Multiple Complaints Research Articles

Sphincter of Oddi dysfunction in the post-cholecystectomy period

The persistent post-cholecystectomy (CE) symptoms can be divided into four groups: 1) surgical errors; 2) recurrence of cholelithiasis; 3) functional disorders due to removal of the gallbladder (transient or persistent); 4) pathology not associated with CE. Biliary pain persists in 20–40% of patients after CE, in most cases caused by sphincter of Oddi dysfunction (SOD). SOD is subdivided into biliary, pancreatic, two-duct types, as well as pancreatobiliary reflux. The SOD is rooted in the increased pressure in the sphincter, which leads to the increased intraductal pressure and, as a result, to the occurrence of biliary or pancreatic pain. In addition, the direct contractile effects of cholecystokinin on smooth muscles of the biliary tract change due to mechanical disturbance of innervation. Hypertension of the pancreatic part of the sphincter of Oddi can cause not only the occurrence of functional pain of the pancreatic type, but also the development of recurrent pancreatitis. SOD is characterized by typical anamnestic data that are common to the functional pathology of the digestive system, such as duration of symptoms, absence of organic pathology, multiple complaints, a non-progressive course, the provoking role of psychoemotional factors. From a practical standpoint, the clinical criteria for SOD can be: 1) an attack of biliary or pancreatic pain; 2) a transient increase in the activity of hepatic or pancreatic enzymes; 3) transient expansion of the common bile or major pancreatic duct. If it is difficult to differentiate diagnosis, endoscopic ultrasonography is advisable. Antispasmodics and ursodeoxycholic acid form the basis of the treatment, especially when biliary sludge and microlithiasis are detected. There must be strong arguments for the surgical treatment.

Ulcerative Lesions of the Mucosa Gastro-Duodenal Zone in Victims of the Chernobyl Accident: Some Features of the Etiology, Pathogenesis and Clinical Signs Identified in the Third of the Century After the Disaster

Ulcerative Lesions of the Mucosa Gastro-Duodenal Zone in Victims of the Chernobyl Accident: Some Features of the Etiology, Pathogenesis and Clinical Signs Identified in the Third of the Century After the Disaster

Turning Toward Monitoring of Gaze Stability Exercises: The Utility of Wearable Sensors.

Few tools are currently available to quantify gaze stability retraining exercises. This project examined the utility of a head-worn inertial measurement unit (IMU) to quantify head movement frequency, velocity, and amplitude during gaze stability exercises. Twenty-eight individuals with multiple sclerosis and complaints of dizziness or a history of falls were randomly assigned to either a strength and aerobic exercise (SAE) or gaze and postural stability (GPS) group. During a 6-week intervention, participants wore a head-mounted IMU 3 times (early, middle, and late). For aim 1, the frequency, mean peak velocity, and mean peak amplitude of head turns during equivalent duration components of group-specific exercises were compared using general linear models. For aim 2, the progression of treatment in the GPS group was examined using general linear regression models for each outcome. Aim 1 revealed the GPS group demonstrated significantly greater velocity and amplitude head turns during treatment than the SAE group. The frequency of head turns did not significantly differ between the 2 groups. The aim 2 analyses demonstrated that the yaw and pitch frequency of head turns significantly increased during gaze stability exercises over the 6-week intervention. Velocity and amplitude of head turns during yaw and pitch gaze stability exercises did not significantly change. A head-worn IMU during rehabilitation distinguished between groups. Furthermore, within the GPS group, the IMU quantified the progression of the frequency of head movements during gaze stability exercises over time.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A320).

Site Visits Reveal Common Gaps in Instrument Reprocessing and Sterilization at Philadelphia Dental Clinics

