Red flag symptoms to consider
Condition
Gastroenteritis
in children
Historical findings
 Tachycardia, hypotension, and lethargy
(significant dehydration)
 Bloody stools and extreme abdominal
tenderness (volvulus, intussusception,
partial obstruction)
 Bloody stool, fever, petechiae, and purpura
(hemolytic-uremic syndrome)
Acute upper
airway
obstruction
Acute
abdominal pain
Abdominal surgery, heart disease, pregnancy,
peptic ulcer disease, diverticulitis, pancreatitis or
HIV infection, last menstrual date and allergies
especially food.
Extremes of age, GI bleeding.
Acute GI
bleeding
BLED B-bleeding ongoing, L-low systolic BP
(<100mmhg), E-erratic mental status, D-disease,
unstable morbid condition
Dysentery, abdominal pain, fever, nausea and
vomiting, syncope/ dizziness, extremes of age,
recent travel, recent ingestions, sexual practices,
immunocompromise, systemic symptoms –
malaises, joint pains.
Red Flags: Suggestive of organic cause
1. Painless Diarrhea
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
 Bloody discharge
 Family history
 Constitutional symptoms
Acute diarrhea
Breast mass
Chest pain
Symptoms and diagnosis
Severe abd. Pain/signs → peritonism
Persistent diarrhea → metabolic /GIT
Blood in stool → intussusception,
dysentery
Unwell child → sepsis
Bilious vomit → obstruction,
intussusception
Vomiting without diarrhea → pyloric
stenosis, UTI
Fever → sepsis, appendicitis, surgical
causes
Indications for urgent intervention
 ↓SaO2– worried, unsettled
and restless
 Fatigue or ↓LOC
 ↑ work of breathing
Any abnormal vital signs, severe pain of
rapid onset, signs of dehydration, skin
pallor and diaphoresis(visceral pain
signs)
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
Low blood pressure, fresh blood in
vomitus or stools especially when
preceded by coffee grounds or malena.
Fever- campylobacter, shigella,
salmonella
Vomiting – r/o obstruction
Constant rather than crampy pain,
weight loss
PR – fistula/fissures, hard stool
(overflow), fecal WBC and Hb.
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Lump fixed to skin or chest wall
Stony hard or irregular lump
Matted or fixed axillary lymph
nodes
Age, male sex, HT, DM, smoking, CAD,
 Abnormal vital signs (tachycardia,
hyperlipidemia, family history, OCP use, lifestyle,
bradycardia, tachypnea, hypotension)
Cough
Diplopia
Dysphagia
Dysuria
Earache
Red painful eye
Fever
Floaters
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
 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
 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
 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
 Fever
 Any signs of sepsis
 Flank pain or tenderness
 Unstable vitals
 Recent instrumentation
 Immunocompromised
 Recurrent episodes in young
 Known urinary tract abnormality
 Diabetes or immunocompromised state  Redness/fluctuance over mastoid
 Severe swelling at external auditory
 Protrusion of auricle
meatus
 Redness swelling beyond the external
ear
 Associated head neck symptoms
 Hearing loss
 Facial palsy or other cranial nerve
deficit
 Fever/ headache/diplopia
 Sudden, severe pain and vomiting
 Decreased visual acuity
 Zoster skin rash
 Halos around light
 Decreased visual acuity
 Any corneal abnormality
 Corneal crater
 Pupillary/Red reflex changes
 Branching, dendritic corneal lesion
 Fundoscopic findings
 Ocular pressure > 40/Trauma
 Impaired ocular mobility, proptosis
 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
 Sudden increase in floaters
 Loss of vision, diffuse or focal
 Lightning like flashes
 Loss of red reflex
Headache
Hematuria
Hypertension
Jaundice
(adults)
Jaundice in
neonates
Joint pain/
swelling (single)
Joint pain/
swelling
(multiple)
Low back pain
 Recent eye surgery or trauma
 Eye pain
 History
o new onset, particularly in middle age or
beyond,change of pattern
o pain with effort or position
o recent head trauma
 Past history of chronic serious illness
 Change in personality or behaviour
 Thunderclap, worse-ever
 Systemic symptoms/seizures
 Gross hematuria
 Persistent microscopic
 Age >50/Hypertension and edema
 Pregnancy
 Signs of end organ dysfunction – CP,
headache, blurred vision, neurodeficit,
reduced urine output
 Seizures
 CCF, IVDU/drug use
 Marked abdominal pain and tenderness
 Altered mental status
 GI bleeding (occult or gross)
 Ecchymoses, petechiae, or purpura
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Jaundice in 1st day
Jaundice onset after 2 weeks
