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of davina rogers not as a joke even if i do poke fun at it but as an example of what constitutes a not insignificant proportion of any medical specialities workload medically unexplained symptoms mus the chest docs have atypical chest pain the gastros have irritable bowel the ent docs get globus hystericus and we more commonly than the florid presentation above see the pseudoseizures yet regardless of their differing labels they all have at least one thing in common there are symptoms for which no organic basis can be identified the tests have been done the colonoscopies the ecg the angiograms the xrays the eegs the cts and whatever else might reasonably be tried but they have all come back plumb normal and it s there that the real problems start the first problem concerns what exactly to do with these patients once you have reached this stage in many ways doctors are like detectives a patient presents with a certain symptom and the doctor works towards solving the mystery of the underlying causative pathology when this mystery fails to yield an answer however the doctor is likely to become fatigued dejected and might well lose interest in the case the temptation is thus to discharge the patient from follow up with the label of medically fit and have done with them once and for all yet this approach fails to acknowledge that medically fit people might still be in need of help even if they have come to the wrong person in search of it indeed in the case of medically unexplained symptoms there is good evidence that if the diagnosis is made early enough and if necessary the patient manoeuvred towards the psychiatrists the prognosis is good the longer they are left to ping pong around within the medical referral system the less the chance of ridding them of their symptoms the most common misconception is that these patients are malingerers this is incorrect from both a psychiatric and indeed a common sense point of view malingering by definition aims to obtain a tangible benefit for the malingerer the classic example being the heroin addict who feigns abdominal pain to obtain morphine but in the case of mus the patient accrues no obvious benefit from their contact with medical specialists they may even suffer harm in the form of side effects of empirical treatments or complications of unnecessary investigations and procedures the essence of mus is illness behaviour in the absence of any identifiable organic disease the absence of identifiable organic disease however in no way implies the suffering of patients with mus is any less real unlike the malingerer who gets up and walks away once his goal is achieved or his scheming uncovered patient with mus are often persistently disabled either physically or socially by their symptoms in a way which dramatically reduces their quality of life in the case of miss rogers above she was wheelchair bound despite the fact that no neurological need for one could be found one of the most difficult things is deciding how best to explain a set of normal investigations to a patient who continues to exhibit symptoms to my mind there are two ways of looking at it either the tests are not good enough to pick up the underlying pathology or alternatively there is no underlying pathology striking the right balance between these two ideas can be tricky though too much of the former and the patient goes away thinking that there must be an organic cause for their problems but it s just too complicated for us to work out yet too much of the latter and they only hear you re making it all up neither impression is likely to be helpful you need to get the patient on your side if you are to stand any chance of having a positive impact on their life you must help the patient come to terms with the fact the there are no more investigations to be done whilst emphasizing that this is not equivalent to saying that we have nothing to offer in the way of help it is essential i think that you frame the idea of a non organic cause for their symptoms in such a way that allows the patient to accept this psychological framework with dignity and without loss of face in addition the stigma surrounding mental health issues is alas still powerful and efforts must be made to mitigate against this if the patient is not to understand a psychological explanation of their symptoms as an accusation of madness with this kind of approach i usually find that patients initial resistance to psychological interventions soon gives way to a willingness to try it currently falls to the psychiatrists to deal with those cases of mus that are actually recognised as such and not just left to bounce backwards and forwards from one physician to another we have an excellent service here at my hallowed institution but i imagine other centres might not be so lucky there is evidence for benefit from a whole range of treatments in mus from physiotherapy through psychotropic medication particularly ssris as depression often underlies mus all the way up to cbt and other forms of psychotherapy as ever in the nhs the clinch comes in the difficulties of balancing demand and supply the scale of the problem is mammoth between 5 15 of all gps workload is estimated to consist of mus yet psychiatry is underfunded and the parapsychiatric specialities even more so clearly a system that is already failing to deal with the tip is never going to cope with the whole of the iceberg the solution of course lies in investment and a recognition that a significant amount of money could be saved in terms of benefits repeated appointments and needless investigations if mus was recognised as such early on and treated accordingly somehow i doubt that will be a recognition that s made within our lifetime functional illness mus medically unexplained symptoms posted by the venial sinner at 4 47 am 33 comments friday april 28 2006 reality vs tv pretty much every doctor in england likes nothing better than a good piss ripping session about the medical dramas that proliferate daily to fill our tv schedules whether it be the upside down x ray the incorrect management plan or the fact that the fresh from med school house officer has just been left to perform open heart surgery on some old dear while the consultant nips out to the bogs to self medicate with another hit of stolen pethidine it does sometimes all conspire to make you think that no amount of medical advisors will ever stop them getting it all so horribly wrong to my own mind however the truly amusing thing about the medical soaps is how wonderfully glamorous they make medicine seem if it s not the fact that everybody is hotter than a page 3 hotty then perhaps it s the fact that they seem to pass their whole day making end of the bed life saving spot diagnoses or cutting people back to health without breaking a sweat and all in time to grab that quick beer after work with the fit patient whose entire previously insoluble life problems they sorted out earlier with a few well chosen words but o the reality of it and o how it bites tonight venflon needs doing for bed 5 and 26 and there s a drug chart needs rewriting for bed 15 was the greeting i received when i stepped onto the ward tonight not even a how are you or sleep well just straight down to the nitty gritty of it i answered my bleep a little later to have dhere s pus needs took to the lab from t eatres barked into my ear by ms mcfeisty the leprechaun of neurosurgical registrar