Background: Most dental clinics lack resources and oversight related to infection prevention and control (IPC) practices. Few dental clinics undergo inspections by regulatory authorities unless the state licensing authorities receive a specific complaint. Many states, including Pennsylvania, do not have continuing IPC education requirements for dental providers. In 2018–2019, the Philadelphia Department of Public Health (PDPH) received and responded to multiple complaints and concerns related to IPC practices at dental clinics. Complaints were investigated in collaboration with the Pennsylvania Department of State (PADOS). Methods: Unannounced site visits were conducted at 7 Philadelphia dental clinics from December 2018 through September 2019 as part of the public health responses. Clinic evaluations and observations by PDPH certified infection preventionists focused on (1) IPC policies and procedures, (2) staff IPC training, (3) hand hygiene, (4) personal protective equipment, (5) instrument reprocessing and sterilization, (6) injection safety, and (7) environmental cleaning and disinfection. The CDC and the Organization of Safety, Antisepsis and Prevention (OSAP) checklists were adapted for this purpose. Results: Most dental practices we visited were small, unaffiliated, owner-operated clinics. The most common gaps we identified were associated with instrument reprocessing and sterilization practices, including inadequate separation between clean and dirty work areas, limited space and availability of sinks, inappropriate use of glutaraldehyde products for instrument cleaning (n = 3, 43%), extended reuse of cleaning brushes (n = 5, 71%), sterilization or storage of sterilized instruments without appropriate packaging (n = 2, 29%), lack of spore testing or reviewing results (n = 2, 29%), and lack of documentation of sterilizer run cycles and maintenance (n = 7, 100%). Additionally, most clinics did not have well-developed IPC policies and procedures, and staff IPC trainings were neither documented nor conducted annually. Alcohol-based hand sanitizer was often not available at the point of use. Conclusions: In Philadelphia, dental clinics often lacked IPC support and oversight. Lapses across multiple key IPC domains were common. These findings suggest that public health may have a role in providing IPC support to unaffiliated dental clinics. Licensing entities can also serve a role in improving IPC practices by more widely mandating continuing IPC education as part of the dental license renewal process.Funding: NoneDisclosures: None

More Gas Wells Linked to More Symptoms in Pennsylvania Residents

Natural gas production has been booming in southwestern Pennsylvania, but it may also yield multiple health complaints, especially for residents surrounded by oil and gas facilities.

Subjective health and well-being of children and adolescents in Germany - Cross-sectional results of the 2017/18 HBSC study.

Subjective health is understood as a multidimensional construct that encompasses the physical, mental and social dimensions of a person’s well-being. Promoting the subjective health and well-being of children and adolescents has strong public health relevance because health impairments in childhood and adolescence are often associated with long-term health problems in adulthood. Therefore, it is very important to gain information about potential risk and resource factors involved. This article presents current prevalences for subjective health, life satisfaction and psychosomatic health complaints among children and adolescents in Germany aged 11, 13 and 15 years from the 2017/18 Health Behaviour in School-Aged Children (HBSC) study (N=4,347, 53.0% girls). It also examines the sociodemographic and psychosocial factors that influence subjective well-being. Most children and adolescents provided positive ratings of their health and life satisfaction. Nevertheless, about one third of girls and one fifth of boys were affected by multiple psychosomatic health complaints. Impairments in subjective well-being were particularly evident in girls, older adolescents, young people with low levels of family affluence and those under a lot of pressure at school. In contrast, high family support was associated with better subjective well-being. These results illustrate the need for target group-specific prevention and health promotion measures aimed at improving the subjective health and well-being of children and adolescents.

Intermittent Weakness and Mediastinal Weakening

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Laparoscopic resection of pediatric gastric schwannoma/perineuroma

Abstract Schwannomas and Perineuromas are rare findings in the GI tract, especially in pediatric patients. They typically present in the fifth to sixth decade of life with a female predominance. In this case, we describe a 13-year-old female who presented with multiple GI complaints including weight loss and anemia. She was found to have an umbilicated mass in the lesser curvature of the stomach suspicious of a gastrointestinal stromal tumor (GIST). The mass was resected via a laparoscopic partial gastrectomy. The pathology report confirmed the diagnosis of a gastric hybrid schwannoma and perineuroma staining for EMA and S-100 protein.

Patterns of Health-Related Gender Inequalities—A Cluster Analysis of 45 Countries

PurposeThe paper explores gender inequalities between 45 countries across 10 health indicators among adolescents and whether those differences in health correlate with gender inequality in general. MethodsData from 71,942 students aged 15 years from 45 countries who participated in the 2018 Health Behaviour in School-aged Children survey were analyzed. For this purpose, 10 indicators were selected, representing a broad spectrum of health outcomes. The gender differences in the countries were first presented using odds ratios. Countries with similar risk profiles were grouped together using cluster analyses. For each of the 10 indicators, the correlation with the Gender Inequality Index was examined. ResultsThe cluster analysis reveals systematic gender inequalities, as the countries can be divided into seven distinct groups with similar gender inequality patterns. For eight of the 10 health indicators, there is a negative correlation with the Gender Inequality Index: the greater the gender equality in a country, the higher the odds that girls feel fat, have low support from families, have low life satisfaction, have multiple health complaints, smoke, drink alcohol, feel school pressure, and are overweight compared with boys. Four indicators show a divergence: the higher the gender equality in a country in general, the larger the differences between boys and girls regarding life satisfaction, school pressure, multiple health complaints, and feeling fat. ConclusionsCountries that are geographically and historically linked are similar in terms of the health risks for boys and girls. The results challenge the assumption that greater gender equality is always associated with greater health equality.

