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Red Flags (CMS)

Complimentary Therapist's Guide to Red Flags and Referrals

QuestionAnswer
Progressive unexplained symptoms over weeks / months (e.g. weight loss, (night) sweats, fevers, poor appetite) ** / * Cancer
Unexplained lump (>1cm, hard, fixed, irregular, painless) ** / * Cancer
Unexplained bleeding (e.g. from skin, rectum, vagina, in urine, in vomit) ** / * Cancer
Bruising, purpura, bleeding, progressive anaemia, recurrent progressive infection *** / ** Bone marrow failure from: - Cancer (secondary / of blood cells infiltrate bone marrow) - damage by medication / radiotherapy - autoimmune disease
Multiple enlarged lymph nodes (>1cm, painless, > 2 weeks) ** / * Cancer (leukaemia, lymphoma) Glandular fever HIV Refer as high priority if otherwise unwell
One enlarged lymph node (>2cm), esp. with fever, weight loss, itching ** / * Cancer (lymphoma)
(Progressive) painless abdominal bloating / swelling from fluid accumulation (ascites) *** / ** Cancer metastasised (colon, stomach, ovarian)
Fever, confusion, diarrhoea, vomiting, spreading inflammation, yellow discharges - infants >3 months, elderly, pregnant, immunocompromised, travel to tropics in last month ** Infectious disease
Child under 8: temp >37.8C not responding to treatment in 2hrs ** Infectious disease
Older child / adult: temp >38.5C not responding to treatment in 2 days ** Infectious disease
Fever persists / recurs over 2 weeks ** / * Infectious disease Inflammatory condition Cancer
Infant: dry mouth & skin, loss of skin turgor, drowsiness, sunken fontanelle, dry nappies *** / ** Dehydration (from infectious disease) Infectious disease
Older child / adult (severe or > 2 days): dry mouth & skin, loss of skin turgor, low blood pressure, postural dizziness, scant urine ** Dehydration (from infectious disease)
Older child / adult: Fever & confusion ** Infectious disease Meningitis Brain abscess
Child: ongoing (>2 min) febrile convulsion *** Infectious disease
Child: recovered from febrile convulsion ** Infectious disease
Persistent oral thrush * Corticosteroids Diabetes Immunodeficiency (HIV / AIDS) Cancer Dentures in elderly
Persistent painless white plaque (leukoplakia) on sides of tongue * Pre-cancer (esp. smokers & drinkers) HIV / AIDS
Painless enlarged salivary gland (week - months) * Cancer
Enlarged salivary gland after eating * Salivary gland stone Dried saliva obstruction
Tender / inflamed gums / salivary glands that don't respond to treatment in days ** Dental abscess Salivary gland infection
Mouth ulcers (> 1 week / preventing hydration) ** Herpes simplex virus Crohn's disease Cancer (mouth) Bone marrow failure (severe ulceration)
Difficulty swallowing, worse with solids (esp. if progressive days-weeks) ** / * Globus pharyngeus (stress) Cancer Scarring (stricture)
Difficulty swallowing, enlarged neck lymph nodes ** / * Cancer Inflamation
Swallowing with chest pain behind sternum (>24 hrs / severe) * Oesophagitis Structure damage to oesophagus
Infant / elderly: severe diarrhoea & vomiting >24 hrs *** / ** Risk dehydration
Adults: diarrhoea & vomiting >5 days ** Infectious disease (bloody diarrhoea = notifiable) Inflammation Food poisoning (notifiable)
Diarrhoea & vomiting with dehydration *** / ** Infectious disease (bloody diarrhoea = notifiable) Inflammation Food poisoning (notifiable)
Vomiting > tablespoon fresh / altered blood (coffee granules / gravel), esp. with shock *** / ** Peptic ulcer Stomach cancer Chronic liver disease (bleeding at base of oesophagus from ruptures varicose veins) Shock = severe blood loss
Projectile vomiting >2 days *** / ** High obstruction in stomach outflow = fluid & salts loss Newborn: pyloric stenosis congenital deformity
Epigastric pain / dyspepsia for fist time in over 40's / not better with treatment after 6 weeks * Cancer Helicobactor pylori infection (if chronic, leads to peptic ulcer / cancer)
Altered blood in stools ('melaena' looks like tar, smells like metal) *** / ** Significant bleeding from proximal digestive tract, incl. stomach
Acute abdomen: Severe abdominal pain (constant / colicky) with collapse (esp. with rigidity, guarding, rebound tenderness) *** / ** IBS Dysmenorrhoea Ovulation Appendicitis Perforated ulcer Peritonitis Obstructed bowel PID Gallstones Ruptured aortic aneurism Colicky = obstructed viscus Rigidity, guarding, rebound tenderness = inflamed / perforated viscus
