This patient with medically unexplained symptoms (MUS) would benefit most from cognitive-behavioral therapy (CBT). She presents with many of the common symptoms seen in patients with MUS, and her symptoms are significantly affecting her quality of life. She has undergone extensive and costly medical evaluation with normal results, and several medications have been tried without benefit. Although it is tempting for the patient and the physician to think that additional testing or medications will elucidate a previously undiscovered diagnosis, this is rarely the case. This pattern of care often leads to iatrogenic injury, excess health care costs, and patient dissatisfaction. Goals of care should be shifted away from medical diagnosis toward addressing the impact of the patient's symptoms on her life. CBT involves educating the patient so that she understands the plan of care and its purpose, obtaining and reinforcing a commitment from the patient for the chosen plan of care, setting and reviewing mutually chosen patient goals, and negotiating new plans and therapy as needed. CBT has been shown to be effective in patients with MUS. Although CBT is generally performed by trained therapists, the internist can reinforce the basic principles of CBT at each follow-up visit.

Ordering further diagnostic testing, such as a brain MRI, when there is no strong clinical suspicion of disease is inappropriate. Despite this patient's various neurologic symptoms, she has no focal neurologic findings and no indication for brain imaging.

Patients with MUS may have underlying depression; however, this patient reports no depressed mood or affect, anhedonia, or problems with concentration. Additionally, a previous trial of a selective serotonin reuptake inhibitor was unsuccessful. Therefore, treatment with another antidepressant medication is not indicated.

Frequently, the patient with MUS will request referral to a specialist, or the internist will contemplate referral due to frustration or uncertainty. In this patient, referral to another physician risks further fragmentation of care and duplicate or more invasive testing, neither of which is indicated.

Regularly scheduled visits with an internist, accompanied by targeted physical examinations, are essential in the patient with MUS. Randomized trials suggest that this care plan may improve patients' physical functioning. Additionally, recent evidence suggests that telephone contact may be an effective substitute for face-to-face visits. An interval of 6 months between follow-up visits is too long to effectively manage this patient with MUS.