P085: Remember that patient you saw last week – Characteristics of patients experiencing unanticipated death following emergency department discharge

Background: The emergency department (ED) is an at-risk area for medical error. We measured the frequency and characteristics of patients with unanticipated death within 7 days of ED discharge and whether medical error contributed. Aim Statement: This study aimed to calculate the frequency of patients experiencing death within 7 days after ED discharge and determine whether these deaths were related to their index ED visit, were unanticipated, and whether possible medical error occurred. Measures & Design: We performed a single-centre health records review of 200 consecutive cases from an eligible 458,634 ED visits from 2014-2017 in two urban, academic, tertiary care EDs. We included patients evaluated by an emergency physician who were discharged and died within 7 days. Three trained and blinded reviewers determined if deaths were related to the index visit, anticipated or unanticipated, or due to potential medical error. Reviewers performed content analysis to identify themes. Evaluation/Results: Of the 200 cases, 129 had sufficient information for analysis, translating to 44 deaths per 100,000 ED discharges. We found 13 cases per 100,000 ED discharges were related and unanticipated deaths and 18 of these were due to potential medical errors. Over half (52.7%) of 129 patients displayed abnormal vital signs at discharge. Patients experienced pneumonia (27.1%) as their most common cause of death. Patient characteristic themes were: difficult historian, multiple complaints, multiple comorbidities, acute progression of chronic disease, recurrent falls. Provider themes were: failure to consider infectious etiology, failure to admit high-risk elderly patient, missed diagnosis. System themes included multiple ED visits or recent admission, no repeat vital signs recorded. Discussion/Impact: Though the frequency of related and unanticipated deaths and those due to medical error was low, these results highlight opportunities to potentially enhance ED discharge decisions. These data add to the growing body of ED diagnostic error literature and emphasize the importance of identifying potentially high risk patients as well as being cognizant of the common medical errors leading to patient harm.

Vulnerability to legal misconduct: a profile of problem lawyers in Victoria, Australia

ABSTRACT Public trust in the legal profession rests on regulators taking timely and effective action in response to misconduct. Usually, case-by-case analysis occurs after a claim or complaint is lodged with little attention on factors that may predispose a lawyer to misconduct. Vulnerability is a useful concept for understanding individuals’ susceptibility to harm and for identifying safeguards to protect against that harm. This empirical study adds to the largely normative research on vulnerability with an analysis of 67 “problem lawyers” who were the subject of multiple complaints and at least one disciplinary hearing, a paid financial misconduct claim, or striking from the roll in Victoria, Australia between 2005 and 2015. We analysed determinations about these lawyers and identified a concatenation of factors associated with legal misconduct. Personal vulnerabilities included older age, male sex, poor health, and patterns of behaviour such as low conscientiousness. Situational vulnerabilities included working as a sole principal or in a small practice, excessive workload, and pressures from relationship breakdowns, death or illness in the family, or financial difficulties. These findings shed light on vulnerabilities to legal misconduct, and have implications for lawyer education and well-being, protection of clients, and efforts to reduce lapses in professionalism.

