Many symptoms in outpatient practice are poorly understood. To determine the incidence,
diagnostic findings, and outcome of 14 common symptoms, we reviewed the records of
1,000 patients followed by house staff in an internal medicine clinic over a three-year
period. The following data were abstracted for each symptom: patient characteristics,
symptom duration, evaluation, suspected etiology of the symptom, treatment prescribed,
and outcome of the symptom. Cost estimates for diagnostic evaluation were calculated
by means of the schedule of prevailing rates for Texas employed by the Civilian Health
and Medical Program of the Uniformed Services for physician reimbursement.
A total of 567 new complaints of chest pain, fatigue, dizziness, headache, edema,
back pain, dyspnea, insomnia, abdominal pain, numbness, impotence, weight loss, cough,
and constipation were noted, with 38 percent of the patients reporting at least one
symptom. Although diagnostic testing was performed in more than two thirds of the
cases, an organic etiology was demonstrated in only 16 percent. The cost of discovering
an organic diagnosis was high, particularly for certain symptoms, such as headache
($7,778) and back pain ($7,263). Treatment was provided for only 55 percent of the
symptoms and was often ineffective. Where outcome was documented, 164 (53 percent)
of 307 symptoms improved. Three favorable prognostic factors were an organic etiology
(p = 0.006), a symptom duration of less than four months (p = 0.009), and a history
of two or fewer symptoms (p = 0.001).
The classification, evaluation, and management of common symptoms need to be refined.
Diagnostic strategies emphasizing organic causes may be inadequate.