The most appropriate management of this patient who has had extensive evaluation of multiple nonspecific symptoms and has been appropriately diagnosed with medically unexplained symptoms (MUS) is regular visits with her internist. Consistent, regularly scheduled follow-up visits with brief focused history and physical examination, rather than ad hoc, unscheduled visits for crisis management, are the cornerstone of management. Regular visits allow for growth of the physician-patient relationship and the ability to discuss the diagnosis and specific symptoms with the patient and anticipate potential problems and issues. This patient's symptoms are persistent but not progressive, and there are no accompanying pathologic findings on examination or with previous diagnostic testing. Additionally, her symptoms have adversely affected her quality of life, and previous trials of antidepressant medication have been unsuccessful. Although co-management with a psychiatrist can be beneficial in the care plan of some patients with MUS, the internist assumes the central role, and this would be the most appropriate approach to managing this patient.

Long-acting benzodiazepines are not recommended in patients with MUS because they have not been proved beneficial in treating symptoms, and the sedative effects and risk for dependence outweigh any potential benefits.

Neuropsychological testing is generally performed to further evaluate cognitive dysfunction and is unnecessary in this patient who has clinically normal cognitive function.

Physical therapy may be beneficial in the patient with prominent musculoskeletal symptoms. However, these symptoms are absent in this patient, and physical therapy should not supplant the central role of regularly scheduled visits with the internist.