Week 24 - red flags

Question 1

The challenge of diagnosis in generalism

Answer 1

-Most patients present with self-limiting and/or benign medical conditions
-Need to be able to identify patients in whom a there is a more serious potential
diagnosis
-This is difficult when faced with a wide range of medical problems in time-limited
encounters

Question 2

What is a “red flag”?

Answer 2

In a medical context, a red flag is a warning symptom, sign or test result that suggests a potentially serious underlying pathology
->Their presence or absence adjusts the probability
of a serious condition – and therefore the threshold for further tests or referral

Question 3

Not all red flags are the same…

Answer 3

Not all red flags have equivalent diagnostic power:
-General red flags: direct the clinicians to recognise a serious illness even though the exact disease is not known, e.g. unexplained weight loss
-Specific red flags: signal specific illnesses and present in specific anatomical regions

Question 4

Techniques for identifying red flags

Answer 4

-Use open questions and start generally, e.g. ‘What can I do for you?’, followed by further ‘open’ investigation, e.g.:
-> ‘Can you tell me a bit more about your symptoms and how they all started’
->‘Is there anything else that you think may be important?’
-> ‘And what happened then?’
-Find out exactly what the reason for the consultation is and explore the presenting symptom/s in detail
-Be alert all the time and actively search for ‘hidden’ red flags
-Be aware of combinations of symptoms that suggest serious disease

Question 5

Low back pain

Answer 5

One of the most common presentations in primary
care:
-1-4% is a fracture
-<1% is a cancer
Despite the potential seriousness of the cause,
cannot justify testing everyone for everything

Question 6

Examples of red flags in low back pain

Answer 6

Fracture:
-Prolonged use of corticosteroids
-Older age (>70 yrs)
-Hx of osteoporosis
-Mild trauma > 50yrs with osteoporosis
-Significant trauma at any age
Cancer:
-Age <20yrs or >50yrs
-Previous Hx of cancer
-Unexplained weight loss
-Night pain not relieved by rest
-Failure to improve with Tx
-Lasts >4-6 weeks

Question 7

Examples of red flags in low back pain 2

Answer 7

Cauda equina:
-Saddle anaesthesia
-Bladder/bowel dysfunction
-Motor weakness/sensory deficit
Infection:
-Systemically unwell: fever, chills
-Recent bacterial infection
-Recent surgery
-Immunocompromised

Question 8

Yellow flags

Answer 8

-Belief that pain itself is harmful
-Sickness behaviours – extended rest
-Social withdrawal/lack of support
-Low mood/depression/anxiety
-Problems/dissatisfaction at work
-Compensation or benefit claims
-Overprotective family
-No active participation in treatment