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Red Flags (CMS)
Complimentary Therapist's Guide to Red Flags and Referrals
| Question | Answer |
|---|---|
| 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 | * |
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Warthogontheweb
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