Red Flag Symptoms to Consider

Red flag symptoms to consider

Condition Historical findings Symptoms and diagnosis Gastroenteritis  Tachycardia, hypotension, and lethargy Severe abd. Pain/signs → peritonism in children (significant dehydration) Persistent diarrhea → metabolic /GIT  Bloody stools and extreme abdominal Blood in stool → intussusception, tenderness (volvulus, intussusception, dysentery partial obstruction) Unwell child → sepsis  Bloody stool, fever, petechiae, and purpura Bilious vomit → obstruction, (hemolytic-uremic syndrome) intussusception Vomiting without diarrhea → pyloric stenosis, UTI Fever → sepsis, appendicitis, surgical causes Acute upper Indications for urgent intervention airway  ↓SaO2– worried, unsettled obstruction and restless  Fatigue or ↓LOC  ↑ work of breathing Acute Abdominal surgery, heart disease, pregnancy, Any abnormal vital signs, severe pain of abdominal pain peptic ulcer disease, diverticulitis, pancreatitis or rapid onset, signs of dehydration, skin HIV infection, last menstrual date and allergies pallor and diaphoresis(visceral pain especially food. signs) Extremes of age, GI bleeding. Bowel sounds, areas of tenderness, guarding and peritoneal signs. Rectal examination – tenderness, rectal tone, prostate size and blood/malena. Extra-abdominal sings – genitals, jaundice, dehydration, hypoperfusion and CVS. Specific signs – iliopsoas/ obturator, Murphy’s or Rovsing’s Acute GI BLED B-bleeding ongoing, L-low systolic BP Low blood pressure, fresh blood in bleeding (<100mmhg), E-erratic mental status, D-disease, vomitus or stools especially when unstable morbid condition preceded by coffee grounds or malena. Acute diarrhea Dysentery, abdominal pain, fever, nausea and Fever- campylobacter, shigella, vomiting, syncope/ dizziness, extremes of age, salmonella recent travel, recent ingestions, sexual practices, Vomiting – r/o obstruction immunocompromise, systemic symptoms – Constant rather than crampy pain, malaises, joint pains. weight loss Red Flags: Suggestive of organic cause PR – fistula/fissures, hard stool 1. Painless Diarrhea (overflow), fecal WBC and Hb. 2. Recent onset in an older patient 3. Nocturnal Diarrhea (especially if wakes patient) 4. Weight loss 5. Blood in stool 6. Large stool volumes: >400 grams stool per day 7. Anemia/Hypoalbuminemia 8. Erythrocyte Sedimentation Rate increased Breast mass  Bloody discharge  Lump fixed to skin or chest wall  Family history  Stony hard or irregular lump  Constitutional symptoms  Matted or fixed axillary lymph nodes Chest pain Age, male sex, HT, DM, smoking, CAD,  Abnormal vital signs (tachycardia, hyperlipidemia, family history, OCP use, lifestyle, bradycardia, tachypnea, hypotension) stress, obesity.  Signs of hypoperfusion (eg, Type/character/radiation, risk factors for PE, confusion, ashen color, diaphoresis) syncope, palpitations, association with vomiting  Shortness of breath Cocaine users, women (atypical pain)  Asymmetric breath sounds or pulses  New heart murmurs  Pulsus paradoxus > 10 mm Hg Neurologic findings – dissection Tracheal deviation - pneumothorax Cough  Dyspnea  Abnormal vitals  Hemoptysis  Unequal breath sounds  Shortness of breath  Airway swelling  Sudden onset/Weight loss  Stridor  Risk factors for HIV or TB  Chest pain/ Fever Diplopia  Mono-ocular – local causes  More than 1 cranial deficit  Binocular – central cause and usually  Pupillary involvement significant  Other neurologic findings  Pain/ proptosis  Fever, headache, meningeal signs Dysphagia  Neck or throat pain  Palpable visible mass  Weight loss  Muscle weakness  Abrupt onset age>50  Neurologic deficits  Pain choking or difficulty swallowing  Fever  Regurgitation of food  Progressive worsening Dysuria  Fever  Any signs of sepsis  Flank pain or tenderness  Unstable vitals  Recent instrumentation  Immunocompromised  Recurrent episodes in young  Known urinary tract abnormality Earache  Diabetes or immunocompromised state  Redness/fluctuance over mastoid  Severe swelling at external auditory  Protrusion of auricle meatus  Redness swelling beyond the external  Associated head neck symptoms ear  Hearing loss  Facial palsy or other cranial nerve deficit  Fever/ headache/diplopia Red painful eye  Sudden, severe pain and vomiting  Decreased visual acuity  Halos around light  Zoster skin rash  Any corneal abnormality  Pupillary/Red reflex changes  Decreased visual acuity  Fundoscopic findings   Corneal crater Impaired ocular mobility, proptosis

