ILA 2 - Paraesthesia and MUS Flashcards
Medically unexplained symptoms (MUS).
a) 3 most common
b) Predisposing factors
c) Precipitating factors
a) Pain, fatigue, functional organ disturbance
b) • Long term conditions with anxiety and depression
• Childhood abuse
• Female gender
•Personality disorder
c) Triggers:
- Recent infection
- Current physical illness
- Death or severe illness of loved one
MUS disorders.
a) Somatisation disorder
b) Conversion disorder
c) Hypochondrial disorder
d) Dissociative disorder
e) Munchausen’s syndrome
f) Malingering
a) - Physical SYMPTOMS for at least 2 years
- Patient refuses to accept reassurance or negative test result
b) - Actual medical SIGNS – typically neurological (loss of motor/sensation)
- Doesn’t consciously feign the symptoms
c) - Persistent belief in presence of underlying DISEASE (often cancer)
- Refuses to accept reassurance of negative test results
d) - ‘Separating off’ memories from normal consciousness
- Psychiatric symptoms, e.g. amnesia, fugue (loss of awareness of identity), stupor (state of near unconsciousness, no idea what’s happening around them)
e) - Intentional production of symptoms in oneself or another (by proxy)
f) Fake/exaggerate symptoms in order to gain something (money, medication), benefits associated with adopting the sick role
MUS: how to manage the patient
- Be there for the patient – reassure, connect. Focus on social aspects, when the symptoms started, the impact on their life it’s having. Establish their concerns
- Most patients with MUS will improve when the GP gives an explanation for symptoms that makes sense, removes blame from the patient and generates ideas about symptom management.
- Name the elephant in the room (“I think you may have what we call ‘functional’ symptoms”).
- Be there for the patient – reassure, connect. Focus on social aspects, when the symptoms started, the impact on their life it’s having. Establish their concerns
- Treat what is treatable – pain ladders, maximise treatment and symptom control in chronic disease (COPD, angina etc.)
- Screen for depression and treat appropriately (PHQ-9)
- Non-medical treatment – physio, CBT, MDT approach to management. SHARE THE PLAN with the patient
- Investigations and referrals – discuss the possibility of normal results, be clear with the specialist with what the question is, copy patients into letters and agree goals
- Safety net - red flags, reassure patient they will be taken seriously, positive risk management (recognising that NOT investigating may be best for the patient)
MUS: good phrases to use
Use the term functional:
- “I think you may have what we call ‘functional’ symptoms”
- “There is no damage of (nerve cells) but a disruption of function”
- “We are not entirely sure what causes functional (pain/weakness/numbness/seizures), but we often see them in patients who are under a lot of stress/who have suffered a loss/who have been badly upset by something” (pause, then gentle probe)…. “I wonder if you recognise any of this in your own life?”
- “When people are anxious/stressed (psychological cause), the muscles in their neck tend to tense up (pathogenesis) and that can cause headaches (symptoms)”
Reference:
- Reuber M et al. Functional symptoms in neurology: questions and answers. Journal of Neurology, Neurosurgery & Psychiatry 2005;76:307-314
(https: //jnnp.bmj.com/content/76/3/307)
MUS: common functional neurological signs
- Collapsing weakness (feels like patient is not trying)
- Hoover’s sign (in organic hip flexion weakness - contralateral hip extension occurs, felt by pressure on examiner’s hand under patient’s heel; in functional weakness, no such pressure is felt)
- Absence of other signs (e.g. tone and reflexes normal)
- Dragging foot gait (vs. stroke - swinging foot, hemiplegic gait)
- Romberg’s test: fall towards examiner no matter where examiner stands
- Non-epileptic seizures
MUS: dangers of under-diagnosing functional disorders
- Inappropriate investigations
- Inappropriate treatment (e.g. anti-epileptic drugs for patients with NES - teratogenic, side effects, death, driving restrictions)
- Poor expectation management
- Failure to offer appropriate psychological support
- Litigation
MUS: reasons for following up patients
- Diagnostic review: ensure no red flags/organic disorders have developed or been missed
- Ensure patient realises their problem is being taken seriously and they aren’t being fobbed off
- Encourage engagement and compliance with psychological/alternative treatments
- Establish consistency and trust, and avoid inappropriate referrals for second opinions, etc.
Causes of paraesthesia.
a) Metabolic
b) Vascular
c) Neurological
d) Environmental
a) Diabetes, alcohol, B12 deficiency, hypothyroidism, hypo-Ca2+, uraemia (renal failure, etc.), liver disease
b) TIA/Stroke, Raynaud’s, PVD, ITP, vasculitis
c) Compression (sciatica, CTS, CES, tumour), MS, GBS, SLE, CMT, migraine, epilepsy
d) Drugs (isoniazid), alcohol, infection (Syphillis, Lyme disease)
Investigating paraesthesia.
a) Imaging -for what?
b) Bloods
a) MRI - lesions (tumour, MS plaques)
b) FBC (B12 anaemia, infection), UEs,
Controlled drugs: schedules
a) Schedule 1
b) Schedule 2
c) Schedule 3
d) Schedule 4
e) Schedule 5
a) Non-medical (LSD, cannabis, etc.)
b) Morphine, diamorphine, oxycodone, fentanyl, pethidine
c) Buprenorphine, Pregabalin, Tramadol
d) Diazepam
e) Codeine
Controlled drugs: considerations
a) Risks
b) Which schedules can be prescribed on repeat?
c) The others can only be prescribed for max ____ days.
a) Tolerance, addiction, overdose, indication, titration of dose, consideration of clinical need over time, review the patient
b) 5 only
c) 30 days
