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

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

Co-proxamol

Co-codamol

Co-proxamol

National Guidance 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

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

National Guidance 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 (whos writers also could not find any evidence)

National Guidance 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

64