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. The physician assures the patient that her blood tests and physical examination are normal. She schedules an appointment 2 weeks later and now reports frequent headaches in addition to her ongoing concerns. The patient says, "These headaches just make me even more tired." Her headaches occur 2-3 times a week and are bilateral and nonthrobbing. She reports, "My neck is sore and my shoulders are so tight I can hardly turn my head without it being painful." The patient has no aura and the headaches are relieved by naproxen. Physical examination is normal apart from some muscle tenderness in the shoulders and neck. When the physician inquires if moving and starting a new job have been stressful, she replies, "It's not the job or the move; it's not feeling well that is stressful. Maybe I should see a neurologist." The patient is very anxious and asks if the physician can order a repeat brain MRI to determine the diagnosis. Her records indicate that a brain MRI performed last year was normal. Which of the following is the most appropriate response to the 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. The physician assures the patient that her blood tests and physical examination are normal.  She schedules an appointment 2 weeks later and now reports frequent headaches in addition to her ongoing concerns.  The patient says, "These headaches just make me even more tired."  Her headaches occur 2-3 times a week and are bilateral and nonthrobbing.  She reports, "My neck is sore and my shoulders are so tight I can hardly turn my head without it being painful."  The patient has no aura and the headaches are relieved by naproxen.  Physical examination is normal apart from some muscle tenderness in the shoulders and neck.  When the physician inquires if moving and starting a new job have been stressful, she replies, "It's not the job or the move; it's not feeling well that is stressful.  Maybe I should see a neurologist."  The patient is very anxious and asks if the physician can order a repeat brain MRI to determine the diagnosis.  Her records indicate that a brain MRI performed last year was normal.  Which of the following is the most appropriate response to the patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c064_93a4_8f63_d34c20976de1_MD0005_00 The best approach to patients with somatic symptom disorder is regularly scheduled visits (eg, monthly) with the same physician, who can develop a trusting physician-patient relationship. In contrast to symptom-driven visits, regular visits decrease overall health care use. Patients seen regularly do not need to have a "new" symptom to see the physician, and unnecessary diagnostic testing and referral to specialists are avoided. Physicians should treat symptoms conservatively and focus on the patient's functioning. Once a trusting physician-patient relationship is developed, strategies include educating the patient about the interaction of psychosocial stressors and somatic symptoms, and promoting stress reduction and healthy behaviors (eg, diet, exercise, return to productive activities). The physician must validate the patient's physical distress and provide reassurance that serious medical illness has been ruled out. Statements that the condition is "psychogenic" or "all in your head" should be avoided. Psychiatric consultation is appropriate to assist with the diagnosis and treatment of psychiatric disorders; however, patients will feel invalidated and rejected by the primary physician if this is done early in the physician-patient relationship. (Choice A) Although it is appropriate to reassure the patient that serious medical conditions have been ruled out, telling her there is nothing to worry about would likely be perceived as invalidating and dismissive. It is important to acknowledge the patient's distress and provide an opportunity to develop the physician-patient relationship through regularly scheduled follow-up visits. (Choices B and C) This patient has no insight into the nonmedical nature of her symptoms as demonstrated by her negative response to the physician's suggestions that they may be stress related. At this point, it would be premature and damaging to the physician-patient relationship to suggest that stress is the major cause of her symptoms or to refer her to a psychiatrist. As the physician-patient relationship develops over the course of regular visits, the patient may become more receptive to these suggestions. (Choice D) Recommending neurology consultation is inappropriate as the patient's symptoms are consistent with tension-type headaches and the diagnosis is not in question. This would serve only to maintain the cycle of repeated consultations and unnecessary evaluations, which are rarely reassuring. Educational objective: Somatic symptom disorder is best managed with regularly scheduled patient visits, minimizing diagnostic testing and specialist referrals, and focusing on functional improvement. References: Approach to the patient with multiple somatic symptoms. (http://www.ncbi.nlm.nih.gov/pubmed/25134874)

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