A 34-year-old man who is usually well has seen you five times over the past two months with a variety of vague symptoms. He is concerned he could have multiple sclerosis. He has had investigations for dizziness three years ago, which included a normal MRI scan of his brain. He seems to expect more tests.
What do you do?
Dr Amit Tiwari's view
This appears to be turning into the classic scenario of a heart sink patient. This is fuelled by the patient's unrealistic expectations and the doctor's inability to reassure the patient.
It is easy to label these patients as hypochondriacs but one should be cautious that nothing is being missed.
Time should be spent going into detail about what the patient thinks is wrong with him and what exactly he expects. His obvious worry is that he has MS.
Explore where his ideas came from. Does he have friends or family who have MS? Has he been exploring his non-specific symptoms on the internet and this was one of the diagnoses mentioned?
Other reasons for his symptoms should be assessed. He may have ongoing problems at home or work, or financial worries, which are causing his symptoms. Check for any psychological symptoms or signs.
Unless there is something specific in the history that is worrying, I would be inclined to stop doing any further tests as this fuels further expectations and causes anxiety.
I would try to negotiate a period of watchful waiting. This would be followed by a fixed review date to see if anything has changed, and I would reassure the patient that he is being taken seriously.
Repeated reassurance with the clear sign that you are available to help when required would probably be all he needs.
- Dr Tiwari is a GP partner in Colchester, Essex. He qualified as GP in 2007
Dr Anna Greenham's view
The patient is certainly concerned or he would not keep coming back. For some reason his worries have not been adequately addressed. It is important to review the notes.
I would try to avoid knee jerk investigations or referrals. Perhaps it is time to take the history again and really listen.
A thorough physical examination can also be reassuring. If all seems normal then all the reassurance in the world will fall on deaf ears if you do not know what his real concerns are.
I wonder what his fear is about MS. Does he have a friend or relative with it?
I would try to probe a bit for any depressive symptoms, or even excessive worry or anxiety in other aspects of his life. This could all be due to psychological distress. Time, confident reassurance and supportive listening can be very therapeutic.
Of course, there is always the possibility that there is something physical and his concerns are justified. In this case a specialist referral or further tests may be warranted.
- Dr Greenham is a locum GP in Gateshead. She qualified as a GP in 2006
Dr Leke Asong's view
A case like this should be approached with an open mind.
I would explore his ideas, concerns, expectations and psychosocial impact from the first visit. My aim here is to elicit any changes from previous consultations.
A welcoming greeting ensures a good start to the consultation, followed by the history.
Is the dizziness the same or worse? Has he had any other symptoms since the last consultation? If there is a change is symptoms, ask if they are interfering with his normal life.
Find out why he is presenting now. Something may have stimulated him to do so, such as an article in a newspaper or on the internet, or a mention from a friend.
This might give a clue as to why he expects more tests and may steer you in the right direction in terms of reassurances.
Establish what he actually understands about tests or investigations for MS.
The very nature of MS makes diagnosis difficult. In addition, a negative MRI does not exclude MS. With this in mind, a decision to investigate further with evoked potentials or analysis of CSF will depend on the present symptomatology.
As the above patient does not appear to be a chronic worrier, I would listen to the patient and make a referral if appropriate.
- Dr Asong is a GP registrar in Mansfield, Nottinghamshire
- This topic falls under section 2 of the RCGP curriculum, 'The General Practice Consultation', www.healthcarerepublic.com/curriculum
A patient who is on multiple medications for BP and non-insulin dependent diabetes mellitus used to spend three months a year in Spain until his retirement. Now, as he has retired, he is planning to live abroad at least nine months a year and asks for an NHS prescription to cover this period of time. Both his BP and diabetes have markedly deteriorated recently.
What would you do?
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