Acute abdomen + severe central abdominal & back pain, vomiting, dehydration *** + nil by mouth Acute pancreatitis (from alcohol / gallstones)
Central abdominal & back pain, weight loss, loose stools over weeks-months ** / * Chronic pancreatitis
Malabsorption syndrome: loose pale stools, thin hair, weight loss, malnutrition, dry skin, cracked lips, peeled tongue, children = failure to thrive ** / * Chronic pancreatitis Coeliac disease Crohn's disease Intestinal lymphoma
Jaundice: yellow skin & eyes, dark urine, pale stools, itch ** Obstructed bile outflow by: - cancer (pancreas, liver) - gallstone - hepatitis (from hepatitis A, B, C, glandular fever, medication, alcohol). Viral hepatitis is notifiable
Right hypochondriac pain, malaise (>3 days) ** Liver / gallbladder pathology
Liver disease + oedema, bruising, confusion ** Advanced liver disease: medical management needed as liver can't make blood proteins (for clotting), or detox blood
Right hypochondriac intense colicky pain (maybe + vomiting / jaundice) ** Gallstones > inflamed gallbladder
Diarrhoea, mucus / gripy pain (not responding to treating in 7 days) ** Crohn's disease Ulcerative colitis Severe bowel infection Food poisoning (notifiable) Dysentry (notifiable)
Blood mixed in with stools ** Bowel infection Diverticulitis Crohn's disease Ulcerative colitis Bowel cancer Dysentery (notifiable)
Swelling in groin pronounced with standing (esp. uncomfortable) ** / * Inguinal hernia (needs assessment for surgery in case bowel look pops out & strangles) Urgent if very painful within hours
Over 50: Altered bowel habit (>3 weeks) ** / * Inflammatory bowel disease Cancer Urgent if increased frequency / more mucus
Anal discharge / soiling with stool (esp. previously continent child) ** / * Child / elderly: constipation with faecal overflow (developmental bowel problem / emotional disturbance) Cancer (rectal / anal)
Painless lump in anus (>2 weeks) * Skin tag Anal wart Cancer (anal)
Painful lump in anus * / ** Prolapsed haemorrhoid Perianal haematoma Cancer (anal)
Anal itch (>3 weeks' treatment) * Short, intense, nocturnal: threadworm Prolonged: skin tags / haemorrhoids Lichen sclerosus Cancer (anal)
Calf pain: worse with exercise better with rest, at night better with hanging leg out of bed, cold purple shiny skin, blackened skin (gangrene) ** / * Severely compromised circulation to extremities > infarction / gangrene > amputation Refer for lifestyle advice (stop smoking), vascular surgery assessment
Pulse in abdomen >5cm wide (esp. > age 50) * = no pain *** = abdominal / central back pain Aortic aneurysm
Acute abdominal / back pain, collapse, shock *** Ruptured aortic aneurysm
Acute purpuric rash, headache, vomiting, fever *** Meningococcal septicaemia (from vasculitis) - notifiable, needs urgent antibiotics
Broken / itchy skin close to varicose veins * Varicose ulcer risk
Hot swollen tender calf, malaise, fever (esp with air travel, surgery, pregnancy, cancer, contraceptive pill) ** Deep venous thrombosis > pulmonary thrombosis risk
Diastolic BP >120, worsening headaches, blurred vision, chest pain *** / ** Malignant hypertension > high risk of stroke / cardiovascular signs (visual disturbance / headaches = serious)
BP - systolic >220, diastolic >120 ** Seriously high hypertension, refer to prevent stroke / cardiovascular event
BP - systolic >180, diastolic >110 (not responding with 2 weeks' treatment / major risk factors) * Severe hypertension
BP - systolic 160-180, diastolic 100-110 (not responding with 4 weeks' treatment / major risk factors) * Moderate hypertension
BP - systolic 140-160, diastolic 90-100 (not responding with 3 months' treatment + major risk factors) Person over 10: BP = 160/90 for 3-6 months * Mild hypertension
Hypertension (>130/80) + diabetes ** / * Risk of renal & vascular complications
Hypertension (>130/80) + kidney disease ** / * Risk of worsening kidney damage
Hypertension + pregnancy ** Risk of pre-eclampsia / placental damage
Heavy gripping central chest pain with exercise / cold / eating, better with rest. May radiate down neck & arms Elderly: breathless / chest tightness episodes, no pain ** / * Stable angina (high heart attack / cardiovascular event risk)
