Vague Presentations

John Lord

In Pairs

• Discuss and write down the types of vague illness or vague presentations that confuse you or irritate or annoy you.

Vague illness - my vague thoughts

• Non-illness• Self-limiting illness• Early illness• Psycho-social problems• Poor history / information• Unclassifiable - just remains vague

Vague illness - my vague thoughts

• Non-illness• Self-limiting illness• Early illness• Psycho-social problems• Poor history / information• Unclassifiable - just remains vague• National guidance• Variation• Multiple pathology & polypharmacy

Text

Non-illness

• We all get transient symptoms for reasons we cannot fathom.

Self limiting illness

• Of those who elect to contact a GP or NP 70% will cease to have a problem in 2 weeks if no action is taken.

Early Illness

Might become serious

•Quickly - meningitis•Slowly - brain tumour

Psycho-social problems

• Relationships• Children• Money• Aging Parents• Physical threats• Work stress

Poor history

• Via an interpreter• Sensory problems - deaf, blind• Brain damage - learning difficulty,

dementia / age• Culturally undemanding conversations

• zzs

Illness that remains ill-defined

From Jones & Menzies 1999 General Practice essential facts

Common vague syndromes

Common vague syndromes

• Alcohol abuse • TATT• Dizzy• Transient confusion on waking ?TIA• Pain in several joints• All over pain

Common vague syndromes 2

• Menopause• Osteoporosis • Embarassament - sexual problems• 2 or more causes - Physical + Mental

Aggravating Factors

• National guidance• Variation• Multiple pathology• Polypharmacy

National Guidance

• Does it help in vague illness?• How much of it applies to your patient?• Do they know any better than you?

National Guidance

Selection bias

National Guidance

Error & Bias - Publication

Extrapolation

Extrapolation

Co-proxamol

Co-codamol

Co-codamol

Co-proxamol

National Guidance5.3.2-Clinical effectiveness of low fat diets for the primary prevention of CVDNo randomised controlled trials were identified in people at high risk of CVD that examined the effectiveness of low fat diet versus no change in diet for the outcomes of all cause mortality, cardiovascular mortality or cardiovascular morbidity.One randomised controlled trial in patients with angina found that advice to eat oily fish or take omega 3 fatty acid supplements was not associated with a reduction all cause mortality or cardiac death

National Guidance

We could not find any evidence that low fat diets make any difference in primary prevention

National Guidance

5.3.4-Clinical effectiveness of low fat diets for the secondary prevention of CVD

One randomised controlled trial was identified in patients with a history of CVD that compared advice to adopt a low fat diet with no dietary advice (Watts, G. F. et al , 1992).

Lipid–lowering diet did not confer any benefit over usual care for the outcomes of cardiovascular death, MI, coronary surgery, angioplasty or stroke

National Guidance

We could not find any evidence that low fat diets make any difference in primary prevention

or for that matter in secondary prevention

National Guidance

it was decided by the GDG that recommendations made in the Joint British Societies' guidelines on prevention of CVD in clinical practice (Wood, D. et al , 2005) would be adopted

(total fat intake should be ≤ 30% of total energy intake and saturated fats should comprise ≤ 10% of total energy intake).

National Guidance

We could not find any evidence that low fat diets make any difference in primary prevention

or for that matter in secondary prevention

in fact with no evidence at all we are going to perpetuate the myth from previous guidelines (who’s writers also could not find any evidence)

National Guidance

5.3.6-Clinical effectiveness of increased fruit and vegetables diet for the primary prevention of CVD

No randomised controlled trials were identified that compared increased fruit and vegetables diet with usual diet in people at high risk of CVD.

National Guidance

Only one randomised controlled trial found on the effectiveness of an increased fruit and vegetables diet in patients with angina (Burr, M. et al , 2003).

Advice to increase consumption of fruit and vegetables was found to be poorly complied with and the advice did not confer any benefit on mortality (all deaths, cardiac deaths and sudden deaths).

National Guidance

It does not help to tell people to eat more fruit / veg

National Guidance

The GDG decided to recommend five portions of fruit and vegetables per day in line with advice given to the general population.

National Guidance

It does not help to tell people to eat more fruit / veg

but tell them that anyway

National Guidance

• Does it help in vague illness?• How much of it applies to your patient?• Do they know any better than you?

National Guidance

Other Strategies

• Masterful inactivity• Safety-net - 4 way - expect, routine

review, come back sooner if, phone that day if...

• Ask - what are worried it might be?• Ask - what do you think it might be?• Discuss - share the dilemma• Investigate

Strategies - 2

• Trial of Rx• Make friends• Ask about something else• BATHE - Stuart & Lieberman• Refer - pass the buck - medicalise.

Thank you

John Lord

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