medically unexplained symptoms

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mdjo

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Anybody have a good script that they use to explain to patients that their symptoms are medically unexplained? I've got a good spiel for fibromyalgia ("these are the common symptoms, it's probably because your nerves have become oversensitive to pain, you need to exercise, treat your depression, and take these meds") but I don't have a nice way of explaining "your symptoms might all be in your head, or it might be something real that we don't know what it is, not really sure which one. I have nothing else to offer you, come back and see me if your symptoms change."
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Basically that.

I dance around the bit about "all in your head," obviously. Along the lines of perceptions are real, the thing is that no one completely understands the human body. It's possible there is a processing error or something along those lines, in the big computer we call the brain. We can all get signals, for example, that are that the arm hurts, but there is nothing structurally wrong with it. Even with a microscope or looking at molecules there is no dysfunction in that part of the body, or in the brain either. It's not always a structural issue with the arm or nerve signals or the brain, it's how the brain is processing all of this.

I don't find this is the point of a problem with patients. I find people will readily accept what I just said. The issue is more that when they accept they have a crazy pants brain, they then think the following 1) there must be a cure I can think myself into or 2) there is nothing I can do about my crazy pants brain.

The first is clearly an issue for some conditions.
The latter is definitely an issue for psych conditions and functional capacity.

I talk about how the lucky thing for us, is that as of this moment, the current symptoms don't seem to suggest an "organic" or purely body-based structural issue gone wrong, that would benefit from more than what we are currently doing. However, the brain is an amazing organ, and how we use it, what we think, and how we act, always has a powerful ability to affect how we feel and function, even if we don't know what's wrong or cure isn't possible.
 
I typically outline some combination of:

1) people often present with bothersome or distressing sensations that are not immediately explainable
2) there are lots of problems we don't have names or tests for
3) we're pretty good at identifying immediately life/organ threatening problems when they are going on
4) sometimes all we can do is manage limiting symptoms and wait and see what develops

And then try to reassure the person that you will maintain an open mind, take their complaints and concerns seriously, and follow up with them in a timely and conscientious manner so that they feel comfortable that you are alert for new or worrisome developments.

If after a visit or two of that nothing obvious has developed, then I start to introduce some of the concepts of fibromyalgia, central pain sensitization, etc.

I would encourage any of you who work with patients to watch this outstanding video on the topic of chronic pain. I will very often write down the title and assign it to fibromyalgia-y patients as homework:
 
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mdjo said:
Anybody have a good script that they use to explain to patients that their symptoms are medically unexplained? I've got a good spiel for fibromyalgia ("these are the common symptoms, it's probably because your nerves have become oversensitive to pain, you need to exercise, treat your depression, and take these meds") but I don't have a nice way of explaining "your symptoms might all be in your head, or it might be something real that we don't know what it is, not really sure which one. I have nothing else to offer you, come back and see me if your symptoms change."
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First, not all medically unexplained symptoms are psychogenic. And it would be extremely, if not impossible, to confirm it. For most of my patients, I would reassure that even if I am not completely sure what is going on, I do not think this is serious and you may get better over time and it is reasonable to observe for now. Any surprisingly works pretty well for most patients. And it is the beauty for primary care or any specialties managing chronic diseases to build rapport with patients to let them trust you.

Then, if I do think it is most psychogenic (likely fibro or "somatoform disorders"), I would tell patient that there is some problems with your brain's software, not hardware. And this is manageable and you need to see a psychiatrist or psychologist. I always admit and recognize pt's symptom but would stress that someone with problem with their software of their brain can feel the same way as they are having a heart attach, because the brain is processing all the sensations and giving you a feeling.
 
drfunktacular said:
I typically outline some combination of:

1) people often present with bothersome or distressing sensations that are not immediately explainable
2) there are lots of problems we don't have names or tests for
3) we're pretty good at identifying immediately life/organ threatening problems when they are going on
4) sometimes all we can do is manage limiting symptoms and wait and see what develops

And then try to reassure the person that you will maintain an open mind, take their complaints and concerns seriously, and follow up with them in a timely and conscientious manner so that they feel comfortable that you are alert for new or worrisome developments.

If after a visit or two of that nothing obvious has developed, then I start to introduce some of the concepts of fibromyalgia, central pain sensitization, etc.

I would encourage any of you who work with patients to watch this outstanding video on the topic of chronic pain. I will very often write down the title and assign it to fibromyalgia-y patients as homework:
Click to expand...


Youtube comments are brutal, which emphasis the difficulty in managing these patients.
 
Crayola227 said:
I talk about how the lucky thing for us, is that as of this moment, the current symptoms don't seem to suggest an "organic" or purely body-based structural issue gone wrong, that would benefit from more than what we are currently doing. However, the brain is an amazing organ, and how we use it, what we think, and how we act, always has a powerful ability to affect how we feel and function, even if we don't know what's wrong or cure isn't possible.
Click to expand...