Sustained intense chest pain with fear / dread. Palpitations, breathlessness, vomit, cold sweat Elderly: sudden breathlessness, palpitations, confusion, no pain *** Heart attack Unstable angina
Sudden tearing chest pain radiating to neck, shock *** Dissecting aortic aneurysm
Worsening / sustained more than seconds: dizziness, faintness, confusion, low BP, >100 bpm, BP < 90/50, cold clammy extremities *** Shock from: - blood loss & extreme dehydration - allergic reaction - overwhelming infection - inadequate circulation by heart (damaged heart muscle / valves / arrhythmia) Risks heart, kidney, brain damage
Slightly swollen ankles, slight breathlessness with exertion / lying flat, cough. No palpitations / pain. Elderly & sedentary: dry cough only * Mild chronic heart failure > increased risk of worsening heart damage. Needs electro-and echocardiogram
Markedly swollen ankles & lower legs, disabling breathlessness & exhaustion ** Severe chronic heart failure > high mortality. Medical management improves life expectancy
Sudden disabling breathlessness, watery cough *** Acute heart failure from: - heart attack - arrhythmia - valve damage
Irregularly irregular pulse ** / * Atrial fibrillation > tiny blood clots in heart go to brain > transient ischemic attack / stroke High priority if heart failure / angina / history of blackouts / neurological symptoms also present
140-250 bpm *** / ** Supraventricular tachycardia > arrhythmia / acute heart failure Atrial fibrillation Urgent referral if not settling in 5 minutes
40-50 bpm, recent onset / associated with dizziness, light headedness, fainting *** / ** Complete heart block (needs pacemaker assessment)
Regular pulse regularly skips beats (1 out of every 3-5 beats) * Incomplete heart block > arrhythmia Needs cardiac assessment
Elderly: unexplained falls / faints ** / * Arrhythmia (cardiac syncope)
Collapse with no pulse *** Cardiac arrest
Sharp central chest pain worse bending forward / lying down, slight fever, pulse <100 bpm ** Uncomplicated pericarditis
Sharp central chest pain worse bending forward / lying down, slight fever, pulse <100 bpm + breathlessness & oedema / tachycardia / heart attack / unstable angina *** Pericarditis with complications
Susceptible people: cough & fever / yellow-green phlegm (>3 days) ** Progressive upper respiratory tract infection
Moderate-severe breathlessness (>30 breaths/minute), malaise, (cough, fever), (cyanosis, need to sit upright, reluctant to speak) *** / ** Progressive lower respiratory tract infection Pneumonia (refer urgently with severe breathlessness)
One big tonsil, fever, bad breath *** / ** Quinsy (tonsil abscess) - may need surgery to avoid blocked airway Urgent if stridor
One big tonsil, otherwise well * Lymphoma
Harsh, noisy breathing in and out *** / ** Upper airway obstruction (laryngotracheitis, quinsy, epiglottitis)
Child <8: new onset difficulty breathing (blocked nostril) *** / ** Lower respiratory tract infection Asthma Allergic reaction Foreign body inhaled Congenital heart disease
One persistently blocked nostril (>3 weeks) ** / * Nasopharynx carcinoma (esp. one nostril bloody discharge)
Two of: - rapidly worsening breathlessness - >30 breaths/min - >110 bpm - reluctant to talk - sits upright & still to breathe - central cyanosis *** Severe asthma Panic attack (no cyanosis)
Coughing >teaspoon of blood ** Haemoptysis (lung cancer, tuberculosis, pulmonary embolism)
Smoker: new onset chronic cough / deep persistent chest pain ** / * Lung cancer
Unexplained hoarseness (>3 weeks) * Chronic laryngitis Cancer (laryngeal / lung) in smokers aged >50
Localised chest pain when breathing in & out, breathlessness, fever ** Pleurisy + pneumonia
Chronic productive cough, weight loss, night sweats, blood in sputum (>2 weeks) ** Tuberculosis (refer for isolation, trace & test contacts, diagnosis, antibiotics, notifiable)
Sudden pleurisy, breathlessness, cyanosis, collapse, (blood in sputum) *** Pulmonary embolism (needs anticoagulants)
Onset of severe breathlessness, (pleurisy), (collapse) *** Pneumothorax
New central cyanosis *** <85% blood oxygen from: - respiratory / cardiac disease - respiratory suppression (drugs / neurological disease)
