RED FLAGS and TREATMENT Flashcards
Acute Cough Red Flags
Sign of choking?
• Rapid breathing, SOB, Wheezing? • Chest pain? • Blue lips, tongue, face? • Acute confusion? • Mucus or Dry? If mucus, pink in color or blood?
• Inhaled smoke/ flame / fumes/chemical irritants
• Cough because of DVT, PE, trauma, recent
surgery Dr.
• Fever >72hr / >40.5C
• Vomiting • Earache/Barking cough (usually child)
• > 3 weeks • Asthma, COPD, HF, GERD
• ACEi? > 3 weeks Notes: <6 yr: non-pharm only
Acute cough treatment
Antitussive for Dry cough: Dextromethorphan, or codeine
Expectorant: Guaifenesin, Honey
Allergic Rhinitis Redflags
Age <2 yr
• Facial pain?
• Unilateral symptoms (one-sided) • Fever? • Loss of smell/taste? • Sudden onset of sorethroat?
• Allergen cannot be identified. • > 2weeks • OM, Sinusitis, Asthma
Closed ended Questions:
• Symptoms interfere with sleep or daily activities?
No – mild Yes – moderate
• Cannot sleep/function -Severe >2 weeks (1+1) of allergen avoidance and OTC product
Allergic Rhinitis Treatment
Antihistamines (SGA > FGA ) Mild AR
FGA (>2 yr)(Chlorpheniramine, diphenhydramine)
SGA Mild AR
cetirizine (>=6 yrs), desloratadine (>=12 yrs), fexofenadine (>= 2 yrs), loratadine (>=2 yrs)
Intranasal corticosteroide Moderate – Severe AR
(Fluticason (>=2 yr), Triamcinolone (>= 4yr)) Decongestant (>=6 yr)
(Oral - Pseudoephedrine and intranasal – Oxymetazoline, Xylometazoline, Phenylephrine)
Canker/Aphthous sores (inside mouth) Red Flags
Red Flags:
• Can’t eat – severe pain
• > 5 ulcers • >1 cm (peanut size) • >14 days • > 6 times/yr. recurrence
• Bleeding
• Red/white patches – painful and swollen • Fever, joint pain, pharyngitis
• Present on roof of mouth / gums
• Lesions on hands, feet, genitalia, eye > 2 weeks
• Fever, Diarrhea develops • Increase in lesion size
Close ended Questions:
• Recently stopped smoking.
• H/O childhood ulcers. • F/H/O canker sores
Canker/Aphthous sores (inside mouth) Treatment
Anesthetics (>=12 yrs) (benzocaine, lidocaine, Benzylamide solution)
• No D/I
• S/E: Application site burning, edema, erythema, pruritus, rash, stinging, tenderness,
urticaria. • Solution – Rinse. Do not swallow.
• Apply QID before eating so less pain while eating • Max 7 days
Protectant
(Carboxymethylcellulose) • No known drug interaction
• S/E: Sticky or pasty sensation in the mouth.
• Coat after eating the involved area of the mouth with a thin film. Hold in position until it becomes sticky. Do not rub it in.
Seborrheic Red flags
Red Flags:
• Greasy, yellow scales over red and inflamed patches involving the folds between the nose and upper lip, behind the ear, eyelashes and eyebrows, groin (anywhere apart from scalp and scalp margin)
• Moderate to severe (even in scalp)
• Silvery, scaly plaques that bleed easily on scalp and present in elbows, knees, pelvis (Psoriasis)
• Drug induced (Lithium, Haloperidol, Methyldopa, etc.)
• Scales ↓50% within 7- 10 days
• Thickness and plaque / surface area - ↓50% within 6-8 weeks • Condition worsens
• Redness ↓50% within 8-12 weeks
• Itch ↓ to tolerable level within 1-2 weeks
Notes:
Treat only mild scalp seborrhea. High/Low temp makes it worse, but sun exposure makes it better.
Closed ended Questions:
• Dry, white scales scattered diffusely on scalp (Dandruff-treat)
• Exposure to any extreme temperatures or dry weather? • Use of hair pdts?
Seborrheic Treatment
Antifungals: Ketoconazole (cream-Rx shampoo-OTC) Onset 2-3 weeks, Max effect – 4 weeks
• S/E: scalp and skin irritation, itching, stinging, greasy or dry hair or scalp.
• If on corticosteroid, maintain and gradually withdraw over 2-3 weeks to allow ketoconazole effect and to prevent corticosteroid flare-up
Selenium sulfide (Selsun) May bleach hair
• Excessive use may cause hair loss or oily hair
• Avoid hair color use within 2 days of using selenium
• Avoid jewelry contact as it may be damaged
Zinc pyrithione
May discolor hair.