on call with me tonight there s something in ms mcfeisty s manner that tells you she didn t get to where she is today by battering her eyelids and smiling coyly no i see scalps taken and the scrotums of enemies crushed beneath a stiletto heel think less goldilocks and more martin mcguinness with tits oh i m sorry i temporarily forgot that mr mcguinness is now a noble statesman committed to the peaceful release of his country from the shackles of its colonial oppressors and not in fact a murderous terrorist in a balaclava who d have your kneecaps off at the drop of a hat anyway i entered theatres to find the mcfeisty energetically sucking the pus from a young man s brain whilst simultaneously berating the scrub nurse for not handing her the gauze fast enough without looking up she quickly spat out 19 ivdu cerebral abscess on cef and rifampicin urgent gramm stain results to itu i waited a moment until i was sure the staccato list of instructions was over before i picked up the sample and left so this is it the culmination of six years and tens of thousands of pounds worth of education ferrying pus around the hospital in the dead of night isn t it just faaaabulous daaarling posted by the venial sinner at 6 46 am 7 comments wednesday april 26 2006 oneiromancy sleep has all but deserted me these days and even when it comes it is spasmodic and punctuated by nightmares the masochistic element of my mind has once again taken to its duties as my own personal torturer with a zeal chief among the tools of its trade is sleep paralysis after a break of several months these terrifying episodes have slowly crept back in to torment me it is as if suddenly and without any warning a part of my conscious mind breaks the surface of the murky waters that have so far shrouded it in sleep and is again aware aware of the position of my body of the feel of the sheets against my skin of the give of the mattress beneath me aware in sum of all the things that you might know if you were lying on your bed awake but with your eyes closed yet still the rest of my mind sleeps on and i cannot move i slowly mounting feeling of panic rises in whatever part of me is aware as it and i struggle to move a body that feels like it is floating in treacle i cannot move i feel my heart beating faster and harder in a chest constricted by the grip of fear i cannot move and yet i must move for there is someone or something in the room i do not know what this thing is i cannot see it but i feel its approach all the same the mattress bends and gives under the weight of its body as it crawls up onto the bed i strain to cry out no sound but perhaps muted and pathetic whimper escapes my throat i struggle to pull myself up from the bed still i cannot break free from the viscous air that smothers me the terror becomes overwhelming as the thing s progress towards me is mapped out in the shifting imprints of its weight on the mattress it is so close now almost over me bearing down my heart feels like it might burst my limbs tense with mental effort and my throat tightens with the scream i cannot emit suddenly there is give the treacle evaporates the constricting bands of fear around my chest break my body lurches up my eyes spring open i am awake and only the pounding of my heart remains this may happen several times in one night sometimes there are voices too children laughing or just the insistent sound of my name repeated slowly again and again i do not know why they happen and i cannot stop them last night i dreamt i was in a tin bath full of the putrid and filthy water from the bath i can see into two other rooms in one i see my family sitting on a white sofa facing away from me around them like a court jester cart wheeling and dancing is the australian with all his hair shaved off the more i stare at him the more he seems to be two people at once the australian and my first ever boyfriend rolled up in one i can feel the happiness they radiate and hear their riotous laughter echoing about after a little while i turn to the other room where enormous snorting wild eyed horses rear up at each other as if in the throes of brain fever these are truly gargantuan beasts and watching them thrash and crash about the room fills me with fear i decide to get out of the bath i pull the plug and the water drains away slowly to reveal that i have been sharing my bath with a joint of raw meat i sit naked and stare at it impassively the dream ends i mean what on earth is that all about any budding freuds want to give it a go posted by the venial sinner at 2 04 pm 7 comments tuesday april 18 2006 money makes the world go round i haven t written for a while there have been too many other competing interests for my energies of late a rather substantial portion has been devoted to work i am not one to rally under the flag of medicine as a vocation nor would i wish to sarifice my own life on alter of altruism nonetheless i do take pride in doing a good job by the people i look after as a system the nhs is inherently inefficient and i find that in order to get a recent result out you have to put a disproportionate amount of energy in at times this can be truely exhausting still whatever its failings the nhs cannot be said to be as inefficient as my boiler it is effectively nothing more than one big unclad kettle sitting in a cupboard at the back of the flat when it s on it is scarcely possible to open the cupboard door without risking third degree burns from the incredible heat that radiates from its thin metal body i have come to suspect that this beast in the backroom has single handedly run up most of the energy for which london electric are currently demanding blood money to the tune of a ludicrous 900 in addition several other companies and organisations claims on my money have become so persistent and menacing as of late that i have been forced to remove my head from the sand and review the situation the situation alas is bleak 1000 council tax unpaid 400 of arrears in my student loans tiresome irksome affairs of which various voices on the other end of the phone speak to me in comically serious tones they seem to find it beyound belief that i have no records of account numbers or am unable to give precise details for a direct debit on my account personally i find it beyond belief that anybody could to be bothered to waste time memorising such banal trivia my dealings have led to the conclusion that i m not one for the crass business of finance i earn it and i spend it that is the limit of my interest in money thankfully i can escape all these mundane concerns in the clubs of london so long as i have the money in my pocket to buy the next round who care s about bills and deadly serious debt collectors let them wait i ll pay eventually posted by the venial sinner at 7 25 pm 3 comments thursday april 06 2006 lolita and the elusive i i am being sexually harassed by one of the patient s on my ward bad eh want to know what s worse she s only 16 years old it s a bit sad really according to her family just a few months ago lolita was a happy normal 16 year old girl one day she complained she felt a bit unwell she stayed at home and slept for 48 hours when she awoke her personality had been altered completely gone was any trace of inhibition in its place a mind focused only on the pursuit of fit men and her newly found habit of smoking rollies it looks likely that lolita may have had encephalitis a infection of the brain tissue itself though it seems to have...