Pallor, tiredness, palpitations, breathlessness on exertion, faintness, depression, sore mouth & tongue ** / * Long-standing anaemia from: - menstruation - bleeding from stomach / bowel - prolonged aspirin / non-steroidal anti-inflammatory drugs - reduced blood production in marrow (from poor diet, iron / B12 / folic acid malabsorption, bone marrow dis
Extreme tiredness, severe breathlessness on exertion, excessive bruising, severe visual disturbance, chest pain on exertion, tachycardia, oedema ** Severe anaemia > cardiac failure / angina
Tiredness, lemon-yellow pallor, gradual neurological symptoms (numbness, weakness) ** / * Pernicious anaemia from: - autoimmune disease causing B12 malabsorption. Needs B12 injections
Continuing blood loss *** Too low BP > shock / organs don't get enough blood
Blood lost + the following getting worse: dizziness, fainting, confusion, >100bpm, BP = <90/50, cold clammy extremities *** Severe blood loss leading to shock
Widespread inflammatory response + warm extremities, puffy face & skin, difficulty breathing *** Anaphylactic shock > respiratory & circulatory collapse
Rapid consciousness deterioration > coma, irregular breathing, pinpoint pupils *** Rapid intracranial pressure increase > brain stem compressed > brain damage / death
Progressive (weeks-months) (morning) headaches & effortless vomiting, (blurred vision, esp. after coughing / leaning forward) ** Slow intracranial pressure increase from: - brain lesion (e.g. tumour / abscess / cerebrospinal fluid not draining)
Progressive decline in mental & social function, difficulty in intellectual function, memory, concentration, language * Dementia Recurrent small strokes Extradural haemorrhage Slow-growing brain tumour Elderly: depression
<2 hr loss of: consciousness, vision, steadiness, memory, sensation, or limb weakness, confusion *** / ** Temporary loss of neurological function from: - migraine / simple faint (benign) - Transient ischemic attack > stroke damage
Persisting loss of: consciousness, vision, steadiness, memory, sensation, or limb weakness, confusion *** / ** Persisting loss of neurological function from: - stroke - rapidly growing brain tumour - multiple sclerosis - Bell's palsy Urgent if happened in last few hours
Neurological function loss over days-weeks ** - Brain tumour - motor neurone disease - multiple small strokes
Sudden very severe headache, need to lie down, (vomit, stiff neck, dislikes bright light) *** - subarachnoid haemorrhage (arterial bleed at base of brain) (inherited malformation)
Severe headache developing over hours-days, fever, vomiting / stiff neck, (drowsy / unconscious, dislikes bright light, arching back of neck, purpuric rash) *** - acute meningitis / encephalitis
Severe headache developing over hours-days, fever, bruising non-blanching rash, (drowsy / unconscious) *** - meningococcal meningitis > septicaemia & endotoxic shock
Elderly: first time severe one-sided headache over temple *** / ** - temporal arteritis > cerebral / retinal arterial thrombosis Higher risk with polymyalgia rheumatica
Long history of progressive headaches (+ fever, appetite loss, exhaustion, other neurological symptoms) ** / *
Recent onset confusion, (agitation, visual hallucinations, poor self-care) *** / ** Organic mental health disorder, e.g. alcohol withdrawal, brain damage, intoxication, dementia) Refer urgently is patient / others at risk of harm
Fist time: - convulsion, unconsciousness, bite tongue, poo / wee - defined period of vagueness / loss of awareness / mood or personality changes - part of body twitches coarsely - wake up groggy with wet bed *** if continues >1 min ** - Epilepsy (rarely from brain tumour) Refer for diagnosis & advice re driving / safety
Mid-late life: progressive coarse tremor, (muscle stiffness) * - Parkinson's Non-urgent referral, as treatment delayed for as long as is reasonable
Quantifiable muscle weakness ** / * - conditions of brain, spinal cord, peripheral nerves, neuromuscular junction, muscles - Guillain-Barre syndrome > may affect respiratory muscles
Facial weakness, (can't lift eyebrows / move mouth / close eye on affected side) ** Bell's palsy from: - viral infection affecting facial nerve - tumour - multiple sclerosis - Lyme disease Urgent referral as: - early antiviral / corticosteroid treatment improves chances of full recovery - open eye damages cornea
