How can you help a patient with undiagnosed health concerns?

How to Help a Patient with Undiagnosed Health Concerns

Begin by systematically ruling out serious medical conditions first, then thoroughly explore the patient's specific concerns, expectations, and life impact through open-ended questions—this dual approach addresses both diagnostic accuracy and the therapeutic relationship that drives patient satisfaction. 1

Immediate Systematic Assessment

Rule Out Life-Threatening Conditions First

• Ask "Could this be sepsis?" immediately in any patient with acute illness and follow established sepsis identification protocols 1
• Assess cardiopulmonary stability, checking oxygen saturation and providing supplemental oxygen if <94% 1
• Identify red flags requiring immediate action or specialist referral 1
• Medical diseases must be adequately ruled out first—studies show 19-63% of patients presenting with psychiatric or unexplained symptoms have underlying medical problems 2, 3

Obtain Targeted Clinical Information

• Document onset and duration, symptom characteristics, associated symptoms, and functional impact systematically 1
• Conduct focused physical examination including vital signs, volume status, and system-specific findings 1
• Obtain appropriate initial tests based on presenting complaint (laboratory evaluation, ECG, imaging as indicated) with results available within 60 minutes 1

Deep Dive into Patient Perspective

Use Open-Ended Questions to Uncover Hidden Concerns

Ask three critical questions that most physicians skip:

• "What worries or concerns do you have about your symptoms?" 4
• "How is this affecting your life?" 4
• "What areas of your life are affected most?" 4

These questions are essential because:

• Two-thirds of patients worry their symptom represents serious illness, yet physicians often underestimate this concern 5
• 78% of patients hope for medication, 46% expect tests, 41% anticipate referrals—but physicians frequently miss these expectations 5
• Unmet concerns and expectations are the strongest predictors of patient dissatisfaction, even when symptoms improve 5, 6

Elicit Specific Details Using the "Movie Playback" Technique

• Ask caregivers or patients to describe symptoms "as if in a movie" to get precise characterization 4
• Identify antecedents, specifics of the presentation, and consequences to uncover modifiable patterns 4
• Encourage symptom diaries documenting patient, caregiver, and environmental factors 4

Comprehensive Investigation of Underlying Causes

Medical Factors to Systematically Evaluate

• Compile complete medication list (bring in bottles) checking for anticholinergic properties and drug interactions 4
• Investigate infections (especially urinary tract), constipation, dehydration, and pain 4
• Obtain chemistries (glucose, electrolytes), complete blood count, urinalysis 4
• Consider prior psychiatric comorbidity, functional limitations, cognitive impairment, poor sleep, sensory changes 4

Psychosocial Factors Often Missed

• Screen for early life adversity using the Adverse Childhood Experience Questionnaire—physical, emotional, or sexual abuse; witnessed domestic violence; caregiver substance abuse or mental illness 4
• Assess symptom-specific anxiety: 43% of IBS patients fear their disorder will become colitis, 21% fear cancer 4
• Evaluate relationship quality between patient and caregivers, communication styles, and cultural context 4
• Screen for domestic violence in children, partners, elderly, and vulnerable populations, especially during times of isolation 4

Building the Therapeutic Relationship

Acknowledge and Validate

• Take time to acknowledge symptoms are real and conduct thorough examination even when diagnosis is uncertain 1
• Address patient fears explicitly—failure to examine or test is often interpreted as failure to care 6
• Build rapport by showing interest in illness burden, which increases likelihood of accepting behavioral health referrals when needed 4

Provide Clear Communication

• Explain findings, provide diagnosis when possible, and discuss management options with patient and caregivers 4
• When patients express disappointment about omitted tests, they may actually be expressing concerns about illness basis, therapy rationale, or the relationship itself 6
• Use disease-specific quality of life questionnaires (like Irritable Bowel Syndrome Quality of Life) rather than generic measures 4

Disposition and Follow-Up

Decision Algorithm

• Refer to specialist if red flags present 1
• Initiate treatment and arrange follow-up for patients with clear diagnosis 1
• Provide self-care guidance with explicit safety-netting instructions for patients whose symptoms can be managed at home 1

When to Reconsult

Instruct patients to return if:

• Symptoms worsen or new symptoms develop 4
• No improvement within 48 hours of starting treatment 4
• Functional impairment increases 4
• New concerns arise 5

Critical Pitfalls to Avoid

• Never diagnose somatic symptom disorder or attribute symptoms to anxiety/depression before adequate medical workup 2
• Depression and anxiety may be consequences rather than causes of chronic unexplained symptoms 2
• Avoid remote prescribing based on telephone assessment alone if symptoms suggest serious illness 1
• Don't assume vague complaints are "functional"—they may fluctuate with stress but still have organic causes 2
• Patients uncomfortable with clinical uncertainty often distrust empiric therapy and endorse early detection—address this explicitly 6