Return to Scenario ListShow Learning Points most relevant to Phase 1:

Medically unexplained physical symptoms

Clinical Discipline(s)/Organ System(s)
General Practice, Psychiatry/Health Psychology
Progress Test Topic(s)
Mental health
While on your Medicine attachment you are asked to see a 28 year old NZ European woman who is suffering from chest pains. She is in the Radiology Department undergoing an X-ray when you come to see her on the ward so you decide to review her electronic patient record. You are shocked to find she has a huge number of presentations with visits to multiple outpatient clinics and many discharge summaries from different hospitals. You also have time to review her blood tests and ECG which are all unremarkable. When she has returned from her X-ray you go to speak with her. She explains that she is constantly unwell and no one has been able to correctly diagnose her. She says the problems have been present for years and can present in a variety of different ways; she has presented with abdominal pain, dyspepsia, pelvic pain and headaches. Things definitely got worse when she lost her job 3 years ago.
Progress Test-Type Questions:   Question 1 | Question 2
Applied Science for Medicine 
   - Neurological pain pathways
   - Factors that exacerbate pain
   - Current biopsychosocial theories of the aetiology of medically unexplained physical symptoms (somatoform disorders, factitious disorder, malingering)
   - Knowledge of disorders that affect multiple organ systems which are important to exclude; e.g. autoimmune disorders
   - Contribution of patient-clinician and healthcare system factors to the development of and maintenance of symptoms
   - Role of psychosocial interventions in managing such disorders effectively
   - Risks of over-investigation
Clinical and Communication Skills 
   - Elicit a history from someone with medically unexplained physical symptoms; consider mental illness and substance abuse/addiction. Recognise patterns suggesting inappropriate use of health care services
   - Perform an examination, including mental state examination, of someone with medically unexplained physical symptoms
   - Interpret relevant investigations: electrolytes, hormonal screening, toxicology screen, ECG, imaging
   - Differential diagnosis of medically unexplained physical symptoms
   - Management of medically unexplained physical symptoms: pharmacological, psychological, psycho-educational and psychosocial
   - Management of pain: pharmacological and non-pharmacological methods
   - Prognosis of patients with medically unexplained physical symptoms
   - Conduct appropriate physical examination and investigations should the symptom profile change and be suggestive of a new or serious disorder
   - Liaise with colleagues in other disciplines so that multi-disciplinary input can be implemented which is consistent for both clinicians (e.g. Emergency Department, Medical, Psychiatry) and patients
   - Acknowledge the limits of the current state of medical knowledge and testing as there are disorders where there are no definitive tests and which may resemble medically unexplained symptoms; the medical and related fields are constantly evolving
Personal and Professional Skills 
   - Awareness of your own feelings whilst taking this history and looking at the notes
   - Time-management of consultation
   - Non-judgemental approach to mental illness
   - Show empathy
   - Discuss diagnosis, share information and reduce diagnostic uncertainty
   - Social impact of mental illness
   - Managing patients with physical symptoms and distress but where there may be no organic pathology
   - Awareness that medical and psychological symptoms can co-exist and are not mutually exclusive
   - Order appropriate investigations and avoid further iatrogenic harm
Hauora Māori 
   - The role of whānau in eliciting past history
   - Working with Māori providers
   - Access to cultural expertise and resources
   - Higher incidence of autoimmune disorders in Māori and Pacific communities
Population Health 
   - Epidemiology of medically unexplained symptoms
   - Impact on healthcare systems including primary and other levels of care
   - Impact on healthcare budgets and expenditures
Conditions to be considered relating to this scenario
somatisation disorder, undifferentiated somatoform disorder, conversion disorder, pain disorder, hypochondriasis, body dysmorphic disorder, depression, substance abuse, addiction factitious disorder, malingering, fibromyalgia, Munchausen syndrome, Munchausen syndrome by proxy
Less common but 'important not to miss'
multiple sclerosis, Lyme disease, ulcerative colitis, subdural haemorrhage, carcinoma of the pancreas, systemic lupus erythematosus (SLE), Sjögren’s syndrome
porphyria, Wilson's disease
Related Scenarios
[Personality disorder]