A 43-year-old woman comes to the office for an initial appointment due to ongoing abdominal pain, general weakness, decreased appetite, and dizziness. She says the pain is ruining her life and is worried that her previous physicians may have missed something. Over the past several years, the patient has been hospitalized 3 times with similar symptoms. No etiology for the pain has been identified despite extensive workups, including several abdominal CT scans and an exploratory laparotomy. The patient describes chronic abdominal pain since adolescence and is concerned as the nonprescription analgesics she takes are ineffective. She has no history of psychiatric diagnoses or substance abuse. Physical examination, vital signs, and laboratory tests (including chemistry panel, complete blood count, and urinalysis) are within normal limits. Which of the following is the most appropriate next step in the management of this patient?

Question

A 43-year-old woman comes to the office for an initial appointment due to ongoing abdominal pain, general weakness, decreased appetite, and dizziness.  She says the pain is ruining her life and is worried that her previous physicians may have missed something.  Over the past several years, the patient has been hospitalized 3 times with similar symptoms.  No etiology for the pain has been identified despite extensive workups, including several abdominal CT scans and an exploratory laparotomy.  The patient describes chronic abdominal pain since adolescence and is concerned as the nonprescription analgesics she takes are ineffective.  She has no history of psychiatric diagnoses or substance abuse.  Physical examination, vital signs, and laboratory tests (including chemistry panel, complete blood count, and urinalysis) are within normal limits.  Which of the following is the most appropriate next step in the management of this patient?

Quizplus · Accepted Answer

11ec160b_3647_0cce_9249_77a68876e12e_MD0001_00 This patient's preoccupation with unexplained medical symptoms and excessive health care use are characteristic of somatic symptom disorder. The best approach is to schedule regular visits with her primary care provider, who can monitor her condition and avoid unnecessary diagnostic testing and specialist referrals (Choices B and C). In contrast to symptom-driven visits, regular visits provide patients with an opportunity to discuss their concerns without the need to have new or worsening symptoms. This may decrease the use of emergency services and encourage formation of a therapeutic alliance. Rather than focusing on symptom elimination, office visits should emphasize a return to occupational and social activities (functional improvement) and promotion of stress reduction and healthy behaviors (eg, diet, exercise). (Choices A and F) This patient currently has no insight into the psychological nature of her disorder and would likely feel invalidated and unreceptive to being told that her condition is psychogenic and/or by getting referred to a psychiatrist for treatment. Once a physician-patient relationship is established, she may be able to accept that psychological distress plays a role in her condition and be more receptive to psychiatric referral. (Choice D) Use of potentially addictive pain medication should be avoided. (Choice E) Reassurance alone is rarely effective in managing somatic symptom disorder. Optimal management consists of regularly scheduled visits so that the patient does not need to have active symptoms to justify a visit. Educational objective: Somatic symptom disorder is best managed with regularly scheduled medical visits that are not contingent on having active symptoms. Unnecessary diagnostic testing and specialist referrals should be avoided. __________ References: Approach to the patient with multiple somatic symptoms. (http://www.ncbi.nlm.nih.gov/pubmed/25134874) Medically unexplained symptoms. (http://www.ncbi.nlm.nih.gov/pubmed/24758967) Somatic symptom disorder. (http://www.ncbi.nlm.nih.gov/pubmed/26760840)

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