A 36-year-old woman comes to the office for evaluation of intermittent chest pain and palpitations. The patient describes episodes of pressure in her chest, occurring 2 or 3 times a week, lasting several minutes to an hour, and typically occurring while she is lying in bed. She also has sensations that her heart is fluttering and reports, "Last week, during a work meeting, my heart started racing, and I felt dizzy for a few seconds." Six months ago, the patient was evaluated by her previous physician for similar symptoms and was told, "Nothing is abnormal," but she adds, "They didn't test me when I have symptoms." She has no other medical or psychiatric history. The patient has eliminated all caffeinated beverages and does not use alcohol, tobacco, or illicit drugs. She reports feeling excited about a recent promotion at work but feels "stressed out" because of increased expectations. Blood pressure is 110/60 mm Hg, pulse is 72/min, and respirations are 12/min. Lungs are clear to auscultation and cardiac examination is normal. Complete blood count, comprehensive metabolic panel, TSH level, 12-lead ECG, echocardiography, and 2-week ambulatory rhythm monitoring are normal. Which of the following is the most appropriate statement to address this patient's concerns?

Question

A 36-year-old woman comes to the office for evaluation of intermittent chest pain and palpitations.  The patient describes episodes of pressure in her chest, occurring 2 or 3 times a week, lasting several minutes to an hour, and typically occurring while she is lying in bed.  She also has sensations that her heart is fluttering and reports, "Last week, during a work meeting, my heart started racing, and I felt dizzy for a few seconds."  Six months ago, the patient was evaluated by her previous physician for similar symptoms and was told, "Nothing is abnormal," but she adds, "They didn't test me when I have symptoms."  She has no other medical or psychiatric history.  The patient has eliminated all caffeinated beverages and does not use alcohol, tobacco, or illicit drugs.  She reports feeling excited about a recent promotion at work but feels "stressed out" because of increased expectations.  Blood pressure is 110/60 mm Hg, pulse is 72/min, and respirations are 12/min.  Lungs are clear to auscultation and cardiac examination is normal.  Complete blood count, comprehensive metabolic panel, TSH level, 12-lead ECG, echocardiography, and 2-week ambulatory rhythm monitoring are normal.  Which of the following is the most appropriate statement to address this patient's concerns?

Quizplus · Accepted Answer

11ec25c8_d2a6_b3b3_bc81_2b4f6f2d68e5_MD0003_00 This patient's preoccupation with somatic symptoms despite negative workup is suggestive of somatic symptom disorder (SSD), a psychiatric disorder characterized by excessive anxiety and time-consuming behaviors related to thoughts about the seriousness of one or more physical symptoms. Patients with SSD frequently and extensively use medical services and request additional testing. Because normal results are rarely reassuring, patients with this condition typically seek care from multiple providers. Initial management of SSD consists of arranging regularly scheduled visits with the same physician to develop the physician-patient relationship and minimize unnecessary testing, interventions, and subspecialty referrals. Regularly scheduled visits that are not symptom driven (ie, do not require patients to develop worsening or new symptoms) are preferable because they help make patients feel that their concerns are being heard and decrease the number of emergency calls and visits. By scheduling a routine visit in a month, the physician can monitor the patient, make judicious assessments regarding any further workup, and begin to shift the focus from physical symptoms to identifying psychologic stressors. The physician can provide education on stress-reduction strategies with the goal of improving coping skills and daily functioning and discuss psychiatric referral if needed. (Choice A) This statement reinforces the idea that new or worsening symptoms are required for the patient to schedule a visit and may encourage inappropriate emergency visits. In contrast, having scheduled visits empowers patients to manage their own symptoms, knowing that they are being heard and monitored regularly. (Choice C) Explaining to the patient that her symptoms are purely stress related would likely be perceived as invalidating because she is preoccupied with those symptoms and shows limited insight into any psychologic contributions to them. This approach would risk damaging the physician-patient relationship. (Choices D) This patient has already undergone a thorough evaluation of her symptoms, including ambulatory rhythm monitoring. Emergency department visits often lead to multiple unnecessary tests and should be avoided if possible. Educational objective: Patients with somatic symptom disorder benefit from regularly scheduled appointments, which establish a strong physician-patient relationship and minimize unnecessary testing, interventions, and subspecialty referrals. References: Somatic symptom disorder. (http://www.ncbi.nlm.nih.gov/pubmed/26760840)

A 36-Year-Old Woman Comes to the Office for Evaluation of Intermittent