RED FLAG FRIDAY: Don't Blow Off Anemia

In a population-based study, 9 percent of adults older than 65 years with iron deficiency anemia had gastrointestinal cancer. Yikes! I know, nine percent doesn't sound like a lot. But think about how many geriatric patients we see each year with anemia! In fact, older adults with anemia had gastrointestinal cancer 31 times as often as adults without anemia. (REFERENCE: Ioannou GN. Am J Med 2002;113:276-80).

RED FLAG FRIDAY: Headaches

This is an awesome tip that I learned from Dr. Jennifer Keehbauch (who is the Associated Director here at Florida Hospital Family Medicine Residency). This tips was given as part of our "Learning Center" teaching series which our faculty personally do for our residents. Enjoy!


      S     =     Systemic Signs (such as fever, meningismus, or weight loss)


      N     =     Neurologic Signs or Symptoms (slurred speech, double vision, abnormal neuro exam)


      O     =     Onset Sudden ("worst headache of life", thunderclap)


      O     =     Onset < 5 years or > 50 years (don't forget about temporal arteritis)


      P      =    Progression of Existing Headache (increased severity or frequency or change in quality)


If a patient has any of these symptoms, consider imaging to look for a secondary cause of the headache. 

RED FLAG FRIDAY: Shingles on Tip of Nose

Herpes Zoster (shingles) is not typically "dangerous". But when the rash presents on the tip of the nose (Hutchinson's Sign), we have to worry about possible eye involvement. Refer those patient's immediately to an ophthalmologist.

RED FLAG FRIDAY: A NORMAL Urine Culture

Let's say that you treat a patient for a urinary tract infection and the initial UA which showed the following:

1+ protein, 1+ blood, 3+ LE, and POS nitrite

Then, several days later, the urine culture comes back normal:

NO GROWTH FOUND.

That result should not provoke rejoicing! It should cause some stress and worrying! Why? Because if the patient did not have a urinary tract infection, then what caused the 1+ blood in the initial UA? Could it be bladder cancer? Could it be renal cell carcinoma?

Whenever, I get a normal urine culture, the first thing that I do is to check the initial UA. If there is blood on the initial UA, I have the patient see me again to repeat another UA with a urine microscopy. If there are more than 3 RBC per high powered field, then I do a urology referral to work-up hematurea.

RED FLAG FRIDAY: Joint Swelling

Joint effusions are common. Most often they are related to injury. But if a patient presents with joint swelling AND fever, that combo is a septic joint until proven otherwise. I usually do a STAT referral to an ER who will then do a STAT orthopedic surgery consult! Although other conditions can cause joint swelling and fevers, this is not one to miss or blow off.

RED FLAG FRIDAY: Sore Throats

When someone comes in for a sore throat, I look especially for a peritonsilar abscess. And when I do NOT find one, this is how I document a normal exam: Tonisilar pillars are symmetric and uvula a midline. If there is a peritonsilar abscess—which happens about once a year in my practice—I send the patient immediately to the ER who then consults an ENT doc to do an incision and drainage of the abscess. (I'm not about to stick a scalpel near someone's carotid artery!)

RED FLAG FRIDAY: Diarrhea

Just like back pain, the vast majority of diarrhea is self-limiting and benign. But here are some "red flags" that I typically screen for:

1. RECENT ANTIBIOTIC USE—consider Clostridium Difficile.
2. RECENT CAMPING (or drinking water form a lake, pond, or stream)—consider Guardia. I once had a man who maintained fountains in ponds who we diagnosed with Guardia. My only case in the last 10 years. 
3. CHRONIC WEIGHT LOSS—consider looking for colon cancer or inflammatory bowel
4. ABDOMINAL PAIN or BLOODY STOOLS—Consider invasive organism such as salmonella. Also entertain other infectious causes of abdominal pain.

Again, those are just some of the "red flags" off the top of my head. Do you have any others?

RED FLAG FRIDAY: Backpain

Although the vast majority of acute low back pain is benign, here are some "red flags" that I learned long ago to screen for:

1. FEVER—Consider infectious etiologies. After a spinal procedure such as epidural, consider spinal abscess. Also consider pylonephritis and pneumonia if pain is higher. I suppose rheumatic etiologies should be entertained (but patient should have other symptoms as well). 
2. PREVIOUS HISTORY OF CANCER—consider metastatic disease.
3. PARANEOPLASTIC SYMPTOMS—such as weight loss, night sweats, fever, etc. Also consider metastatic disease or even multiple myeloma.
4. FALL or TRAUMA or RISK OF OSTEOPOROSIS—consider fracture. 
5. CAUDA EQUINA SYMPTOMS—never seen a case in the last 15 years in medicine. And these patients would unlikely present to my office. The ER seems way more likely. But I suppose like all things, it's good to keep in mind.
6. PULSATILE MASS ON ABDOMINAL EXAM—consider abdominal aortic aneurysm. Again, I have never seen a case of this present as isolated low back pain. But I suppose someone has. 

I'm sure that there are other "red flags" for back pain. These are just the ones that come to mind off the top of my head. Does anyone else have other "red flags" to add?