Lethargy, irritability, resp distress, fever
h/o trauma vs. none
Fever
Acute onset in sexually active adult
Underlying bleeding disorder,
hemoglobinopathy or anticoagulation
Extra-articular symptoms
Fever/ malaise – infection, RA, vasculitis
Recent pharyngitis – Rheumatic fever
Recent blood product use – serum sickness
History
 cancer
 unexplained weight loss
 fever
 recent infection
 immunosuppression
 Abnormal retinal findings
Examination
 fever
 neck stiffness
 neurological findings
 abnormal vitals
 papilledema
 red eye + pupil findings
 jaw pain and temporal headache +
age>50
 Abnormal vitals
 Red cell casts
 Abdominal masses/Trauma
CCF, neurodeicit, papilledema,
hematuria, proteinuria
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Signs of encephalopathy or
coagulopathy – mental status
changes, asterixis, easy bleeding,
pupura, malena/hematemesis
Signs of portal hypertension – abdo
collateral vasculature, ascites
Marked fever - cholangitis
TSB >200mmol/l
Direct bilirubin >17µmol/L or >20%
of TSB
Macrosomia – maternal DM
Plethora – fetal transfusion
Hypotonia – hypothyroidism
Fever/RD – sepsis
Down’s – D. atresia, Hirschsprung’s
Erythema, warmt, effusion and
↓ROM
Skin breaks with cellulitis
Bone tenderness/chest pain –
Sickle
 +tendinitis – gonococcal
 Conjunctivitis, abdo pain – reactive
 Raised silver plaques – psoriasis
 Lymphadenopathy – HIV
 Oral/genitalulcer – Behcet’s
Neurological
 bladder control
 bowel control
 loss of "saddle" or leg sensation
 severe/progressive leg weakness
Examination
General back
pain
N & V in
children
Neck mass
Palpitations
Rash
Sore throat
Syncope
Urticaria
Vision blurred
Vision loss
acute
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intravenous drug use
pain when supine or severe at night
trauma: major in young, minor in elderly
acute tearing mid-back pain
all of above/duration >6weeks
fever
lethargy/ listlessness
inconsolability
persistent vomiting with poor growth or
development
 older patient
 persistent hoarseness or dysphagia –
thyroid Ca
 acute onset vs. insidious – infection vs.
serious
 pain and tenderness
 pre-syncope, syncope
 new onset in older patient
 family h/o sudden death
 chest pain/ drug use
 underlying heart disease
 Fever, age (very young or elderly), toxicappearing, immunocompromised,
adenopathy, diffuse
 erythroderma, petechiae/purpura,
mucosal/oral lesions, hypotension, severe
localized pain/tenderness, recent
 new drug use (1-4 weeks), arthralgias
 stridor or respiratory distress
 drooling
 muffled, ‘hot potato’ voice
 severe symptoms with normal pharynx –
epiglottitis.
Prodrome – pallor, chest/abdominal pain,
weakness, dizziness, confusion, dizziness. Postsyncope findings – confusion → seizure. Drug
use. Past GI bleeds/PE. Pregnancy. CHESS
Red flag symptoms – exertional onset, chest
pain, dyspnea, low back pain, palpitations,
severe headache, focal neurologic deficit,
diplopia, ataxia or dysarthria
 Stridor, wheezing or resp distress
 Syncope/ LOC
 Hoarseness, dysphagia, dyspnea
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Sudden change
Eye pain with/without movt
HIV/AIDS or immunosuppression
Systemic disorders – sickle, RA, DM, HT
Red flag symptoms in itself
All causes are dangerous and vision
threatening
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anal sphincter weak
major leg weakness
loss of anal or "saddle" sensation
abdominal aorta >5cm, tender,
pulse deficits
neurologic deficit/abdominal signs
bulging fontanelle
nuchal rigidity, photophobia, fever
peritoneal signs or distension
bloody stools or bilious vomiting
hard fixed mass
erythroplakia/ leukoplakia –
malignancy
generalized adenopathy/
splenomegaly – infectious mono,
lymphoma, HIV
irregularly irregular rhythm
HR >120 or <45
Injuries from syncope
Temperature, fevers, unstable vitals,
LOC, unwell looking.
 Visible bulge in pharynx
 Tonsillar exudate
 Tender lymphadenopathy
 Fever, abnormal vitals/RR
 Absence of cough
Unstable vitals, orthostatic
hypotension,, carotid bruits, systolic
murmurs, pulsatile masses, cranial
nerve deficits or neurologic deficits.
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Angioedema, unstable vitals
Hyperpigmented lesions, ulcers or
urticaria >48h
Signs of systemic illness – fever,
l’pathy, jaundice or cachexia
Signs of underlying disorder –
retinopathy
Neurologic deficit
Mono-ocular vs. binocular causes
Classify between mono-ocular and
binocular
Transient vs. persistent