Diagnosis in General Practice

When no diagnostic label is applied

BMJ 2010; 340 doi: http://dx.doi.org/10.1136/bmj.c2683 (Published 25 May 2010)
Cite this as: BMJ 2010;340:c2683

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  1. Roger Jones, Wolfson professor of general practice1,
  2. Kevin Barraclough, general practitioner2,
  3. Christopher Dowrick, professor of primary medical care3
  1. 1King’s College London, London SE1 3QD
  2. 2Painswick GL6 6TY
  3. 3University of Liverpool
  1. Correspondence to: R Jones roger.jones{at}kcl.ac.uk

    Resisting the temptation to attach a diagnostic label to indeterminate symptoms can be in the patient’s interests

    Case scenario

    A 38 year old woman presented with “indigestion type” symptoms. She had a long history of frequent visits to her general practitioner (GP) and investigations for unexplained pelvic pain, dizziness, and headache. On this occasion she felt a “burning” sensation “in a band across my tummy” and felt as though the ground was unsteady when she walked. Her GP could reach no diagnosis and said he believed her symptoms were likely to resolve, advising follow-up in a few weeks.

    Diagnostic labels

    A “diagnostic label” in general practice is generally a working diagnosis that functions as a decision node. It is different from the histologically or microbiologically proved diagnoses made in secondary care and tends to take one of three forms:

    • A working diagnosis on which treatment is based (such as “acute otitis media”)

    • A working diagnosis on which further investigations are planned (such as “bloody diarrhoea ? inflammatory bowel disease”)

    • A working diagnosis indicating the absence of serious disease (such as “calf pain, not DVT”).

    The aim of this article is to understand why diagnostic labels are sometimes not applied in general practice consultations and to understand how this approach contributes to making decisions about diagnoses.

    Why is a diagnosis sometimes missing?

    Bruce Thomas, a general practitioner in Hampshire, UK, pointed out in the 1970s that in up to 40% of patients in general practice no diagnostic label could be attached.1 2 These patients did not require, and generally were not given, specific treatment, and most recovered spontaneously. This remains the case. In a 2005 review of consultation data in the UK, “symptoms, signs and ill-defined conditions” was the computer coded group of disorders presenting most frequently in general practice.3

    Also in the 1970s, Howie described “the relative rarity …

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