Prolonged hip & shoulder muscle weakness & stiffness, malaise, depression (sudden onset severe one-sided headache / visual disturbance) *** = if one-sided headache / visual disturbance, as indicates temporal arteritis * Polymyalgia rheumatica
Measurable numbness / pins & needles (not nerve root impingement / doesn't respond to treatment in 1 week) ** / * Underlying cause could be serious Refer urgently with cauda equina syndrome
Numb buttocks & perineum, bilateral leg numbness / sciatica, difficult urination / defecation, impaired sexual function ** Cauda equina syndrome from: - compression of cauda equina nerve roots by tumour, prolapsed disc, spinal growth Refer urgently to avoid permanent damage to urination / defecation / sexual function
Intense one-sided pain + fluid-filled crusted blisters corresponding to neurological dermatome ** Shingles Refer quickly as treatment with antiviral drug (aciclovir) reduces pain severity after recovery. Also contagious
Lancing one-sided facial pain radiating from focal point, (twitching) * - trigeminal neuralgia - brain tumour - multiple sclerosis
Fixed deep aching / boring pain, (tender on palpation / percussion), (central boring back pain at night) ** / * Bone pain from: - infection (osteomyelitis) - cancer - degenerative condition (osteoporosis / osteomalacia) - bone bruising / fracture - Paget's disease Refer for medical management of osteoporosis / cancer diagnosis
Sudden - joint pain / swelling - severe pain & swelling around joint, reluctance to move - tender swelling in muscle - knee joint locking ** - haemarthritis (bleeding into joint) - sprain / strain / fracture - haematoma in muscle - meniscal cartilage tear in knee
Sudden low back pain so severe that can't walk, difficultly urinating / defecating ** - Intervertebral disc prolapse & severe nerve root irritation Refer for anti-inflammatory & relaxant medication if pain is very severe High priority referral if difficulty urinating / defecating as could signal cauda equina syndrome
Single hot swollen very tender joint, unwell, not necessarily associated with injury ** - Sceptic arthritis (joint infection) = Grave risk to joint's health - crystal arthritis (gout). Medication if CAM doesn't help in 3-7 days
Intense persistent shoulder pain not related to movement (>2 weeks) * - Tumour at apex of lung - frozen shoulder - shoulder impingement syndrome - acromioclavicular joint inflammation
Severe disability from long-standing hip / knee / shoulder pain & stiffness * - Degenerative arthritis Refer so patient can go on surgery waitinglist
Days-weeks: Symmetrical joint (incl. sacroiliac) pain stiffness swelling, (fever, malaise) ** / * Inflammatory arthritis from: - e.g. autoimmune disease Refer to prevent permanent damage as may be erosive
Blood in urine / sperm (not woman with acute cystitis) ** / * - blood from kidneys / tumour - kidney infection - trauma to genitals (refer blood in sperm non-urgently)
Recurring: burning wee, cloudy / (blood-stained) urine, low abdominal pain, (abdominal discomfort, fever) >5 days ** / * - Cystitis Refer if not responding to acupuncture in 3 days More suggestive of underlying case in men
Oedema (pitting) - Ankle swelling extending >2cm above malleoli - abdominal / scrotal swelling ** - Kidney disease - Chronic heart failure
Acute loin pain (in waves), (vomit, collapse) *** - Obstructed kidney stone
Persistent loin pain ** - Kidney infection - Kidney disease High priority if with cystitis / fever & malaise
Fever, malaise, loin pain, cloudy urine ** - Kidney infection > kidney scarring. Needs antibiotics
Child: current / recurrent cloudy urine / burning wee * = no symptoms ** = symptoms - vesicoureteric reflux disease (VRD) > kidney damage > kidney disease & hypertension as adults
Existing urinary disorder / diabetes / pregnancy / paraplegia: urinary tract infection ** Pregnancy & diabetes = higher risk of infection ascending to Kidneys, increases miscarriage / early labour risk
Men: difficulty urinating, nocturia * - Enlarged prostate - Cancer (prostate)
Fever, malaise, loin pain, cloudy urine ** - Kidney infection Refer to avoid permanent scarring of kidneys
Child: bedwetting over 5 yrs * Refer to exclude physical causes & for parents to get expert advice
Incontinence * - prolapsed uterus - prostatic obstruction - nocturnal seizures Refer for guidance and support from incontinence specialist nurse
