Multiple Somatic Complaints
Multiple Somatic Complaints: Excerpt from Field Guide to Bedside Diagnosis
Differential Overview
❑ Anxiety
❑ Depression
❑ Hypothyroidism
❑ Premenstrual syndrome
❑ Hypochondriasis
❑ Somatization disorder
❑ Chronic fatigue syndrome
❑ Fibromyalgia
❑ Panic disorder
❑ Malingering
❑ Conversion reaction
Diagnostic Approach
This presentation is marked by multiple vague complaints, symptoms out of proportion to the physical findings, symptoms outside the anticipated spectrum of the organic disease, and symptoms that do not follow anatomic distributions. The patient is often more concerned with the physician accepting authenticity of symptoms than relieving them. Vague, diffuse descriptions or overly detailed and elaborate symptoms are suggestive. The patient seems to be amplifying normal bodily sensations. Psychological factors may be revealed in the symbolic choice of words (e.g., “lump in the throat”).
“Stress” for most patients is an acceptable framework within which to obtain psychological information. Care must be taken during the interview not to suggest that the symptoms are “all in the head.”
A thorough and thoughtful history and physical examination are the basis for chosing specific diagnostic tests, and signal to the patient that the complaints are being taken seriously.
Clinical Findings
Anxiety Chronic anxiety presents with a pattern of the patient focusing on and becoming alarmed by normal bodily sensations. Patients will often suspect the most dire cause. Key symptoms of a panic attack include palpitations, chest pain, shortness of breath or choking, nausea or diarrhea, lightheadedness or faint, paresthesia, fear of dying or losing control, sweating or tremulousness.
Depression Although multiple vague somatic symptoms may be the presenting finding, vegetative signs of depression such as change in weight and appetite, sleep disorder, fatigue, and decreased libido are usually present if searched for. Finding depressed affect, anhedonia, or abnormal cognition is also helpful. Typical patterns may be unusual worry and preoccupation with the body, a “positive review of systems,” chronic pain, symptoms related to multiple organ systems, and complaints that are difficult to characterize pathophysiologically.
Hypothyroidism Sluggishness, constipation, impaired concentration, cold intolerance, and edema are typical of the vague symptoms caused by this condition.
Premenopausal syndrome This occurs cyclically with the menses and is characterized by irritability, fatigue, depressed mood, and waxing and waning somatic symptoms.
Hypochondriasis Chronically preoccupied with their bodies and health, patients are convinced that they have a serious occult disease. Symptoms shift and fluctuate, but worry is constant and is not assuaged by reasonable reassurance. The patient uses language that is “medicalized.” Many symptoms are recited in boring detail—a process known as the “organ recital.” Either the patient’s chart becomes quite thick with trivial diagnoses or he or she changes doctors frequently in a quest for “answers.”
Somatization disorder Multiple symptoms are present in multiple organ systems, are medically unexplained, and are severe enough to lead the patient to take treatment or see a physician. Presence of three of seven symptoms of amnesia, burning in sex organs, dysmenorrhea, lump in the throat, painful extremities, shortness of breath, and vomiting was associated with somatization disorder in one study. The onset is usually before age 30 and is associated with depression and with chaotic interpersonal relationships.
Chronic fatigue syndrome This syndrome is recognized by prominent persistent fatigue that interferes with role function, and other somatic complaints such as impaired concentration and short-term memory, low-grade fevers, arthralgias, and adenopathy. It may be a subset of the aforementioned diagnoses, however, it is suspected by sufferers to be viral in origin.
Fibromyalgia Fatigue and poorly referent periarticular pain and stiffness are found. Exquisite tenderness at eleven or more of the eighteen specific trigger points is the most helpful finding. Paired sites include the base of the skull, the neck at C5 to C7, the midtrapezius, the upper medial scapula, the second costochondral junction, the lateral epicondyle, the upper outer buttock, the posterior greater trochanter, and the medial fat pad of the knee.
Panic disorder The patient presents with discrete unprovoked attacks of anxiety and a sense of impending doom, accompanied by symptoms of dyspnea, palpitations, dizziness, tremors, sweating, choking, nausea, paresthesias, and/or chest pain.
Malingering Consider this explanation when there is obvious secondary gain (often pending litigation) and the patient has exaggerated symptoms, demonstrates suggestibility, and varies his or her description of symptoms. A self-limited form of this is seen in persons required by their jobs to have a medical excuse for a time off.
Conversion reaction Symptoms are either sensory or neuromuscular, such as weakness, paralysis, ataxia, blindness, anesthesia, seizures, or aphasia. Clues include short-lived symptoms, a prior history of similar reactions, major emotional stress prior to the onset of symptoms, symbolic meaning to the symptoms, inappropriate lack of concern about the symptoms (“la belle indifference”), secondary gain contingent upon illness, or the presence of other psychopathology.
Pictures
Book Source Details
- Book Title: Field Guide to Bedside Diagnosis
- Author(s): David S. Smith
- Year of Publication: 2007
- Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Field Guide to Bedside Diagnosis
Authors: David S. Smith
Publisher: Lippincott Williams & Wilkins
Copyright: 2007
ISBN: 0-78178-165-5
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