Intended for healthcare professionals

Rapid response to:

Clinical Review

Assessment and management of medically unexplained symptoms

BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39554.592014.BE (Published 15 May 2008) Cite this as: BMJ 2008;336:1124

Rapid Response:

A judicious Evaluation of unexplained symptoms

Our patients owe us at least a thorough listening (without interruption) and a complete clinical evaluation to put their complaints into context. Simon Hatcher et al, psychiatrists by training, bring their bias to their article. Why do we always have to rush to judgment whenever we fail to make a diagnosis? One reason, in my view, is the pressure physicians feel to give a diagnosis right away. How about if you just gather clinical information, glean clues, and solidify those with a judicious laboratory (or sometimes imaging) investigation. Then you see the patient again in a second visit and try to put all these objective information together, and add to that a screening for psychiatric disorders such as depression and anxiety, keeping in mind many patients are depressed as a reaction to their symptoms being dismissed, and not necessarily the depression itself causing the symptoms. My colleagues above bring up the possibility of porphyria and chronic lead poisoning in people with vague abdominal pains associated with depression; I find these as valid points. I do add to these 2 points the following: I thoroughly evaluate nutritional status of patients especially when it comes to the levels of: iron, vitamin B12, and 25 hydroxy vitamin D. In the right clinical context, I also screen for celiac disease, subtle thyroid disease by measuring both TSH and free T4 (free T4 is essential in this population to rule out central hypothyroidism). I also include morning cortisol and ACTH (to rule out central hypoadrenalism). In women with estrogen therapy I check copper level since copper overload in this population causes severe fatigue.

If these tests are done in the right clinical context, they bring a lot to the table in terms of clarifying mysterious symptoms. Of course every patient with unexplained symptoms should have a baseline CBC, to rule out anemia, or cytopenias, comprehensive metabolic panel and magnesium levels, to rule out renal, hepatic, and electrolyte derangements. Finally, attention to sleep hygiene, and optimal blood pressure and lipid profiles, is important. I have seen many patients who present with fatigue or unexplained cognitive function because of uncontrolled hypertension, or severe hypertriglyceridemia. I usually tailor these tests to specific patients rather than doing them all in every patient.

If we are too lazy to do the right evaluation, more of our patients come to us with "unexplained symptoms" and it would be convenient to label them with depression, chronic fatigue syndrome, and similar "empty" diagnoses.

Competing interests: None declared

Competing interests: No competing interests

19 May 2008
Shirwan A Mirza, MD, FACP, FACE
Clinical Assistant Professor
Private Practice, New York, USA