A 58-year-old woman comes to the office due to abdominal pain. The patient describes a long-standing history of abdominal discomfort characterized by intermittent episodes of cramping, bloating, and nausea. She describes the pain as severe and disabling but has difficulty describing its quality or location. There is no clear relationship to eating or specific foods. Neither rectal bleeding nor melena is present. The patient has seen 2 other physicians over the past year for similar symptoms but felt that her concerns were not taken seriously. During review of systems, she reports headaches, fatigue, muscle weakness, joint pain, urinary frequency, anxiety, and insomnia. She also reports losing 2.3 kg (5.1 lb) over the past year by following a low-calorie diet. The patient does not use alcohol or drugs. Vitals signs are stable. Abdominal examination shows mild, diffuse abdominal tenderness to palpation that improves when she is distracted. Physical examination is otherwise unremarkable. Laboratory testing, including complete blood count, comprehensive metabolic panel, lipase, Helicobacter pylori testing, TSH, and a CT scan of the abdomen, is negative. When discussing the test results with the patient, which of the following is the most appropriate initial statement by the physician?

Question

A 58-year-old woman comes to the office due to abdominal pain.  The patient describes a long-standing history of abdominal discomfort characterized by intermittent episodes of cramping, bloating, and nausea.  She describes the pain as severe and disabling but has difficulty describing its quality or location.  There is no clear relationship to eating or specific foods.  Neither rectal bleeding nor melena is present.  The patient has seen 2 other physicians over the past year for similar symptoms but felt that her concerns were not taken seriously.  During review of systems, she reports headaches, fatigue, muscle weakness, joint pain, urinary frequency, anxiety, and insomnia.  She also reports losing 2.3 kg (5.1 lb) over the past year by following a low-calorie diet.  The patient does not use alcohol or drugs.  Vitals signs are stable.  Abdominal examination shows mild, diffuse abdominal tenderness to palpation that improves when she is distracted.  Physical examination is otherwise unremarkable.  Laboratory testing, including complete blood count, comprehensive metabolic panel, lipase, Helicobacter pylori testing, TSH, and a CT scan of the abdomen, is negative.  When discussing the test results with the patient, which of the following is the most appropriate initial statement by the physician?

Quizplus · Accepted Answer

This patient has several clues suggesting somatic symptom disorder (ie, long-standing symptoms without a clear diagnosis, vague history of present illness, persistent thoughts about the seriousness of the symptoms, health concerns not alleviated despite consultation with multiple providers, exaggerated pain on examination). However, when discussing the negative results of the medical workup, the physician must adopt a patient-centered approach and treat the patient with respect and tact. This patient is worried about her physical health and test results. At this point, she does not have insight that her symptoms may be caused or exacerbated by psychologic factors. The most appropriate initial statement is to deliver the negative test results as good news that a serious medical illness has been ruled out. Although it is important to eventually discuss the role of psychologic factors, the patient's coping style, and the diagnosis of somatic symptom disorder, initiating the discussion with statements like these would likely be perceived as dismissive and judgmental (Choices A, B, and D). They may even lead to an unproductive debate about the cause of the symptoms and damage the physician-patient relationship. The physician should initiate the discussion by acknowledging the distressing and real nature of the symptoms and providing the test results in a positive tone. (Choice C) Recommending counseling with another provider is premature and may be experienced as a rejection. A discussion of how stress and coping skills can impact symptoms should precede any referral for psychiatric care. Educational objective: When medical workup fails to identify a medical etiology in a patient with suspected somatic symptom disorder, the results should be communicated in a positive tone assuring the patient that there is no evidence of serious medical illness. The distressing and real nature of the symptoms should be acknowledged first, followed by a discussion of the suspected disorder and contributing psychologic factors. References: Medically unexplained symptoms. (http://www.ncbi.nlm.nih.gov/pubmed/24758967) Somatic symptom disorder. (http://www.ncbi.nlm.nih.gov/pubmed/26760840)

A 58-Year-Old Woman Comes to the Office Due to Abdominal