P43 POEMS neuropathy in the rheumatology clinic

Abstract Background POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, skin changes) is a rare, disabling, auto-inflammatory condition that may present to multiple specialties including rheumatology. We describe a case fulfilling all diagnostic criteria. Methods Please refer to the results section. Results A 52 year old lady of Venezuelan origin was referred to the rheumatology clinic with myalgia and arthralgia. She had a recent diagnosis of hypothyroidism. Her main concern was of skin hyperpigmentation, hypertrichosis and a reticular rash. She had been diagnosed with undifferentiated connective tissue disease (CTD) in Panama and had received a good symptomatic response to IM depomedrone. Initial examination findings revealed generalised skin pigmentation, hyperaemia and limited weakness of both shoulders. There were no other features of CTD. Initial bloods revealed normal FBC, UE, LFTS, CRP 18mg/l and ESR 37mm/hr. Serum electrophoresis, immunoglobulins, CK, cortisol, calcium, TSH, ANCA and urinalysis were normal. ANA was normal but had previously been positive in Panama. MRI of spine showed multiple abnormalities consistent with bony metastases. CT of chest, abdomen and pelvis (CAP) confirmed changes consistent with widespread sclerotic bony metastases with bilateral axillary lymphadenopathy, splenomegaly and diffuse bladder wall thickening. Lymph node biopsy confirmed Castleman-like changes, but this was not pathognomonic. Thyroid biopsy showed reactive changes. A bone biopsy of a sacral lesion revealed haemangioma. A PET scan highlighted sclerotic lesions and splenomegaly only. Mammogram and cystoscopy were normal. She then presented via ophthalmology to the acute medical unit at a different hospital with visual disturbance and confirmed papilloedema. CT head was normal. Lumbar puncture confirmed high CSF pressure and high protein levels of 1.75g/l. MRI of brain with enhancement showed leptomeningeal enhancement felt to be post-lumbar puncture change. Repeat CT CAP showed mild ascites and splenomegaly. Extensive infectious disease tests were all negative including HIV and TB Quantiferon. A review of medical literature and input from radiologists raised the diagnosis of POEMS. Immunofixation was requested and this confirmed a low level IGA lamba monoclonal band. Vascular endothelial growth factor was significantly elevated at 4800. Bone marrow biopsy confirmed low level lambda restricted plasma cell infiltration consistent with POEMS. She is now being treated with Lenalidomide and dexamethasone under the care of haematology and is likely to require an autologous stem cell transplant in the future. Conclusion The challenge of diagnosing POEMS is well recognised. Few patients meet the full criteria for diagnosis. The heterogeneity of its clinical presentation means that patients may present to several specialities with multiple complaints. The combination of musculoskeletal symptoms, skin changes and inflammatory neuropathy may give rise to a rheumatology opinion and therefore it is important rheumatologists have awareness of the condition. We recommend that POEMS should be considered in patients presenting with an inflammatory neuropathy. Disclosures L. Waters None. R. Benson None. M. Mahindrakar None. R. Moots None. R. Abernethy None.

Medication-related osteonecrosis of the jaws and quality of life: review and structured analysis.

Medication-related osteonecrosis of the jaws (MRONJ) is a rare complication of bisphosphonates, or antiresorptive or antiangiogenic medication. Treatment is difficult as the bone has a poor capacity for healing, and further progression after surgery can occur. Quality of life (QoL) in patients with MRONJ has not been well documented. The aim of this study therefore was to identify and analyse data on QoL in this group of patients. Eight studies that were identified through a systematic search of the literature were qualitatively analysed. Overall, data on QoL are lacking and are complicated by concurrent disease such as cancer. Patients generally have a poor QoL because of MRONJ, and multiple oral-specific complaints including pain and problems with speech. Development of a questionnaire specific to patients with MRONJ would help improve the specificity of the data collected. Prospective questionnaires before and after intervention, including information on stage and comorbidities, would guide future treatment strategies.

Epidemiology and outcome of emergency medical service witnessed out-of-hospital-cardiac arrest by prodromal symptom: Nationwide observational study

