This patient with medically unexplained symptoms (MUS) should not undergo repeated or additional testing. Repeated physical examinations and appropriate laboratory and ancillary testing by internists and specialists over an extended period of time have been unrevealing of significant disease. Without significant change in the clinical picture, no further testing is indicated. The physician should instead focus on establishing and strengthening a therapeutic alliance with the patient using patient-centered methods. Cognitive-behavioral therapy that consists of 1) educating the patient so he or she understands the symptoms, 2) obtaining a commitment from the patient to assume responsibility for his or her improvement, 3) facilitating realistic goals, and 4) negotiating a treatment plan can be helpful in the office setting. A systematic review of 34 randomized controlled trials demonstrated that, in most studies, cognitive-behavioral therapy was effective in treating patients with MUS.

Although this patient may have intolerance to certain foods and believes that dietary manipulation improves her symptoms, she does not have evidence of significant food allergy, which may be manifested as an IgE-mediated allergic reaction or more chronic symptoms isolated to the gastrointestinal tract. She has also been evaluated by an allergist who did not pursue food allergy testing. Therefore, food allergy testing would likely be of low yield in this patient.

Although this patient has chronic low back pain, she is without concerning symptoms or physical examination findings that would warrant further imaging of her lumbosacral spine, and MRI would not be beneficial.

Repeat Lyme disease serologic testing is unwarranted in this patient. Although systemic symptoms and chronic fatigue are often attributed to Lyme infection, this is a very uncommon occurrence and would be extremely unlikely in this patient with no clinical findings and negative serology.