This chapter explores the difficulties of diagnosis and management of patients with unexplained symptoms and what has been referred to as psychosomatic illness. The scenario draws attention to the working relationship of a practice nurse and a GP, as well as the value of experience in consultations of this type.

The personal trainer

Andrew Norton is a 29 year old personal trainer (as recorded in his notes). An extremely fit looking young man thinks Dr Paula Chang as Andrew enters the room. Dr Chang is however surprised to see that this is Andrew's sixth consultation in the last few weeks. In his first consultation he complained of strange feelings in his arms, then intermittent headaches, followed by aching hands and feet, and two episodes of chest pain, lasting about 5 minutes. He has seen two of the other GPs in the practice about these symptoms. Both had elicited fairly full histories and carried out focused physical examinations. Andrew had then had some blood tests (all normal). The notes from his last visit state that he was concerned about having a serious physical illness. Dr Smith has written: ‘Pattern of symptoms not conclusive. Possibly excessive exercising. Denies steroid use. Medical certificate for one week; advised to rest and then review’. For some reason Andrew has not chosen to see Dr Smith again. Dr Chang wonders if this is because Andrew is not happy with the way he has been dealt with. She wonders if Andrew has now chosen to see the female doctor who has a reputation in the community of being more empathic.