BackgroundAlthough emergency medical service– (EMS-) witnessed out-of-hospital-cardiac arrest (OHCA) has a high survival rate and potential for prevention of progression to cardiac arrest, its characteristics and prodromal symptoms are not well known. The purpose of this study was to investigate the epidemiologic characteristics and outcome of EMS-witnessed OHCA by focusing on its prodromal symptoms. MethodsPopulation-based observational study was conducted for resuscitation-attempted EMS-witnessed adult OHCAs between 2012 and 2017. The prodromal symptoms were categorized according to the patients’ chief complaints, which were checked in the EMS run sheets: no prodromal, respiratory, cardiac, neurologic, gastrointestinal (GI), or other symptom. If multiple complaints were checked, the patient was assigned to multiple groups. The OHCA characteristics and time from EMS scene arrival to cardiac arrest were investigated by symptom groups and presumed etiology of OHCA. The age- and sex-standardized survival rate and good neurological outcome rate were calculated for each symptom group. ResultsOf 12,969 eligible OHCAs, 5246 (40.5%) had prodromal symptoms, 1410 (10.9%) had respiratory symptoms, 505 (3.9%) had cardiac symptoms, 1987 (15.3%) had neurologic symptoms, and 541 (4.2%) had GI symptoms. Of 9361 patients with cardiac etiology, 3522 (37.6%) had prodromal symptoms, and patients with cardiac symptoms had the best rate of survival to discharge and good neurological outcome (42.7% and 38.2%, respectively). Of 3424 patients with non-cardiac etiology, 1651 (48.2%) had prodromal symptoms, and patients with respiratory symptoms had the best survival outcomes (19.0%). The age- and sex-standardized rates of good neurological outcome were better in patients with prodromal symptoms than in patients with cardiac etiology and no prodromal symptoms (cardiac, 30.4%; neurologic, 9.8%; respiratory, 8.9%; GI 7.3%; and no prodromal symptoms, 6.8%). EMS-witnessed OHCA occurred earlier in patients with no prodromal symptoms (5–9 min from EMS arrival) than in those with prodromal symptoms (10–14 min). ConclusionAbout 40% of EMS-witnessed OHCA patients had prodromal symptom before cardiac arrest. In cardiac etiology, patients with cardiac symptoms had the best rate of survival to discharge and good neurological outcome. Promoting public awareness of prodromal symptoms is needed to earn time for preparedness and prevention of progression to cardiac arrest.

Long-Term Follow-up of Functional and Radiographic Outcome After Revision Surgery for Fibula Malunion.

Background. Ankle fractures are some of the most common injuries seen in the emergency department. Malunited ankle fractures are uncommon. Patients with malunion frequently present with multiple complaints. Radiographs often show abnormalities in anatomical alignment. Aim. To evaluate the anatomical alignment on radiographic imaging in patients with malunited ankle fractures. Secondary aims were to evaluate patient satisfaction after reconstruction and to investigate the relationships between radiological alignment and functional outcome. Methods. All consecutive patients (n = 25) treated for a fibula malunion between January 1, 2002, and September 1, 2017, were included. The primary outcome was anatomical alignment of the ankle mortise. The talocrural angle (TCA), talar tilt (TT), and medial clear space (MCS) were used to investigate to what extent revision surgery had improved alignment. The patient-related outcome measure consisted of the Olerud and Molander Ankle Score (OMAS). To assess quality of life (QoL) the EQ-5D-5L was used. Results. The median TCA was 78.4° before revision and 79.25° after revision; P = .297. The median TT was 2.95° before revision and 0.70° after; P < .001. The MCS before revision was 5.2 mm and 3.17 mm after; P < .000). The OMAS had a median of 67.5 points. Analysis of the QoL questionnaires yielded a score of 0.84 points. Conclusion. Anatomical alignment improves significantly after revision surgery of malunited ankles. Measurements of the TCA appeared less useful in determining the anatomical alignment. In our series, 60% of patients reported good to excellent results. The QoL scores of our patient were comparable to those in the healthy population in the Netherlands.Levels of Evidence: Level IV: Case series

Toxicological analysis of acetone in a forensic case for the diagnosis of fulminant type 1 diabetes mellitus

Background: A male in his thirties was found dead in his apartment. On the day before he found dead, he had multiple vague physical complaints, including abdominal pain, vomiting, mouth dryness, and chillness. On autopsy, his liver showed extensive fatty changes, but changes in the other organs were unremarkable.&#x0D; Method: Toxicological analysis showed high concentrations of acetone in his blood (1651 μmol/l) and urine (1913 μmol/l), without any measurable amounts of ethanol.&#x0D; Result: Biochemical analysis indicated high levels of 3-hydroxybutyric acid and acetoacetic acid in the plasma, low levels of plasma C-peptide, and normal levels of hemoglobin A1c. Tests for islet-related antibodies in the plasma yielded negative results. Immunohistological examination indicated selective destruction of the pancreatic islet β cells. Based on these findings, we concluded that the cause of death was fulminant type 1 diabetes mellitus associated with diabetic ketoacidosis.&#x0D; Conclusion: Thus, the toxicological analysis of acetone in the blood and urine is important for the diagnosis of death from fulminant type 1 diabetes mellitus.&#x0D; Bangladesh Journal of Medical Science Vol.19(3) 2020 p.414-419&#x0D;

Hot Off the Press: Troponin Testing and Coronary Syndrome in Geriatric Patients With Nonspecific Complaints: Are We Overtesting?

