Common symptoms: When to test, treat
From the June ACP Observer, copyright © 2004 by the American College of Physicians.
By Janet Colwell
NEW ORLEANS—Common symptoms and complaints may be the bread and butter of daily practice, but they get relatively little attention when it comes to research and teaching. As a result, many common symptoms leave doctors with a dilemma: Should they wait, test or treat?
At an Annual Session presentation, Kurt Kroenke, MACP, gave some insights into the problem by examining the results of studies on common complaints. As professor of medicine at Indiana University and the Regenstrief Institute for Health Care, he has focused much of his own research on puzzling problems like fatigue and dizziness, as well as on depression and other mental disorders that crop up constantly in primary care.
Dr. Kroenke said that while physicians must ultimately make a judgment call on what to do about common symptoms and complaints, reviewing statistics can give them a basis in evidence for avoiding unnecessary testing and referrals.
A conservative approach
In one study in which Dr. Kroenke said he examined 500 patients with physical symptoms, 70% of all subjects improved two weeks after seeing a primary care physician. While symptoms persisted in about 25% of patents, follow-up studies showed that serious diseases not suspected during initial evaluations rarely emerged after one year.
'Additional testing is often quite negative, so we want to avoid repeating workups and referrals.'
—Kurt Kroenke, MACP
The lesson, said Dr. Kroenke, is that a full battery of testing is often not the solution to common complaints. "Additional testing is quite often negative, so we want to avoid repeating workups and referrals," he explained. "What we really want to do is get down to symptom management."
After years of studying common complaints, in fact, he said he has found that many common complaints and symptoms resolve themselves. He presented some basic take-home messages from his body of research to help internists judge when action is necessary:
Half of all outpatient visits are triggered by common symptoms, such as cough and other respiratory complaints, dizziness, fatigue, and a variety of pain symptoms.
Three-quarters of patients who present with these complaints report improvement in two weeks, no matter what their symptom.
At least one-third of all symptoms are medically unexplained, so testing will not reveal a precise diagnosis.
There is substantial overlap among syndromes, such as chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome and tension headaches.
The presence of persistent, unexplained or multiple (three or more) symptoms increases the risk for accompanying depression or anxiety.
Dizziness, one of the most common complaints in the outpatient setting, is often difficult to assess because of the wide range of possible causes, from mild to severe. Research, however, has shown that vertigo is the most common diagnosis, affecting about half of patients who complain of dizziness. Another 20% of cases of dizziness, Dr. Kroenke said, are related to common psychological conditions, including depression, anxiety or somatization.
The pressing question for internists, however, is whether a complaint of dizziness is a manifestation of a serious, underlying cause.
"Physicians often ask themselves whether they should order neurological or cardiac tests" when presented with the complaint, Dr. Kroenke said. "But the evidence says 'no' for the vast majority of cases." In the absence of other neurological or cardiac problem signs, he said, testing is warranted only in a minority of dizzy patients.
With dizziness, it is useful to question the patient about the specific sensation to determine the source of the symptom. Those sensations generally fall into three categories: spinning (vertigo), fainting (presyncope) and falling (disequilibrium).
The specific type of dizziness indicates whether it is rooted in the vestibular, cardiovascular or locomotor regions, or whether it is psychiatric in origin. (The latter symptom is typically a more vague sensation such as "lightheadedness.") The peripheral forms of dizziness—those not rooted in serious neurologic or cardiac problems—fall into three categories:
Labyrinthitis is an acute, constant dizziness typically resolving in several days to a week.
Benign positional vertigo is more subacute, triggered by positional changes and gradually resolving over weeks to several months.
Meniere's disease is a chronic, episodic condition with recurrent spells over years.
Referrals for dizziness are indicated in a minority of patients and include a referral to ENT for vestibular testing; neurology in the presence of other neurologic signs or symptoms; cardiology for syncope, aortic stenosis or arrhythmia; and psychiatry for psychotherapy of a complex disorder.
Persistent cough can be another perplexing complaint. In most cases, Dr. Kroenke said, the cause is postnasal drip, asthma or gastroesophageal reflux (GERD). Physicians should also consider possible effects from ACE inhibitors, which produce cough in 10% to 15% of patients receiving the medication; a recent respiratory infection; and smoking.
A patient with persistent cough—defined as two months or longer—should be examined for symptoms of rhinitis or sinusitis suggesting postnasal drip; wheezing or dyspnea suggesting asthma; or acid reflux or dyspepsia pointing to possible GERD.
In a patient with unexplained cough and none of these associated symptoms, a sequential empiric approach that is supported in part by algorithm studies would include: antihistamine-decongestants and possibly nasal corticosteroids for postnasal drip; bronchodilators and possibly inhaled corticosteroids for asthma; and H2-blockers or proton pump inhibitors for GERD.
When it comes to diagnostic testing, physicians may order a methacholine challenge test in selected cases and, if it is positive, initiate asthma treatment. If the methacholine challenge test is normal or asthma treatment fails, either empiric treatment for GERD or diagnostic testing (24-hour pH monitoring) should be considered. If the cough still persists, refer the patient to a pulmonary specialist.
A persistent cough is due to something serious in less than 5% of patients, said Dr. Kroenke. Symptoms indicating a more serious diagnosis include hemoptysis, fevers or night sweats, weight loss, or other systemic symptoms. Physicians may decide to refer smokers for imaging procedures sooner than other patients because they are at higher risk. The most common serious cause is lung cancer, although some patients may have a chronic infection, such as tuberculosis.
Pain accounts for 20% of office visits in primary care and costs the country $60 billion every year in lost work productivity, Dr. Kroenke said. The most common complaints are headache, back pain, chest pain, abdominal pain and musculoskeletal pain.
Analgesics account for 12% of all prescriptions and are the second most commonly prescribed class of medications, second only to cardiovascular drugs. Unfortunately, chronic pain is a common problem in primary care and often responds poorly to simple analgesics.
While opioids might be required in some patients, other options are desireable. Dr. Kroenke noted that in some cases, antidepressants are an effective adjunct in pain control.
Patients, however, sometimes resist these therapies because they think the physician is treating a psychiatric rather than a physical problem. In addition, antidepressants often give only partial relief, and their long-term effectiveness is not known. Nonpharmacological evidence-based treatments include cognitive-behavioral therapy, pain self-management programs and multidisciplinary pain clinics.
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