Sly Saint
Senior Member (Voting Rights)
London School of Paediatrics - HEE NHS UK
(I skipped the case examples)
youtube generated transcript:
pt1
(I skipped the case examples)
youtube generated transcript:
pt1
think about what is
mus or also known as PP so there are
multiple terms used to describe the same
issue the one that's most common used in
the UK is probably
medically unexplained symptoms it's also
known by some people as perplexing
presentations and in
creasing in the literature but more so
overseas in the UK it's known as bodily
distressed disorder and so these are all
interchangeable terms and sometimes
you'll heard of it referred to as a
functional disorder the most important
thing is there's no one pattern of
symptoms this can affect any organ
system or more than one organ system and
the hallmark of mus is that the symptoms
that an individual describes are not
fully explained by physical examination
or investigation what's really important
and something that occasion gets lost in
mus is that the symptoms the patient's
experiencing are absolutely 100% real to
them they are frequently distressing an
anxiety inducing both to them their
family and indeed the clinical team who
treats them because they committed why
the Chaves have no symptoms apologies
for the fire alarm in the background
hopefully I won't have to evacuate talk
um what is it not well it's absolutely
not malingering and that's very important to
understand and people sometimes get
labeled as faking their symptoms because
we can't explain them medically but
actually when you look at the literature
on these young people they are
absolutely not malingering it's not
exactly the same as fabricated or
induced illness but women come back and
talk about the overlap a little bit
later the talk in terms of the other
things that some that it used some
people may have heard of somatoform
disorders and it's a little bit pedantic
that if you're talking to mental health
colleagues this is distinct from em us
the difference between em us in
somatoform disorders is that in
somatoform disorders something is
physically wrong with you so for example
you have ankle pain and what happens is
the patient become psychologically
fixated on that real symptom to the
point where it becomes overwhelming so
it's an over-exaggeration of symptoms
due to psychological fixation for a real
condition as opposed to mus where there
isn't accurate information for symptoms
and organic illness well the distressing thing is that if
you look at the adult studies about four
to ten percent of adults with presumed
mus do eventually turn out to have an
organic diagnosis and I think that's the
other thing that's really important when
you're treating a possible mus you have
to keep in mind because some of them
will turn out eventually to have a rare
or unsuspected disorder which does
explain everything so what do we know
about mus
well we don't know very much
about mus in children young people
specifically there is quite a lot of
research in adults but not as much
that's been explicitly done only on a
pediatric population some so you suggest
up to ten percent of children will get
some medically unexplained symptoms at
some point in their childhood and that
sounds a lot but remember that a child
who has a nonspecific tummy pain which
is a well recognized common presentation
general Pediatrics could potentially
fall into the category of medically
unexplained symptoms in the literature
what you find is that most mus is
managed by self care approximately 30%
of adults with mus a suit primary care
support and in frontof draw acute mus is
managed in primary care body one percent
of adult patients with mus will seek
second to care support however this 1%
are often very frequent attenders of
second tear frequent users of services
and frequent requesters of tests and so
they come to people's attention it's
possible if it goes for this a slightly
higher on children but we don't have any
published evidence and supports this so
what happens to people with mus so as
you can see and although the majority of
people with mus and this is adults again
do recover within 12 months
I'm not insignificant percentage will
continue to have ongoing symptoms for
all the 12 months and that is higher air
in things like elegy than it is in most
fierceful at all we don't have the
figures for children but we know it is
possible for these children to go on
with long-term symptoms.
so what can you do to help for these young
people who you suspect may have mus well
the good news is there is some guidance
available and currently available is the
Royal College of Psychiatrists and experienced symptoms in children and
young people which is published in all
this 2018 and that is freely available
to Google and I've linked it at the end
of the talk in the resources slide at
the end of this presentation the Royal
College of pediatrics and child's health
has a new guideline which is due for
publication very soon I confirmed with
the college it is due out but I don't
have an actual date for publication at
this point in time but keep watching
this space there are some basic
principles when dealing with children
with possible mus the first thing is to
really think about it early so always
have in the back of your mind that
anyone presenting with unusual signs and
symptoms could mus be part of the
differential and it's important to be
open with children young people and
their families about the possibility of
mus as soon as you consider it and I
would list it in the normal list of
differentials and assuming I will be
explaining the possible medical
differentials and the reason for that is
the best way of managing these young
people is by parallel investigation
management strategies.