Elderly patients frequently present to the emergency department with nonspecific complaints and it falls to the emergency physicians to determine whether a workup for acute coronary syndrome is warranted. We discuss a study by Wang et al published in Academic Emergency Medicine, January 2020, looking at the value of troponin testing in elderly patients presenting to the emergency department with nonspecific complaints. We provide critical analysis of the article, and summarize the social media discussion and a podcast in which the authors discuss their work.

Use of Telemedicine in the Evaluation of Patients with Mast Cell Activation Syndrome

Eighteen months ago, our office began evaluating patients for Mast Cell Activation Syndrome (MCAS). Patients present with multiple complaints and co-morbidities, often requiring lengthy record reviews. To manage this volume of requests, our team developed an approach that leverages telemedicine for new and established patients. We thus found ourselves capable of determining whether our approach improved care and maintained satisfaction. We employ a three-pronged approach. First, we request records from providers, after which summaries are prepared and billed ahead of initial visits. We then schedule a telemedicine visit with patients to review records and determine subsequent treatment steps. The third step is a mandatory office visit that includes a detailed physical exam and review of ordered scans and laboratory. Subsequent treatment interactions occur via telemedicine or in-office, as dictated by patient preference and office availability. Referring providers sent records prior to initial interaction, usually a telemedicine visit. Telemedicine evaluations were elected primarily due to distance from the office (> 2 hrs. travel in state or out-of-state). Patient satisfaction was approximately 90% with this approach. Compliance with treatment was encouraging considering insurance coverage, concern for adverse drug effects or satisfaction with previous regimens. Reimbursements for pre-visit records review (99358, 99359), consultant level (99244, 99245), new level (99204, 99205) or established level (99214, 99215) with extended time (99354) were acceptable. Telemedicine for MCAS evaluation proved useful for initial and follow-up visits with satisfactory patient acceptance and outcomes. Our three-pronged approach for patients with complex disorders enhanced their evaluation and continuing care.

Clinical Manifestations of Adult Langerhans Cell Histiocytosis with Multisystem Involvement Successfully Treated Using Chemotherapy

Abstract Introduction: Langerhans cell histiocytosis (LCH), the most common histiocytic disorder, characterized by the abnormal over production of histiocytes that tend to infiltrate single or multiple organ systems leading to significant tissue damage. Here we report a case of an adult patient who was diagnosed with LCH presenting as multisystem involvement. Case presentation: We describe a 23-year-old man suffering from central diabetes insipidus, "hemorrhoids", progressive hearing loss and a surge in weight. Physical examination revealed lesion involvement of the skin and mucous membranes, including the perianal area, gingiva, and external auditory canal. He was diagnosed as LCH, who achieved remission following a chemotherapy regimen. Discussion: LCH is common in children, but it is not surprising to see it in adults. The clinical manifestations of LCH are highly variable and may involve multiple organs and systems. While, skin involvement is the most obvious symptom, and dermatologists should be familiar with it. Chemotherapy is the first-line treatment for multisystem or multifocal single system adult LCH. Conclusion: Characteristic features of LCH involving the perianal area was described in this case which helped the dermatologist to make quick judgments. We also emphasize that a global concept should be established confronting with a patient with multiple complaints.

Somatics Symptoms and Depression: A Review

Aims: The objective of this review has been to highlight the importance of non-specific and painful symptoms of depression since sometimes the person does not notice or is not able to talk about their emotional symptoms. This leads us to refine the search for symptoms that can mask depression and not be treated properly. This is important as it is predicted that by 2020 depression will be the leading cause of disability in the world.&#x0D; Method: We review some articles that relate depression to painful symptoms.&#x0D; Results: Patients with the major depressive disorder may present, as initial complaints, multiple somatic complaints, nonspecific and especially pain, which complicates their diagnosis and sometimes leads them to not receive treatment for depression, complicating its evolution and deteriorating the quality of life.&#x0D; Conclusion: Depression can have many forms of presentation, people can complain of multiple non-specific symptoms, which do not allow a diagnosis of medical disease so it will be necessary to look for affective symptoms, investigate factors that trigger their condition to achieve an adequate diagnosis, provide the indicated medication and allow them a better quality of life.