Goitre + hyper/hypothyroid symptoms / tender / irregular / noticeably enlarged *
Tiredness, depression, weight gain, heavy periods, constipation, cold intolerance, dry puffy skin, dry thin hair, slow pulse, (progressive over months) * - Hypothyroidism - Depression Refer for medical replacement therapy to avoid metabolic consequences
Irritable, anxious, insomnia, increased appetite, loose stools, weight loss, scanty periods, heat intolerance, sweaty skin, hand tremor, staring eyes, rapid pulse, (progressive over months) ** / * - Hyperthyroidism - Anxiety disorder Refer as, if prolonged, can damage cardiovascular system High priority referral if very agitated / chest pain, palpitations, breathless
Confusion, coma with dehydration *** - Hyperglycaemia
Agitation, sweating, dilated pupils, confusion, coma *** - Hypoglycaemia
Short history of rapidly progressive: thirst, weight loss, excessive urination *** = clouding consciousness ** - Poorly controlled type 1 / 2 diabetes Patient at risk of coma
Progressive weeks-months: feels generally unwell, thirst, profuse urination ** / * - Type 2 diabetes Hyperglycaemia risks heart, kidney, vascular disease & chronic infections
Increased tendency to infections (cystitis, boils, oral thrush) ** / * - Type 2 diabetes
Poor wound healing, esp. feet ** / * - Type 2 diabetes
Weight gain, hypertension, weakness & wasting of limb muscles, stretch marks & bruises, mood changes, red cheeks & acne * - Cushing's syndrome > hypertension, diabetes, osteoporosis
Increased skin pigmentation, weight loss, muscle wasting, tiredness, loss of libido, low BP, diarrhoea, vomiting, confusion, collapse & dehydration *** / ** - Addison's disease
Progressive headaches, visual disturbance, double vision ** / * - Pituitary tumour
Loss of libido, infertility, menstrual disturbance, tiredness, low BP, inappropriate lactation ** / * - Hypopituitarism
Inappropriate lactation, infertility * - Hyperprolactinaemia from pituitary tumour / contraceptive pill
Coarsening facial features, bigger hands & feet, enlarged tongue, deepening voice, joint pains, hypertension, breathlessness ** / * - Acromegaly from pituitary tumour
Girl over 16: not yet menstruating * - with secondary sexual characteristics: imperforate hymen / intersex
No periods >6 months *
Menorrhagia (heavy periods) + tiredness, breathlessness, palpitations on exertion ** - fibroids - endometriosis - ovarian cyst
Irregular metrorrhagia (bleeding between periods) * - tumour (uterine / cervical) - STI (esp. chlamydia)
Post-menopausal bleeding ** / * - tumour (uterine / cervical) - uterine prolapse
Post-menopausal vaginal discharge * - infection - carcinoma
Pre-puberty vaginal discharge ** - yeast / bacteria overgrowth - abuse
Itchy / offensive / blood-stained / increased vaginal discharge * - yeast / bacteria overgrowth (thrush) - STI - Recurrent: diabetes / immune deficiency
Prolonged vaginal itch >1 week, not responding to advice / simple treatment * - thrush - atrophic vaginitis - lichen sclerosis - vulval cancer - abuse (child)
Discharge from penis * - STD
Sores / warty lumps / ulcers on vagina / penis ** / * - genital warts - herpes - cancer
Vaginal discharge, gripy abdominal pain, pain on intercourse, dymenorrhoea, infertility ** / * - chronic pelvic inflammatory disease - STD
Low abdominal pain, collapse, fever *** - Acute pelvic inflammatory disease > serious infertility risk
Cluster of painful ulcers on penis / vulva / anal margin, fever, malaise, (inguinal nodes big & tender) ** - Genital herpes first outbreak Refer as high priority as antiviral medication reduces duration of outbreak & recurrence
3rd trimester: genital herpes outbreak * Refer to decide birth plan, as could transfer to baby during birth
Pregnancy: offensive, fishy, watery vaginal discharge ** - bacterial vaginosis > early labour / miscarriage
Pelvic pain / deep pain on intercourse ** (see PID) / * - PID - endometriosis - fibroids - ovarian cyst
Discreet abdominal swelling (supra-pubic / inguinal) * - fibroids - ovarian cyst - tumour - pregnancy
Generalised abdominal swelling increasing days-weeks * - ascites (fluid accumulation from tumour) - multiple fibroids - pregnancy - weight gain
Lump in vulva * - vulval carcinoma - warts - Bartholin's / sebaceous cyst