I think this script sounds really nice. Shows that you're taking them seriously and also sounds positive and optimistic.

drfunktacular said:
I typically outline some combination of:

1) people often present with bothersome or distressing sensations that are not immediately explainable
2) there are lots of problems we don't have names or tests for
3) we're pretty good at identifying immediately life/organ threatening problems when they are going on
4) sometimes all we can do is manage limiting symptoms and wait and see what develops

And then try to reassure the person that you will maintain an open mind, take their complaints and concerns seriously, and follow up with them in a timely and conscientious manner so that they feel comfortable that you are alert for new or worrisome developments.
Click to expand...
I like this outline, particularly the reassurance that we're good at identifying truly dangerous conditions and that we won't let it get to that point.

Thanks guys, very helpful!
 
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So, what is the explanation of the pain that comes from both arms hammer in the chest and goes away through the feet?
 
IMreshopeful said:
I mean pretty much everyone does

It’s okay, surgery still needs us to fix their messes. I’m fine with it
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Hey it's not my fault little old ladies have so much diastolic dysfunction. Can't help em. Normal lungs. Can't fix old heart. I do get a pretty easy level five new and level four return out of it before sending them back.
 
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jdh71 said:
Hey it's not my fault little old ladies have so much diastolic dysfunction. Can't help em. Normal lungs. Can't fix old heart. I do get a pretty easy level five new and level four return out of it before sending them back.
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I mean we also get the “PH” referrals from pulm who have normal right heart caths (turns out, sorry, their lungs just suck).

Truthfully though you get vague unexplained symptoms in pretty much every specialty alas. I’ve seen my fair share of non-physiologic chest pain
 
IMreshopeful said:
I mean we also get the “PH” referrals from pulm who have normal right heart caths (turns out, sorry, their lungs just suck).

Truthfully though you get vague unexplained symptoms in pretty much every specialty alas. I’ve seen my fair share of non-physiologic chest pain
Click to expand...

Hm. Why would Pulm send PHTN to cards?
 
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jdh71 said:
That would be nice. Always seemed odd so many of y'all think that's our problem.
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cardioVASCULAR


Isnt that what you guys say when trying to justify all those unnecessary neck and leg stents
 
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Psai said:
cardioVASCULAR


Isnt that what you guys say when trying to justify all those unnecessary neck and leg stents
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If you’re going to be a dick to someone how about directing this towards the cardiologist and not the pulmonologist?

I am actually fine taking care of PH patients but there are certainly group 3 patients (ILD, COPD) where there’s little I can really do. Otherwise I’m happy to help. RV failure, pulmonary vasodilators, and mechanical support def in my wheelhouse. Truth be told these guys should be comanaged to some degree by both pulm and cards depending on their PH etiology and preferably by some PH expert... it can be a pain in the butt

Also I don’t put in leg and neck stents so you’re barking up the wrong tree. Sounds like you have to get something off you’re chest huh?
 
IMreshopeful said:
If you’re going to be a dick to someone how about directing this towards the cardiologist and not the pulmonologist?

I am actually fine taking care of PH patients but there are certainly group 3 patients (ILD, COPD) where there’s little I can really do. Otherwise I’m happy to help. RV failure, pulmonary vasodilators, and mechanical support def in my wheelhouse. Truth be told these guys should be comanaged to some degree by both pulm and cards depending on their PH etiology and preferably by some PH expert... it can be a pain in the butt

Also I don’t put in leg and neck stents so you’re barking up the wrong tree. Sounds like you have to get something off you’re chest huh?
Click to expand...

Sorry that I don't have your field memorized? lmao
 
IMreshopeful said:
If you’re going to be a dick to someone how about directing this towards the cardiologist and not the pulmonologist?

I am actually fine taking care of PH patients but there are certainly group 3 patients (ILD, COPD) where there’s little I can really do. Otherwise I’m happy to help. RV failure, pulmonary vasodilators, and mechanical support def in my wheelhouse. Truth be told these guys should be comanaged to some degree by both pulm and cards depending on their PH etiology and preferably by some PH expert... it can be a pain in the butt

Also I don’t put in leg and neck stents so you’re barking up the wrong tree. Sounds like you have to get something off you’re chest huh?
Click to expand...

Bass boats don't pay for themselves!!

Vasodilators in Dana Point group 3 disease just causes worsening v/q mismatch.

Now if you've got some CTD, phtn, and associated ILD without too much fibrosis then vasodialite away.

I'd love to send all these patients to an expert but those fancy pants experts live in fancy pants cities a long long long way away.
 
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jdh71 said:
Bass boats don't pay for themselves!!

Vasodilators in Dana Point group 3 disease just causes worsening v/q mismatch.

Now if you've got some CTD, phtn, and associated ILD without too much fibrosis then vasodialite away.

I'd love to send all these patients to an expert but those fancy pants experts live in fancy pants cities a long long long way away.
Click to expand...

I find pulmonary vasodilators to be frustrating drugs in terms of when they work well with the CTD/ILD population, irrespective of the degree of fibrosis. But that’s my limited exposure.

I do need a yacht one day. That’s minimum doctor requirement right?
 
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"Right now, I don't know what you have, but I know what you don't have, and here's why, and what I would expect if you did have disease x,y,or z (that you probably read about and is the real reason why you're here today)."

Showing that you take their concerns seriously is 90% of the battle. The majority of the weird nagging issues that are in fact nothing usually go away with time anyway (or after a therapeutic cxr/kub done on the third work-in visit in 3 weeks shows all good).
 
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