so it's not a case of we do all the medical things and then
we hand you over to psychiatry and walk
away we talk from the very beginning
about the importance of involving the
mental health teams in managing young
people with possible mus
so this talk is obviously specifically
around management and PGD is part of our
Penn week so probably the most important
thing is to recognize that you might be
dealing with a young person with MUS
and obviously D is different to the ward
and outpatients you get to see people
for a short period of time and it isn't
always apparent about early stage this
is kiram us but there are some things to
look out for so look out for frequent
attenders pre-competitive medical
presentations not so much with injuries
and another thing to account for is the
tense in multiple places what's
sometimes known as hospital shopping so
yes they've been to your department
three times but actually mum also
mentions that they've been to different
number two hospitals in the local area
and they've been seeing the GP and maybe
they've seen something outpatients at
another hospital and maybe they've seen
somebody privately but essentially a
pattern of people looking for an answer
when they can't find one because people
can't give them a straightforward answer
there's often quite significant mismatch
between the anxiety the child noon
person or their family and the medical
concerns so a lot of these symptoms are
not what we would consider red flag
symptoms they're ongoing and they're
chronic and they're annoying but they're
not normally immediately worrying but
that isn't always mirrored by the family
and often the reason that is by the time
you're seeing them in the emergency
department they may well have seen
several other people in several of the
places and being told there's nothing to
worry about but the symptoms are still
present and that leads on to the next
thing which is often you get to the end
of the consultation and you find there
is expressed or hidden dissatisfaction
so you'll experience the family that
everything's fine there's nothing to
worry about and the looks you're getting
clearly tell you that they're not happy
about it and what's important actually
that one is this explore with the family
why they're not happy about it and what
their concerns and expectations are from
a junior perspective these cases can be
quite complex and I think the most
important thing is if you think you're
seeing in running that might have any us
for these reasons or for some of the
things we've talked about and then it's
important to escalate early to a senior
doctor to discuss the best way of
managing them so things you can do in
the emergency department it's to be open
and non-judgmental as we talked about
it's really important to make it clear
that
mus is not malingering or fabricating it
is dealing with symptoms that we cannot
explain with a standard organic model
it's really important to acknowledge the
child in young person families distress
it's very tempting to say oh it's
nothing to worry about without actually
acknowledging that is disabling or
painful for the young person what you
can do is be reassuring about the
diagnosis you can exclude and one of the
phrases that I often use in the emergent
part is to be reassuring about we know
there's nothing immediately dangerous or
worrying and clearly there's something
that needs addressing but it doesn't
need to happen today and we don't need
to admit you to do it and really what
you're looking for is a pathway to
ongoing care that practically doesn't
involve admission or returning to the
emergency department so this is where
things like urgent review clinics if you
have access to them are really important
discussion with your inpatient
colleagues discussion with primary care
sometimes you do still need to provide a
safety net because members children will
end up having orgasms you can introduce
a holistic body mind link concept the
young person to do that things not to do
so really really importantly not to
minimize or ignore the symptoms they are
real to the patient also try not to over
investigate or admit if alternatives
exist these young people often have very
weird and wonderful symptoms and it is
tempting to assume that something really
serious is going on and just throw the
entire laboratory at them if not half of
radiology but actually all that's doing
is reinforcing that there is something
dangerous going on the we haven't
detected yet and that that's reinforced
by this concept of not focusing on
getting a specific specific diagnosis as
an alternative to MU S but actually
thinking of mus as being the diagnosis
and this is where having something
senior to have that conversation can be
helpful some of these young people will
end up getting admitted and the three
cases I've talked about all ended up
being admitted for different reasons
what's really important is as soon as
suspicion of mus for an inpatient then
you need an earlier senior review
preferably elite consultants and they
need to grow few things they need to
come up with a list of appropriate and
proportionate list of differentials
investigations and specialty referrals
and there is a fine balance to be struck
between not under investigating because
we don't want to miss something but also
not over investigating so a sensible
discussion that bit eginning about which
tests are appropriate and then if
they're all normal that actually we
don't need to do any more tests it's
really important that there is a lead
clinician who will oversee case
management and communication with
children young people in their families
because these cases by their definition
are difficult to explain what's
happening and if different people tell
the family different things that just
exacerbates the problem and you want to
link to your local cams or pediatric
liaison team and then probably led by
the senior you want a no discussion and
the first thing to actually explore what
they think is going on do they have any
theories about the symptoms that they
have any belief systems around a health
or ill health and - they have people in
the family who have experienced
something similar but different it's not
uncommon to discover for example in a
relatively early stage and some of these
medically unexplained symptoms that a
beloved relative has recently had a
significant diagnosis of a similar organ
system and it's really important to
introduce the concept of mus or P P at
an early stage if you think it's part of
the differential don't surprise families
with it at the end of a period of
investigation
introduce the concept of the mind-body link and set out a plan
with the children and young people about
what tests you're gonna do and actually
it's good to be clear at the outset that
you are doing these tests in the
expectation that the tests will be
normal what families don't like is where
the Toolman will do this tests and then
we tell all that's normal okay well
we're doing other tests oh that's normal
and all we're reinforcing is we don't
know what's going on actually it is a
positive thing we think this is mus we
are ruling out the other things and once
we've ruled them out we don't need to do
any more tests and early joint working
with cows and PLT is really helpful and
even if the family haven't yet bought
into the diagnosis of mu s and P P then
talking some about the importance of
managing the uncertainty in the symptoms
is an important part of engagement with
cans or PLT outpatients well it's all a
bit more relaxed it's the same as
inpatient care but there's less urgency
to manage it in a single consultation
it's still however important to induce
the possible of a diagnosis at the
beginning not at the end and where the
facilities exist then the best way of
managing these is joint clinical
consultations with somebody from PLT or
Cam's in the room with you and the
patient and joining together to manage
the patient and it just highlights the
joint nature of this condition the
investigation there's a question there
do you find that cans appear too happy
too involved so yes I find they are
often happens well my experience of
working with them is absolutely if I go
to them as a clinician I say I think
there's a really high likelihood this is
mus we're gonna do this test and this
test and if they're normal it's really
looking like mus then they will
definitely want to get involved they'd
rather not sooner rather than later so
that needs us onto cams and PLT so
they'd like to be involved early but
even before the presence of your mental
health colleagues you as pediatricians
can still explore some things with the
family and the Chan young person it's
really important to get a good
chronology of the child's symptoms and
to compare that with what was going on
when the child's life at the same time
and one of the phrases that I learned
from working with PLT colleagues was to
consider the entrances and the exits
into a young person's life who's come
who's left who they left at they moved school have
a loss to close friends as a grandparent
died as a parent spit-up has a new step
parent arrived as a new step sibling
arrived these are all big events in
children young people's lives and it's
really important to have them documented
my chronology alongside the symptoms
because that's what allows you to start
making links as to what might be
potentially leading as mus
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