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August 2014Case
A 28-year-old woman presents for evaluation of exhaustion, widespread myalgias and muscle spasms. In addition, she has numerous symptoms spanning multiple organ systems, including paresthesia, atypical chest pain and abdominal bloating. She has previously undergone evaluation at other medical centers and by multiple subspecialists, and no specific pathology or diagnosis has been established. She has difficulty continuing her employment due to disabling symptoms. A comprehensive evaluation for malignancy and infectious diseases has been unrevealing. Neurological evaluation, including detailed physical examinations, imaging of the brain, electromyography and testing for large- and small-fiber neuropathy, has been negative. Extensive laboratory studies, autoimmune serologies and radiographic imaging studies are unremarkable.
You review the history and conduct a comprehensive physical examination and find no abnormalities, except for widespread muscle tenderness without weakness. The patient is not reassured by the negative evaluation and is concerned that a progressive autoimmune disorder is being missed. Additional evaluation is pursued, including magnetic resonance imaging (MRI) of proximal muscles, which is negative. The patient requests further testing, including a muscle biopsy. Her request conflicts with your recommendation that the diagnostic evaluation has been completed and your plan to pursue symptomatic management for fibromyalgia.
Dilemma
As access to medical information expands, patients increasingly present to clinical encounters with specific preconceptions regarding their possible diagnosis and requests for testing and interventions. Medical literacy, if applied appropriately, can lead to patient education and empowerment, and can improve shared decision making. However, if the information obtained is of questionable accuracy, incomplete, misinterpreted or outdated, such requests and expectations can lead to challenging clinical encounters, especially when the patient’s preconceptions differ from the physician’s assessment.