• Safe to use after perm solution • 2nd line
Corn/Callus/Bunion/Ingrown toenail Red Flags
Red Flags:
• Pain 1st MTP joint
• Great toe deviation / deformity.
• Nail appears thickened / discolored.
• Changes in skin color / texture of lesion
• Bump on the outside of foot
• Skin edge surrounding toenail is swollen, painful, bleeding/oozing (Ingrown toenail)
• >65 yr , Malnourished
• PVD, DM, immunocompromised
Closed ended Questions:
• Assess footwear • Pain, burning, hyperkeratosis (to confirm corn/callus)
• Lesion with black dots or seed in the Centre (plantar wart) • Rule out athlete’s foot symptoms
• Bunion / Ingrown toenail – Symptomatic/Ice packs and refer always
• Corn / Callus – No improvement >2 weeks Lesion becomes red/inflamed
Corn – usually on toes
Callus – soles of feet/heel
Corn/Callus/Bunion/Ingrown toenail Treatment
Analgesics For Bunions & Ingrown toenail Acetaminophen
• Avoid excessive alcohol
• Increases INR if on warfarin, check INR if acetaminophen ≥2g/day for ≥ 3 days and adjust warfarin accordingly.
• Antiepileptics increase acetaminophen metabolism leading to increased toxic metabolite
NSAIDs (Ibuprofen, Naproxen)
• Increase risk of bleeding – Anticoagulants, ASA, SSRI increase risk of bleeding
• Caution in HTN, CVD, renal dysfunction and Asthma.
• Increase lithium and MTX levels
Keratolytic For Corn/Callus
Salicylic acid 12–17.6% liquid 12–40% pads and plasters
• Soak in water, debridement with pumice
stone. Apply Vaseline on normal skin.
• S/E: Burning or irritation.
• Trim pad or plaster to fit the size and shape of the clean and dry area of the lesion.
• Wash hands thoroughly after application.
• Highly flammable
Plantar Warts Red Flags
Red Flags: • Pain at 1st MTP joint • Great toe deviation / deformity. • Nail appears thickened / discolored. • Bump on the outside of foot • Skin edge surrounding toenail is swollen, painful, bleeding/oozing (Ingrown toenail) • Change in color, appearance, or pain • PVD, DM, immunocompromised • Doubt about Diagnosis Closed ended Questions: • Black dot at center, pain when squeezed, skin ridges curved around lesion (to confirm diagnosis) • Warts not gone > 12 weeks • skin has been damaged/painful/inflamed
Plantar Warts Treatment
Salicylic acid (Compound W) 12–17.6% liquid 12–40% pads and plasters
• Soak in water, debridement with pumice stone. Apply Vaseline on normal skin.
• S/E: Burning or irritation.
• Trim pad or plaster to fit the size and shape of the clean and dry area of the lesion.
• Wash hands thoroughly after application.
• Highly flammable
• Contagious Cryotherapy (Compound W Nitro freeze – Nitrous Oxide)
• Do not use it on conditions that are not warts, it may cause serious burns (frostbite) and permanent scarring on the skin.
• Do not inhale nitrous oxide -symptoms can include feeling dizzy or confused and headache.
Athlete’ s Foot Red flags
• Weeping/severely inflamed / eczematous
• Oozing with purulent material
• Painful • Malnourished, elderly
• Toenails thickened or discolored • <16 y/o
• Comorbidities of DM, PVD, cancer, immunocompromised
• No improvement in 2 weeks.
• Symptoms not resolved completely in 6 weeks
Closed ended Questions:
• Blister, burning, redness, maceration, odor +/- (to confirm diagnosis)
• Ask occupation / sport activities
Athlete’ s Foot Treatment
Tolnaftate powder (Tinactin)
• For recurrent infection only.
• Powder sprayed directly on feet – not on shoes opical
(Clotrimazole (Canesten), Miconazole (Micatin spray / cream),Terbinafine - Rx)
• S/E: Local skin irritation or hypersensitivity (burning, erythema, pruritus, rash, stinging
• No known D/I as systemic absorption is minimal
• Oral antifungals only if treatment resistant to topicals
Bacterial Conjunctivitis Redflags
• Painful eyes • Visual disturbance
• Light sensitivity • Blunt Trauma
• Chemical exposure
• Heat exposure (e.g. welder’s arc)
• Foreign body inside eye
• wears contact lenses • eyes protruding Dr.
• clear discharge but eyes not itchy
• child • Discharge very severe
• No improvement / worsening in 2 days.
Closed ended questions:
• Watery (allergic/viral) or purulent discharge?
Bacterial Conjunctivitis Treatment
Ocular antibiotic
Gramicidin/polymyxin B (Polysporin eye drops) (>6 yrs)
• Continue treatment for 2 days after symptoms have resolved.
