The document discusses medically unexplained symptoms (MUS), describing them as persistent complaints lacking sufficient pathology and highlighting their complexity in diagnosis and management. It outlines a 10-step protocol for managing MUS, emphasizing the importance of doctor-patient rapport, thorough examinations, personalized reassurance, and considering psychological aspects. The take-home message stresses the significance of validation and continuity of care in improving patient well-being, even when symptoms are unexplained.

1. Medically Unexplained Symptoms
Presented by: Anish Dhakal
(Aryan)
Presented by: Anish Dhakal
(Aryan)

2. • Medically unexplained symptoms are ‘persistent
bodily complaints for which adequate examination
does not reveal sufficient explanatory structural or
other specified pathology’.
• These patients are challenge to medical
professionals

3. Not to be missed conditions
• Malignancy,
• Vasculitis/connective tissue disease (e.g. SLE)
• Endocrine disease
• Diabetes
• Thyroid disease
• Adrenal disease
• Hyperparathyroidism
• Renal disease
• Occult infection (such as TB, HIV, Leprosy, Syphilis)
• Anaemia
• Inflammatory musculoskeletal disease (e.g. spondyloarthritis,
rheumatoid arthritis)

4. Risk / associated factors for
MUS
• Long Term Conditions with anxiety/depression.
• Childhood adversity/abuse
• More common in women
• In severe cases overlap with Personality Disorder
• Recent infection; current physical illness; severe
illness or death of close relative.

5. 10 step protocol for
management:
• Acknowledge distress
• Elicit the patient’s perspective
• Focused examination
• Specific reassurance
• Discuss alternative explanations
• Consider medication .
• General coping techniques
• Specific stress solutions
• Discuss responsibility
• Appointment for review

6. 1. Acknowledge distress
• doctor patient relationship is a key part of
managing this patients problems
• helps to develop rapport and the patient believes
that you are doing your best for them
• doctor must listen carefully to the patients
problems, and be empathic

7. 2. Elicit the patients
perspective
• understanding patient’s Ideas, Concerns and
Expectations.
• need to try and elicit any hidden agendas.

8. 3. Focused examination
• doctor must do a thorough but rapid physical
examination and send appropriate tests (esp in
elderly) eg anaemia, DM
• Focused examination helps to exclude underlying
illness and at the same time helps to reassure
patients.

9. 4. Specific reassurance
• Acknowledge and indicate commitment to
understand the patient’s concerns and symptoms.
• Encourage an open and honest transfer of
information that will provide a more
comprehensive picture of the patient's concerns
and medical history.
• Indicate commitment to allocate sufficient time
and resources to resolving the patient’s concerns.
• Avoid open skepticism or disapproving comments
in discussing the patient’s concerns

10. 5. Discuss Alternative
explanation
• explain to the patient the complex relation
between the body and the mind.
• Explain that there is a “switch” in the brain that
controls happiness and sadness and when the
switch is off, a person struggles to feel happy.
• doctors use the term, “nasaa ko rog”.
• the doctor should try to use the patients
understanding of illness to explain their condition

11. 6. Consider medication
• Not every patient will need medication
• Patients with anxiety disorder or depression should
be treated appropriated with antidepressants at
therapeutic doses
• for some people who do not meet criteria for
anxiety or depression, a low dose of amitryptilline
(25mg) or fluoxetine 20mg can be very helpful.
• Avoid the use of anxiolytics such as
benzodiazepines as these are highly addictive and
lead to long term problems of dependency and
abuse

12. 7. General coping
techniques
• Behavioral therapy can be very effective in helping
people with unexplained physical problems
• We can also encourage them to make more short-
term goals and regular evaluation of themselves

14. 8. Specific stress solution
• Help patient to find own solutions to problem, help
patient to decide on ways of coping with stress that
can’t be resolved

15. 9. Discuss responsibility
• The doctor should aim to take emphasis away from
searching for a cure.
• The patient needs to come to terms with their
symptoms and deal with symptoms as they are.
• This has the effect of reducing stress.

16. 10. Appointment for review
At each patient visit, the clinician should consider the
following:
• Ask if there are unaddressed or unresolved concerns.
• Summarize and explain all test results.
• Schedule follow-up visits in a timely manner.
• Explain that outstanding or interim test results and
consultations will be reviewed during the follow-up
visits.
• Offer to include the concerned family member or
significant other in the follow-up visit.

17. Take home message
• People want to be taken seriously – show you
believe them
• Doctors can make a difference to the patient’s
well-being even when their symptoms are
unexplained
• Sometimes the only “therapy” needed may be
the strength of your doctor-patient relationship
– continuity of care and the long-term
relationship helps.
• Be explicit about your thoughts, your
uncertainties and your expectations of referrals
to specialist care.