 Branching, dendritic corneal lesion

 Ocular pressure > 40/Trauma

Fever  Altered mental status  Localizing signs  Headache, stiff neck, or both  Features of sepsis  Petechial skin rash/Hypotension  Unstable vitals  Significant tachycardia or tachypnea  Signs of meningismus  Temperature > 40° C or < 35° C  Signs of reduced tissue perfusion  Recent travel to malaria-endemic area  Recent use of immunosuppressants  Rigors/Extremes of age  Sickle cell anemia/CRF/DM Floaters  Sudden increase in floaters  Loss of vision, diffuse or focal  Lightning like flashes  Loss of red reflex  Recent eye surgery or trauma  Abnormal retinal findings  Eye pain Headache  History Examination onew onset, particularly in middle age or  fever beyond,change of pattern  neck stiffness opain with effort or position  neurological findings orecent head trauma  abnormal vitals  Past history of chronic serious illness  papilledema  Change in personality or behaviour  red eye + pupil findings  Thunderclap, worse-ever  jaw pain and temporal headache +  Systemic symptoms/seizures age>50 Hematuria  Gross hematuria  Abnormal vitals  Persistent microscopic  Red cell casts  Age >50/Hypertension and edema  Abdominal masses/Trauma Hypertension  Pregnancy CCF, neurodeicit, papilledema,  Signs of end organ dysfunction – CP, hematuria, proteinuria headache, blurred vision, neurodeficit, reduced urine output  Seizures  CCF, IVDU/drug use Jaundice  Marked abdominal pain and tenderness  Signs of encephalopathy or (adults)  Altered mental status coagulopathy – mental status  GI bleeding (occult or gross) changes, asterixis, easy bleeding,  Ecchymoses, petechiae, or purpura pupura, malena/hematemesis  Signs of portal hypertension – abdo collateral vasculature, ascites  Marked fever - cholangitis Jaundice in  Jaundice in 1st day  TSB >200mmol/l neonates  Jaundice onset after 2 weeks  Direct bilirubin >17µmol/L or >20%  Lethargy, irritability, resp distress, fever of TSB  Macrosomia – maternal DM  Plethora – fetal transfusion  Hypotonia – hypothyroidism  Fever/RD – sepsis  Down’s – D. atresia, Hirschsprung’s Joint pain/  h/o trauma vs. none  Erythema, warmt, effusion and swelling (single)  Fever ↓ROM  Acute onset in sexually active adult  Skin breaks with cellulitis  Underlying bleeding disorder, hemoglobinopathy or anticoagulation  Extra-articular symptoms Joint pain/  Fever/ malaise – infection, RA, vasculitis  Bone tenderness/chest pain – swelling  Recent pharyngitis – Rheumatic fever Sickle (multiple)  Recent blood product use – serum sickness  +tendinitis – gonococcal  Conjunctivitis, abdo pain – reactive  Raised silver plaques – psoriasis  Lymphadenopathy – HIV  Oral/genitalulcer – Behcet’s Low back pain History Neurological  cancer  bladder control  unexplained weight loss  bowel control  fever  loss of "saddle" or leg sensation  recent infection  severe/progressive leg weakness  immunosuppression Examination  intravenous drug use  anal sphincter weak  pain when supine or severe at night  major leg weakness  trauma: major in young, minor in  loss of anal or "saddle" elderly sensation General back  acute tearing mid-back pain  abdominal aorta >5cm, tender, pain  all of above/duration >6weeks pulse deficits  fever  neurologic deficit/abdominal signs N & V in  lethargy/ listlessness  bulging fontanelle children  inconsolability  nuchal rigidity, photophobia, fever  persistent vomiting with poor growth or  peritoneal signs or distension development  bloody stools or bilious vomiting Neck mass  older patient  hard fixed mass  persistent hoarseness or dysphagia –  erythroplakia/ leukoplakia – thyroid Ca malignancy  acute onset vs. insidious – infection vs.  generalized adenopathy/ serious splenomegaly – infectious mono,  pain and tenderness lymphoma, HIV Palpitations  pre-syncope, syncope  irregularly irregular rhythm  new onset in older patient  HR >120 or <45  family h/o sudden death  Injuries from syncope  chest pain/ drug use  underlying heart disease Rash  Fever, age (very young or elderly), toxic- Temperature, fevers, unstable vitals, appearing, immunocompromised, LOC, unwell looking. adenopathy, diffuse  erythroderma, petechiae/purpura, mucosal/oral lesions, hypotension, severe localized pain/tenderness, recent  new drug use (1-4 weeks), arthralgias Sore throat  stridor or respiratory distress  Visible bulge in pharynx  drooling  Tonsillar exudate  muffled, ‘hot potato’ voice  Tender lymphadenopathy  severe symptoms with normal pharynx –  Fever, abnormal vitals/RR epiglottitis.  Absence of cough Syncope Prodrome – pallor, chest/abdominal pain, Unstable vitals, orthostatic weakness, dizziness, confusion, dizziness. Post- hypotension,, carotid bruits, systolic syncope findings – confusion → seizure. Drug murmurs, pulsatile masses, cranial use. Past GI bleeds/PE. Pregnancy. CHESS nerve deficits or neurologic deficits. Red flag symptoms – exertional onset, chest pain, dyspnea, low back pain, palpitations, severe headache, focal neurologic deficit, diplopia, ataxia or dysarthria Urticaria  Stridor, wheezing or resp distress  Angioedema, unstable vitals  Syncope/ LOC  Hyperpigmented lesions, ulcers or urticaria >48h  Hoarseness, dysphagia, dyspnea  Signs of systemic illness – fever, l’pathy, jaundice or cachexia Vision blurred  Sudden change  Signs of underlying disorder –  Eye pain with/without movt retinopathy  HIV/AIDS or immunosuppression  Neurologic deficit  Systemic disorders – sickle, RA, DM, HT  Mono-ocular vs. binocular causes Vision loss  Red flag symptoms in itself  Classify between mono-ocular and acute  All causes are dangerous and vision binocular threatening  Transient vs. persistent