• Limit use to 4–5 days
• Contagious
• Do not use ear drops in eye
• Patients are sometimes given an antibiotic prescription to fill 3 days after being assessed, if needed
Allergic Conjunctivitis Redflags
• Painful eyes • Visual disturbance
• Light sensitivity • Blunt Trauma
• Heat exposure (e.g. welder’s arc)
• Foreign body inside eye • Chemical exposure
• wears contact lenses • eyes protruding Dr.
• clear discharge but eyes not itchy
Closed ended Questions
• Watery & itchy (allergic)
• Watery & non itchy (viral) or purulent discharge?
• Any environmental allergy?
• No improvement / worsening in 3 days
Allergic Conjunctivitis Treatment
Ocular
Decongestants (Tetrahydrozoline, Naphazoline, Oxymetazoline)
• S/E: stinging, burning
• Caution in closed angle Glaucoma
• Reduces redness and edema
• Do not use >10 days due to risk of rebound hyperemia
Mast cell stabilizer
(Sodium cromoglycate)
• S/E: cu stinging
• Takes 2–3 days to see symptom improvement
Ocular Lubricants
• Help wash out allergens and reduce eyelid swelling and reduce redness.
• Keep in fridge – soothing effect
Viral Conjunctivitis
• Always refer
Contagious
• Children should be kept out of school until there is no ocular discharge (approximately 1 week)
Dry Eye Red Flags
• Painful eyes • Visual disturbance • Light sensitivity • Blunt Trauma • Chemical exposure • Heat exposure (e.g. welder’s arc) • Foreign body inside eye • wears contact lenses • eyes protruding Dr. • clear discharge but eyes not itchy • if medication-induced or undiagnosed condition (blepharitis) • No improvement / worsening in 5 days Closed ended Questions: • Burning, fatigue, foreign body sensation
Dry eye treatment
Ocular Lubricants
(CMC, Polyvinyl alcohol,propylene glycol)
Keep in fridge – soothing effect
Constipation Red flags
- <2 y/o • Fever • Vomiting • Eating disorder
- Severe or persistent belly pain
- Unexplained Weight loss
- Blood or mucus in stools
- Severe pain when defecating
- Alternating with diarrhea
- Moderate to extreme thirst
- Rectal or abdominal mass
- Fatigue or overall weakness
- Nocturnal symptoms
- Recent abdominal surgery
- F/H/O colon cancer in > 50 yr patient
- No bowel movement in 7 days or does not resolve in 14 day despite medication use
- Bloating and cramping not relieved after defecating
Constipation Treatments
Bulk-forming:
Psyllium (>6 yr) (Metamucil)
• Onset: 5-15 min • S/E: Flatulence, bloating
• Separate 2 hrs. from other meds
• Drink with 250 ml water.
• Psyllium powder and capsules are gluten-free.
Enemas (>2 yr) • Onset: 15-30 mins
(mineral oil, phosphate, tap water)
• Risk of mechanical trauma to rectal wall
Osmotic agents
Glycerin suppository
• S/E: Rectal irritation
Lactulose (>=1 yr) • Onset: 24 48 hrs
.• S/E: Flatulence, abdominal cramps
• Separate 2 hrs. from other meds
Magnesium citrate
• May reduce bioavailability of digoxin and tetracycline
• Use only if not responsive to other agents
PEG (>2 yrs) • Onset: 48-96 hrs
• S/E: diarrhea, flatulence, nausea, retching, abdominal bloating, cramping, anal irritation
• Separate 2 hrs. from other meds
Sodium phosphate • Onset: 0.5 – 3 hrs
• S/E: Hypocalcemia, hypokalemia and hypernatremia
• ACEi, ARBS, diuretics AND NSAIDS may enhance nephrotoxic effect of NaPO4
Stimulants
Bisacodyl tabs & suppositories
(Dulcolax) (>= 6yrs)
• Onset: PO: 6–12 h PR: 0.5–1 h
• Milk, antacid, PPI decrease acidity of the stomach which may damage the special (enteric) coating of bisacodyl leading to decreased effect
Senna (>2 yr) • Onset: 6-12 hrs.
