A Practical and Evidence-Based Approach to Common Symptoms

Abstract

Physical symptoms account for more than half of all outpatient visits, yet the predominant disease-focused model of care is inadequate for many of these symptom-prompted encounters. Moreover, the amount of clinician training dedicated to understanding, evaluating, and managing common symptoms is disproportionally small relative to their prevalence, impairment, and health care costs. This narrative review regarding physical symptoms addresses 4 common epidemiologic questions: cause, diagnosis, prognosis, and therapy. Important findings include the following: First, at least one third of common symptoms do not have a clear-cut, disease-based explanation (5 studies in primary care, 1 in specialty clinics, and 2 in the general population). Second, the history and physical examination alone contribute 73% to 94% of the diagnostic information, with costly testing and procedures contributing much less (5 studies of multiple types of symptoms and 4 of specific symptoms). Third, physical and psychological symptoms commonly co-occur, making a dualistic approach impractical. Fourth, because most patients have multiple symptoms rather than a single symptom, focusing on 1 symptom and ignoring the others is unwise. Fifth, symptoms improve in weeks to several months in most patients but become chronic or recur in 20% to 25%. Sixth, serious causes that are not apparent after initial evaluation seldom emerge during long-term follow-up. Seventh, certain pharmacologic and behavioral treatments are effective across multiple types of symptoms. Eighth, measuring treatment response with valid scales can be helpful. Finally, communication has therapeutic value, including providing an explanation and probable prognosis without "normalizing" the symptom.

Red flags presented in current low back pain guidelines: a review

“…Nevertheless, the majority of guidelines inferred that the presence of a red flag was absolute by recommending further diagnostic workup (e.g., advanced imaging). Given that up to 80 % of patients presenting to primary care may have at least one positive red flag [43], when combined with weak evidence in support of many red flags, this advice may cause harm to many patients through unnecessary imaging (increased radiation and health care costs), unnecessary alarming the patients (resulting in reduction of quality of life) and unnecessary treatment (including unnecessary surgery) [42,44].…”

The role of diagnosis in delirium

“…Speed and parsimony are less helpful when people present with multiple symptoms, multiple illnesses and multiple causal factors, all of which are the norm with older people rather than the exception (Kroenke, 2014). A recent study conducting a post-hoc analysis of errors made by resident physicians under experimental conditions suggested that one such potential mechanism might be the influence of "salient distracting features" (SDFs) (Mamede et al, 2014).…”

Reply

“…We read with interest the recent editorial by Dr. Wolfe (1), in which he summarized the status of the American College of Rheumatology (ACR) 2010 preliminary diagnostic criteria for fibromyalgia (2) and the 2011 modification of those criteria (3). He notes that the 2 components of the 2010 criteria, the Widespread Pain Index and the Symptom Severity Scale, can be summated, and that the resultant score that is obtained will fall within a defined range, allowing a "fibromyalgia symptom scale" to be constructed (3).…”

“…. an uncomfortable or distressing bodily sensation experienced by a person that is not observable by the clinician" (2). Distress "does not necessarily imply a psychological component (there can be distress solely in the form of bodily complaints like pain and dizziness)" (3), but neither does it exclude a psychological component; most dictionaries allow that distress can be physical or mental.…”