary incontinence, reflex or motor asymmetry, paralysis of executive functioning,

12)    Parkinson’s disease – tremors, slowed movements, gait disorder, amnesia, cognitive problems, masked facies, soft voice, tiny handwriting, limb rigidity cogwheel type, loss of arm swing in walking,

13)    Transient global amnesia – TGA – sudden onset amnesia, leading to confusion, and anxious perseveration, lasting few hours, full recovery without any residual neuro deficits, no recurrences, middle-aged patients, anti-platelet therapy if risk factors for stroke present,

14)    Head injury and Postconcussive syndrome – headache, poor memory, mental dullness, depression after a head injury, lasting few days to few weeks, and resolving in most cases

15)    Drugs – hypnotics, antihistamines, psychotropic drugs, pain medicine used after surgery

16)    Alcohol and Illicit drugs use – heavy alcohol use causes B1 deficiency and consequent memory problems

17)    Sleep deprivation – lack of quality sleep can cause memory failure whether it is from stress, primary insomnia or even sleep apnea.

18)    ADHD in adults – sense of restlessness, diffulty in relaxing and settling down, dysphoria when inactive, lack of concentration on detail, need to re-read material several times, forgetting activities and appointments, losing things, losing the thread of conversations, thoughts are unfocused, ‘on the go’ all the time, rapid shifts in mood from depression, excitability, irritability, temper tantrums, above behaviors causing relationship problems, disorganization in life common, uncompleted tasks, lacks problem solving strategies, lacks time management strategies, impulsivity causes problems with teamwork, abrupt initiation and termination of relationships, tendency to make rapid and facile decisions without full analysis of the situation, these symptoms might not be seen at the clinic situations but full blown in day to day life situations and obvious to family members and the co-workers, symptoms start early in life by definition before the age 7 yrs, symptoms are persistent and so long standing that they may look more like traits than new onset  medial symptoms, in the adult ADHD mood instability is so common ADHD may be misdiagnosed as other affective disorders like minor affective disorders, personality disorders, comorbid conditions of ADHD are antisocial personality disorder, alcohol misuse, substance dependence, dysthymia, cyclothymia, anxiety disorders, general and specific learning difficulties, Utah criteria for adult ADHD are childhood ADHD AND hyperactivity and poor concentration with any 2 of the following – labile affect (that is euphoria, depression, anxiety, anger episodes, short lasting, usually intense emotions, usually patient says being out of control of emotions when in a affective swing),   temper tantrums, inability to complete tasks and disorganization, stress intolerance, impulsivity,  Tx – Methyphenidate (start with 5-10 mg daily titrating to a maximum of 40-90 mg daily), Pemoline (start with 37.5 mg daily and titrate to 75 mg daily), Desipramine (start with 10-20 mg daily, titrate to 100-150 mg daily), Imipramine (start with 10-20 mg daily, titrate to 100-150 mg daily), Nortriptyline (start with 10-20 mg daily, titrate to 100-150 mg daily), Bupropion (start with 37.5, titrate to 300-450 mg )

19)    Recoverable Cognitive Decline – RCD – acute illness, hospitalization for the acute illness, reduction of admission MMSE score by 3 points at least by discharge, cognitive  decline is unexplained by delirium (CAM criteria – acute onset and fluctuating course, inattention, disorganized thinking, altered level of consciousness) nor dementia (presence of cognitive symptoms at least for 6 months), higher educational level, higher preadmission functional impairment, higher illness severity, risk factors for RCD,

1)      Head injury – retrograde amnesia (cannot remember events prior to head injury) and anterograde amnesia (cannot remember events after the head injury)

2)      Thyroid function tests - abnormalities

3)      Vitamin B12 assay - abnormalities

4)      Delirium state with ataxia, eye movement abnormalities, elderly persons with poor nutrition, alcoholism

5)      Ataxia, visual changes, neuropathy, memory deficits onset and evolve within day to weeks (paraneoplastic limbic encephalitis in lung cancer, Hodgkin’s, breast, colon, bladder,  testicle cancer) 

1)      Bleeding PV and any change in vital signs

2)      Bleeding PV and postural hypotension (Admit for resuscitation and Blood grouping)

3)      Evidence og peritonitis (Intraperitoneal bleeding)

4)      Fever, chills with bleeding PV and POA - Septic abortion

5)      No intrauterine gestational sac when serum QhCG level is more than 6500 (ectopic pregnancy)

6)      Serial serum QhCG values fall or level off before 10^th week of gestation (ectopic pregnancy)

7)      Abnormally high serum QhCG values (multiple gestation, gestational trophoblastic disease)

8)      Anemia

9)      Rh negative (needs Rhogam to prevent isoimmunization)

Absence of menses for 6 consecutive months in a woman who has had regular periods.

1)      Exclude pregnancy

2)      Polycystic Ovary Syndrome – PCOS – amenorrhea, hirsutism, acne, alopecia, acanthosis nigricans, moderate elevations of prolactin levels up to 2500 miu/L, Ix – elevated LH levels without FSH elevations,

3)      Premature ovarian failure – Ix = FSH levels greater than 15 iu/L not associated with preovulatory surge seen in impending ovarian failure, levels greater than 40 iu/L irreversible ovarian failure,

4)      Weight-related amenorrhea – underweight for the height

5)      Exercise-related amenorrhea

6)      Spurious secondary amenorrhea – primary amenorrhea treated with hormones and having withdrawal bleeding presenting with secondary amenorrhea

7)      Female Athlete Triad -  FAT consists of amenorrhea, osteoporosis, and disordered eating, other symptoms experienced are fatigue, anemia, depression, cold intolerance, lanugo, eroded tooth enamel, use of laxatives, 

8)      Menopause – see under MMSSC medically unexplained symptoms

1)      Virilization – clitoromegaly, deepening of the voice, increased muscle mass

2)      F/H of fertility problems, autoimmune disorders, premature menopause (familial medical or gynae disorders)

3)      Central obesity, moon facies, buffalo hump, plethoric complexion, thin skin, abdominal striae, ecchymotic patches, proximal myopathy, hyperglycemia (Cushing’s syndrome)

4)      Hyperprolactinemia, galactorrhea, visual field defects (pituitary tumors)

5)      Hypothyroidism/hyperthyroidism

6)      S. Prolactin concentration of more than 1000 miu/L on more than 2 occasions (cranial CT or MRI to exclude pituitary or hypothalamic tumors)

7)      Abnormally low levels of FSH and LH levels (pituitary or hypothalamic lesions)

8)      Recent curettage or endometritis, normal genitalia, normal hormonal profile, absent withdrawal bleed in progestogen challenge (Asherman syndrome – HSG for intrauterine adhesions)

9)      Prolonged secondary amenorrhea followed by intermenstrual bleeding (exclude endometrial carcinoma)