Kroenke (1) published the following stepped approach for evaluation and management of medically unexplained symptoms in primary care setting:
STEP #1: Determine Severity
(a) for acutely serious (chest pain, sudden changes in consciousness, labored breathing etc.) –> do expedited diagnostic evaluation.
(b) for minor symptoms (muscle pain, fatigue, stomach upset etc.) –> they are self limiting, respond to symptom-specific therapies and often resolve at a follow up visits.
(c) for persistent symptoms at follow up –> move to next step #2 below.
STEP #2: Assess and Treat Psychiatric Symptoms and Functional Syndromes
(a) Screen for depression and anxiety (using Patient Health Questionnaire) –> treat with pharmacotherapy and/or referral to psychotherapy.
(b) Assess for functional syndromes –> initiate syndrome specific therapy.
STEP #3: Develop Plan for Managing Medically Unexplained Symptoms (MUS)
Initiate personalized treatment plan for patient failing Step #1 and Step #2 above.
(a) Help patients to feel understood:
- detailed evaluation of physical and psychological symptoms.
- evaluate for patient’s beliefs regarding illness and prior treatment.
- perform physical examinations (as indicated).
- focus on findings experiences that both patient & physician can agree on and validate.
(b) Negotiate on agenda:
- avoid communication to patient that “all is in their head”.
- provide each assessment feedback
- clarify patient’s reactions to feedbacks & treatment preferences.
(c) Take actions:
- create the explanation in collaboration with patient.
- negotiate requests for medical investigations and interventions
- continue with physical & psychiatric symptoms monitoring.
- have specific plans for coping with stress, self-management, lifestyle changes, or watchful waiting.
(d) Terminate consultation:
- make follow up appointments if needed.
- educate patient that plan will be reconsidered if symptoms gets worse or new symptoms develops in future.
- emphasize on importance of continued collaboration.
- Int J Methods Psychiatr Res. 2003;12(1):34-43.
- Am J Lifestyle Med. 2016 Mar-Apr; 10(2): 109–119.
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Dr. Harvinder Singh, M.D. (Admin)
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