Lump in testicle / scrotum * - sebaceous cyst - testicular cancer
Acute testicular pain radiating to groin / scrotum / lower abdomen, (collapse, vomiting) *** (collapse, vomiting) / ** - inflamed testicle (orchitis) - twisted testicle (torsion)
Chronic dull testicular pain, radiating to groin / scrotum / lower abdomen * - chronic epididymitis - sebaceous cysts
Secondary sexual characteristics appear <8 yrs (girls), <9 yrs (boys) * - endocrine dysfunction
Secondary sexual characteristics don't appear >15 yrs (girls), >16 yrs (boys) *
Vaginal bleeding in pregnancy *** (shock) / ** - miscarriage After 12 weeks: - placenta previa - placental abruption
Sustained abdominal pain in pregnancy *** - ectopic pregnancy (severe / worsening pain) Later pregnancy: - placental abruption - preeclampsia - Braxton Hicks contractions - premature labour / labour
Nausea & vomiting with dehydration in pregnancy ** Refer for hospital admission for fluids
Oedema in pregnancy (>2cm above malleoli / facial oedema), (BP >15 above normal / any hypertension) ** - preeclampsia - cardiac abnormality
Palpitations in pregnancy, rapid / irregular pulse / >1 beat missing in every 5 ** - cardiac abnormality - anaemia
Pubic symphysis pain in pregnancy affecting mobility ** Refer for physio advice & aids
Severely itchy palms & soles in pregnancy ** - cholestasis (can damage foetus)
BP >30 systolic, >15 diastolic higher than normal in pregnancy * - Pregnancy-induced hypertension
BP 90-99 diastolic, <140 systolic * - Mild pregnancy-induced hypertension
BP >140/100 in pregnancy ** - Moderate-severe pregnancy-induced hypertension
Pregnant: headache, abdominal pain, visual disturbance, nausea, vomiting, oedema (mid-late pregnancy) *** - HELLP syndrome (haemolysis, liver abnormalities, low platelets) - Preeclampsia
Pregnant: Pain in calf, swollen / discoloured leg, breathlessness, chest pain / blood in sputum *** - Thromboembolism (deep vein thrombosis / pulmonary embolus / stroke)
Pregnant: temp >38.5C + no response to treatment in 24 hours ** Refer as high fever can affect foetus
1st trimester: fever with rash ** - chickenpox - rubella
3rd trimester: fever with rash ** - chickenpox - shingles Can kill foetus
Watery vaginal leakage mid-late pregnancy ** - premature rupture of the membranes > uterine infection
Fever (>38C for >24 hours) during 2 weeks after giving birth ** - uterine infection
Post-partum haemorrhage > blood-stained discharge *** (shock) / **
Post-natal depression >3 weeks / not responding to treatment ** (suicidal ideas / baby at risk)
Peurperium: delusional / paranoid ideas, hallucinations ** - Post-natal psychosis High risk of suicide / harm to baby
Insufficient breast milk ** (reducing feeding) / *
Sore nipples / blocked ducts during breastfeeding ** - thrush Needs expert advice / treatment
Mastitis during breastfeeding, not responding to treatment >2 days ** / * - abscess
Lactation / nipple discharge but not breastfeeding * - pituitary disorder - cancer
Inflames breast tissue but not breastfeeding ** / * Inflamed tumour
Breast pain, no lump / inflammation * - angina - PMT (refer for reassurance)
Breast lump * - cancer - cyst
Breast tissue develops in teenage boy / adult man * - endocrine disease / disorder - cancerous change
Nipple eczema (one-sided) * - cancer (Paget's disease)
Maternal concern ** / *
Inconsolable baby >3 hours **
Child: progressive loss of weight, sweats, poor appetite, lump, unilateral lymph node >1.5cm, recurrent infections, bruising, anaemia, bleeding ** (signs of bone marrow failure) / * - cancer
Baby <3 months: fever ** Risk of rapid worsening > dehydration / convulsions / circulatory collapse
Any immunisable disease ** All immuniseable diseases are notifiable
Child vomiting: persistent / distressing / projectile / causing dehydration ** - pyloric stenosis (projectile in new born) - food poisoning
Child diarrhoea: persistent / dehydration / poor weight gain / weight loss / chronic ill-health ** (dehydration) / * - infectious organism - coeliac disease - inflammatory bowel disease
Child: recurrent / constant intense abdominal pain, fever, vomiting, collapse, rigidity, guarding *** / ** - appendicitis - bowel obstruction (hernia / twist): needs urgent surgical assessment