• S/E: Abdominal pain, diarrhea, hypokalemia, dehydration, allergic reactions
• Discolor urine to pink
Stool softner
Docusate • Onset: 12-72 hrs
• S/E: Usually well tolerated. Mild, transient nausea or GI cramps may occur
Diaper Dermatitis Red Flags
Red Flags:
• Acute onset with oozing pus, blisters, or ulceration
• Frequent recurrence, with no rash-free period in between
• Rash outside the diaper area
• Moderate or severe presentation
• Fever, nausea or vomiting
• Complicated by secondary infection or UTI comorbidity
• Behavioral change like crying nonstop, overall weakness
• Signs if abuse or neglect
• Immunocompromised
• Rashes don’t get better after 7 days of treatment or worsen
• Symptoms do not completely resolve within 14 days despite medication use
Closed ended Questions:
• Fungal – Beefy/tomato red plaques, satellite pustules, Inguinal folds involvement, thrush in oral cavity
• Inflammatory – redness, swelling, warmth, pain
Diaper Dermatitis Treatment
Barrier
Zinc oxide 10-40 %
• Onset: skin protection is immediate
• Duration: skin protection lasts about 3 h.
• Should be always applied as barrier with each diaper change.
Antiinflammatory
Hydrocortisone 0.5% (>2 yr)
• Onset: for pruritus relief is immediate; inflammation relief takes about 2 days
• Caution (Dr.) if <2 y/o due to increased absorption
• Should not be used for more than 2 wk.
Antifungals (clotrimazole, ketoconazole, miconazole)
• Onset: clinical improvement and relief of pruritus within 1 wk.
• Duration: continue for minimum of 4 wk.
• S/E: Blistering, irritation, mild burning, transient pruritus, stinging
Diarrhea Red Flags
Red Flags:
• Blood / Mucus in stools
• Severe diarrhea (>6 unformed stool for >48h)
• Worsening, persistent, or chronic diarrhea
• Extensive stomach pain or cramping
• Vomiting >4h
• Fever >38.5C
• < 2 y/o
• Frail elderly
• Pregnant
• DM, kidney failure, HF, immunocompromised
• Dehydration - weakness, dry mouth, decreased urination, child – reduced no. of diapers, few/no tears when crying
• Recent antibiotic use
• Weight loss
Symptoms of diarrhea persist >48 hrs even with antidiarrheal
• Dehydration symptoms despite being on ORS
• Blood in stools
• Fever develops
Diarhhea Treatment
Attapulgite Discontinued -2021
Loperamide (>12yr. - OTC) (Imodium)
• S/E: Abdominal cramps or discomfort, drowsiness, dizziness, dry mouth, skin rash
• Increased level by ritonavir or quinidine
• Use with caution in children <12 y of age.
• Discontinue if symptoms persist longer than 48 h
• Not used in C. Diff, IBD
Bismuth subsalicylate (>12yr. - OTC) Liquid and tabs
• S/E: Black tongue and stools, tinnitus
• Avoid if taking anticoagulants, MTX, probenecid, salicylates
• Avoid in salicylate allergy
• D/C if develop ringing of ear
Psyllium (>6 yr.) (Metamucil)
• S/E: Cramping, flatulence
• Space by 2hrs with other meds
ORS C/I:
• Protracted vomiting despite small frequent feedings.
• Worsening diarrhea and an inability to keep up with losses
• Stupor or coma
• Intestinal ileus
• Breastfeeding should be continued during episodes of diarrhea and ORS should be offered.
GERD Red Flags
Severe belly pain
• Weight loss
• Black tarry stools or blood in stools / vomit
• Difficulty/painful swallowing
• Chest pain radiating to the back and jaw
• Choking
• Dizziness, fatigue, pale appearance, cold extremities
• Vomiting
• Abdominal mass
• >50 y/o
Symptoms persist >14 days despite medication use
Closed ended Questions:
• Mild/ Mod/ severe
• NSAIDs us
GERD Treatment
Antacid (Alginic acid (Gaviscon), CaCo3, Mg salts)
• Decrease absorption of fluoroquinolones, tetracyclines, iron and digoxin, INH
• S/E: Constipation with Ca and Al, Diarrhea with Mg
H2RA
(famotidine (>12yrs), Ranitidine (>16 yrs), Nizatidine)
• S/E: Headache, Dizziness, Nausea
• All level decreased by antacid so separate by 0.5-1 hour
PPI (OTC: esomeprazole 20mg)
• Take 30 min before food
• S/E: Headache, nausea, diarrhea, rash.
• CYP2C19 inhibitors so may increase levels carbamazepine, triazolam, warfarin but conflicting data with clopidogrel.
• May decrease absorption ampicillin, iron, digoxin
Fever Red flags
Red Flags: 911 • <3 months • Stiff neck, seizure, localized pain, redness, swelling • New wheeze/cough • Recent / ongoing chemo • Child very ill, fussy, irritable crying incessantly Dr. • <6 months • Persistent wheeze/cough • New onset rash/fever • Confused/delirious • Recent surgery/dental procedure • Recent travel • intake of raw food • Recent new medication •Persists > 24 hours with medication or for more than 3 days • > 40.5C at anytime
