A 43-year-old woman comes to the office for an initial evaluation. The patient recently moved to the area for a new job and is worried about her poor health. She explains that she had to call in sick several times this past month because either "I felt too exhausted" or "I was lightheaded and had an upset stomach." The patient has a history of hypothyroidism, chronic headaches, insomnia, and dysmenorrhea. She describes a long history of fatigue, but previous doctors have assured her that her hypothyroidism is well controlled with medication. She also describes chronic problems with urinary frequency; stomach bloating; and dry, itchy skin. The patient is worried about her symptoms and wonders if all the doctors she has seen may have "missed something." Her medications include levothyroxine, daily multivitamins, and zolpidem and naproxen as needed. The patient does not smoke or use illicit drugs. She stopped drinking alcohol a year ago as it made her symptoms worse. Blood pressure is 110/70 mm Hg, pulse is 84/min, and respirations are 12/min. Physical examination is normal. T4 is 10 µg/dL and TSH is 1.3 µU/mL.
Which of the following is the most likely diagnosis in this patient?

Question

A 43-year-old woman comes to the office for an initial evaluation.  The patient recently moved to the area for a new job and is worried about her poor health.  She explains that she had to call in sick several times this past month because either "I felt too exhausted" or "I was lightheaded and had an upset stomach."  The patient has a history of hypothyroidism, chronic headaches, insomnia, and dysmenorrhea.  She describes a long history of fatigue, but previous doctors have assured her that her hypothyroidism is well controlled with medication.  She also describes chronic problems with urinary frequency; stomach bloating; and dry, itchy skin.  The patient is worried about her symptoms and wonders if all the doctors she has seen may have "missed something."  Her medications include levothyroxine, daily multivitamins, and zolpidem and naproxen as needed.  The patient does not smoke or use illicit drugs.  She stopped drinking alcohol a year ago as it made her symptoms worse.  Blood pressure is 110/70 mm Hg, pulse is 84/min, and respirations are 12/min.  Physical examination is normal.  T4 is 10 µg/dL and TSH is 1.3 µU/mL. 
Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c063_f763_8f63_b58af0bf4c54_MD0005_00 This patient's preoccupation with multiple unexplained medical symptoms suggests somatic symptom disorder. The diagnosis requires excessive preoccupation with >1 somatic symptom(s) for >6 months, causing significant social and occupational impairment. Symptoms may represent catastrophic interpretations of normal bodily sensations or discomfort that does not generally signify serious disease. These patients often have excessive health anxiety that typically interferes with their ability to work and causes stress in their relationships. They often make extensive use of medical services and are rarely reassured by negative findings. Physicians must keep in mind that these patients are truly suffering, even if their symptoms are not medically explained, and that concurrent medical illness (eg, this patient's hypothyroidism) is not mutually exclusive. (Choice A) Factitious disorder is characterized by the intentional falsification of symptoms in the absence of obvious external rewards. There is no evidence that this patient has fabricated her symptoms. (Choice B) Although generalized anxiety disorder is frequently accompanied by multiple anxiety-related somatic symptoms (eg, tension headaches, palpitations, gastrointestinal distress, fatigue, dizziness), this patient's anxiety is restricted to her physical concerns. Patients with generalized anxiety disorder have excessive anxiety about multiple issues and situations, not just their health. (Choice C) In illness anxiety disorder, the patient has minimal or no actual symptoms but is preoccupied with having a serious undiagnosed specific disease (eg, if the patient feared having a brain tumor). This patient has multiple somatic symptoms and would be more accurately diagnosed with somatic symptom disorder. (Choice D) In malingering, there is clear evidence of external gain. Although this patient's somatic symptom disorder affects her job performance, she is not consciously feigning symptoms to avoid work. Malingering patients typically exhibit antisocial personality traits and have a history of avoiding responsibilities and seeking long-term disability. Educational objective: Patients with somatic symptom disorder have excessive anxiety and preoccupation with >1 somatic symptoms. They may have concurrent medical illness, or the symptoms may represent misinterpretations of normal bodily sensations. References: Somatic symptom disorder. (http://www.ncbi.nlm.nih.gov/pubmed/26760840)

A 43-Year-Old Woman Comes to the Office for an Initial