Vague Presentations

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• Vague Presentations
• John Lord

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In Pairs

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

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Vague illness - my vague thoughts

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

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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

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Non-illness

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

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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.

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Early Illness

• Might become serious
• Quickly - meningitis
• Slowly - brain tumour

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Psycho-social problems

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

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Poor history

• Via an interpreter
• Sensory problems - deaf, blind
• Brain damage - learning difficulty, dementia /
  age
• Culturally undemanding conversations
• zzs

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Illness that remains ill-defined
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From Jones Menzies 1999 General Practice
essential facts
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Common vague syndromes
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Common vague syndromes

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

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Common vague syndromes 2

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

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Aggravating Factors

• National guidance
• Variation
• Multiple pathology
• Polypharmacy

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National Guidance

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

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National Guidance
Selection bias
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National Guidance
Error Bias - Publication
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Extrapolation
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Extrapolation
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National Guidance
5.3.2-Clinical effectiveness of low fat diets for
the primary prevention of CVD No 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
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National Guidance
We could not find any evidence that low fat diets
make any difference in primary prevention
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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). Lipidlowering diet did not
confer any benefit over usual care for the
outcomes of cardiovascular death, MI, coronary
surgery, angioplasty or stroke
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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
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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).
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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 (whos writers also
could not find any evidence)
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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.
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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).
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National Guidance
It does not help to tell people to eat more fruit
/ veg
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National Guidance
The GDG decided to recommend five portions of
fruit and vegetables per day in line with advice
given to the general population.
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National Guidance
It does not help to tell people to eat more fruit
/ veg but tell them that anyway
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National Guidance

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

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National Guidance
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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

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Strategies - 2

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

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• Thank you
• John Lord

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