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

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.