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A Practical and Evidence-Based Approach to Common Symptoms: A Narrative ReviewA Practical and Evidence-Based Approach to Common Symptoms

Kurt Kroenke, MD
[+] Article, Author, and Disclosure Information

From Veterans Affairs Health Services Research & Development Center for Health Information and Communication, Indiana University, and Regenstrief Institute, Indianapolis, Indiana.

Disclosures: Author has disclosed no conflicts of interest. Form can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-0461.

Grant Support: None.

Requests for Single Reprints: Kurt Kroenke, MD, Regenstrief Institute, 1050 Wishard Boulevard, 5th Floor, Indianapolis, IN 46202; e-mail, kkroenke@regenstrief.org.

Author Contributions: Conception and design: K. Kroenke.

Analysis and interpretation of the data: K. Kroenke.

Drafting of the article: K. Kroenke.

Critical revision of the article for important intellectual content: K. Kroenke.

Final approval of the article: K. Kroenke.

Collection and assembly of data: K. Kroenke.

Ann Intern Med. 2014;161(8):579-586. doi:10.7326/M14-0461
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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.





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A practical approach to common symptoms: differences between primary care and emergency medicine
Posted on June 15, 2015
Alexandra Malinovska, Roland Bingisser, Christian H. Nickel
Department of Emergency Medicine, University Hospital Basel, Switzerland
Conflict of Interest: None Declared
Recently, Kurt Kroenke authored an interesting narrative review, presenting a general approach to manage common symptoms (1). The literature cited in the review ‘includes articles familiar to the author, complemented by relevant papers identified by a bibliographic search of those articles’. Using such an approach, relevant studies may be omitted, as the author focuses on a specific medical environment, namely primary care. We would like to extend the discussion to patients presenting to emergency departments (EDs). This population has a higher pre-test probability of serious illness and is increasing across many different health care systems.

The author categorizes physical symptoms into three groups: ‘Pain’, ‘respiratory’, and ‘nonpain and nonrespiratory’ (NP+NR). Examples for ‘NP+NR’ are ‘fatigue’ or ’diarrhoea’. In ED settings, ‘fatigue’ should be assigned as a nonspecific complaint (NSC) with a wide array of differential diagnoses (2), while ‘diarrhoea’ should be classified as a specific complaint (SC) due to its limited differential diagnostic spectrum. Thus, the proposed ‘NP+NR’ group encompasses both NSCs and SCs.

As patients with NSCs represent up to 20% of ED patients and NSCs and SCs show fundamental differences, there are three main issues to consider: First, the used classification with three groups of physical symptoms is not easily applicable to all settings: When applying this classification to a Swedish cohort of about 13000 ED patients (3), the amount of ‘NP+NR’ symptoms reaches up to 50%. Even if the classification is applied using all presenting complaints, the amount of ‘NP+NR’ symptoms is about 45% (own, unpublished data, 6282 ED patients). This demonstrates that ‘NP+NR’ encompasses too many symptoms in one single group. Second, the author describes that initially not expected serious diseases seldom lead to serious outcome. This may be accurate in primary care and for SCs but not for ED patients with NSCs. These are at risk for delayed diagnoses, acute morbidity (60%) 30-day mortality (6%) (4). Third, the assumption that history contributes to the final diagnosis in up to 75% of cases (1) might be true for SCs. However, establishing a working diagnosis in patients with NSCs solely by history taking is less successful. Diagnostic accuracy in NSC relying on history exceeds chance performance, but varies largely across the different presentations (5).

In conclusion, we believe that any practical approach to common symptoms should address NSCs separately. Unfortunately, ‘NP+NR’ contains both SCs and NSCs and is a rather impractical approach in the emergency physician’s perspective.

1. Kroenke K. A Practical and Evidence-Based Approach to Common Symptoms: A Narrative Review. Annals of internal medicine. 2014;161(8):579-86.
2. Karakoumis J, Nickel CH, Kirsch M, Rohacek M, Geigy N, Müller B, et al. Emergency presentations with nonspecific complaints – the burden of morbidity and the spectrum of underlying disease.
3. Safwenberg U, Terént A, Lind L. The Emergency Department presenting complaint as predictor of in-hospital fatality. European journal of emergency medicine. 2007;14(6):324-31.
4. Nemec M, Koller MT, Nickel CH, Maile S, Winterhalder C, Karrer C, et al. Patients Presenting to the Emergency Department With Non‐specific Complaints: The Basel Non‐specific Complaints (BANC) Study. Academic Emergency Medicine. 2010;17(3):284-92.
5. Hertwig R, Meier N, Nickel C, Zimmermann P-C, Ackermann S, Woike JK, et al. Correlates of diagnostic accuracy in patients with nonspecific complaints. Medical Decision Making. 2013;33(4):533-43.

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