Child: recurrent mild abdominal pain (worse in morning, around belly button, worse with anxiety) * Refer if not responding to acupuncture
Child: jaundice ** - Liver disease
Child <8 yrs: New onset difficulty breathing (nocturnal wheeze / noisy breathing / one nostril suddenly blocked) *** / ** - lower respiratory tract infection - asthma - allergic reaction - inhaled foreign body - congenital heart disease
Tonsillitis not better after 4 days **
Child: squint / double vision * - congenital weakness of external ocular muscles - brain tumour - pituitary gland tumour - orbital cavity tumour
Persistent fever / pain / confusion >3-4 days after onset of earache ** - complicated otitis media - mastoiditis - brain abscess
Child: new difficulty hearing >3 weeks, (interfering with social interaction / education / associated with pain / dizziness) * - glue ear
Child: slow speech development, impaired social interaction / little imaginative play / obsessional repetitive behaviour * - autism Refer for extra educational & psychological support
Child: unexplained or implausible injuries / miserable & withdrawn / 'frozen watchfulness' / overtly sexualised behaviour / vaginal or anal discharge or itch ** - sexual / physical abuse
Rapidly enlarging patch of painful crusting / swollen red skin ** (esp. if person has eczema) - erysipelas - severe impetigo - herpes virus infection of broken skin
Red line advancing rapidly up line of lymphatic vessel ** - cellulitis - lymphangitis
Thrush of skin / mouth * - diabetes - immunodeficiency
Generalised itch >a few days * - cholestasis - iron deficiency - cancer - scabies
Redness over >90% of body *** / ** Erythroderma from: - eczema - psoriasis Refer as risks dehydration, loss of salts, cardiovascular strain
Generalised macular rash (flat red spots) ** / * - rubella - measles - rubella - chickenpox
Non-blanching purpura / bruising rash *** / ** - bleeding disorder - vasculitis - meningitis (if with headache / fever / vomiting)
Lump / mole: recent shape change / irregular / tends to bleed / crusty / >5mm / irregular pigmentation / intense black colour * - basal-cell carcinoma - squamous cell carcinoma - malignant melanoma - seborrhoeic keratoses
Progressive swelling of soft tissues of face & neck +/ urticardia (nettle rash), (itchy throat, wheeze) *** Angio-oedema from: - acute allergic reaction - life-threatening asthma
Increasing hairiness is mid-life * - endocrine disease - PCOS
Intensely painful red eye *** / ** - iritis - choroiditis - acute glaucoma - corneal ulcer - keratitis
Painful red swollen eye & lid *** - orbital cellulitis
Eye movements deeply & intensely painful, no inflammation ** - optic neuritis - choroiditis
Severe prolonged painful discharge from eye, esp. in newborn, malnourished, immunocompromised ** - acute allergic / viral / bacterial conjunctivitis
Sudden blurred / lost vision *** / ** - thromboembolic disease - optic neuritis - retinal tear - corneal ulcer
Gradual onset painless blurring / sight loss * - refractive error - cataract - glaucoma - macular degeneration
Adult: recent double vision ** - orbital cavity distorted - cranial nerve damage
Recent drooping eyelid * - tumour - muscle wasting disease
Foreign body in eye **
Young person / pregnant / previous episode / neurological disturbance / thromboembolic disease: vertigo (for >6 weeks / causes recurrent vomiting) ** / * - labyrinthitis - stroke - multiple sclerosis
>45 yrs old: vertigo ** / * - stroke
Persistent discharge from ear (>1 week since otitis media cleared up) * - chronic otitis media
Suddenly can't hear ** - acoustic nerve damage / brain auditory centre
Gradual onset of deafness for >7 days * - acoustic neuroma - ear wax
Tinnitus: progressive / with hearing loss * - progressive ear / auditory nerve disorder
Adult: earache >3 weeks * - cancer of nasopharynx
Suicidal thoughts + old age / male / social isolation / concrete plans **
Hallucinations / delusions / thought disorder + deteriorating self-care & personality change ** - psychosis, e.g. schizophrenia
Increasing agitation, grandiosity, pressure of speech, sleeplessness, delusional thinking ** - mania from bipolar disorder
Severe depression / obsessive-compulsive disorder / anxiety affecting quality of life *
Body image disturbance resulting in bulimia / anorexia nervosa *
Created by: Warthogontheweb