Box 5.

Possible response to the potential referral letter to the rheumatology clinic in Box 1; Dr D

Dear Doctor,
re Patient A
I reviewed Patient A in our multidisciplinary clinic from a liaison psychiatry perspective. As Dr C suggests, there is a complex interplay between her physical symptoms which are likely unified by hypermobility. She reports, as is often found in similar presentations, a degree of anxiety with panic symptoms and some issues relating to her change in circumstances and impact of physical symptoms on mental health.
She is going to engage with our physiotherapist to improve strength and stability with the hope of reducing pain and fatigue. Given her psychological symptoms and the symptoms suggestive of orthostatic intolerance (again very common in hypermobile presentations), I would suggest a trial of a low-dose beta blocker (providing no contraindications) to manage both anxiety and dysautonomic symptoms.
She will likely benefit from a biopsychosocial approach, so I am referring her to our health psychologist and also signposting Patient A for vocational support and advice regarding reasonable adjustments and additional support to help her remain in work.
Yours etc