Importance of evaluation of

red flags
in primary care

Prof. R P J C Ramanayake
 What are red flags

Red flags are signs and symptoms found in the patient's

history and clinical examination

These are clinical indicators of possible serious underlying . .

condition
 History of red flags

The term “red flag” was originally associated with back pain.

The first Catalog of red flags for back pain appeared in the
literature in the early 1980s.
 Importance in primary care
• Primary care physicians encounter a broad range of problems.

• They encounter patients at early undifferentiated stage of a

disease.

• Most of the presentations are due to non sinister problems but

in minority of patients same presentations could be due to
serious conditions.
 Importance in primary care
Differentiating between innocent symptoms and a rare, but
serious organic disease is a challenge for the primary care
physician.

patient evaluation and decision making is mainly dependent on

history and examination with the availability of minimal investigatory
facilities.
 Importance in primary care
Unnecessary referrals and diagnostic testing need to be
balanced against the risk of missing a diagnosis.

The red flag concept is of immense value in facing this

challenge.
 Types of red flags
General red flags - loss of appetite / loss of weight
could be due to many pathologies

Specific red flags - melaena / haematemesis

indicate GIT bleeding

All red flags, whether highly diagnostic or not, general or

specific, warn us the possibility of life-threatening disorders.
“Red flags” are widely used in evaluation of patients present
with

- Low back pain

- Red eye

- Headache

- Gastro esophageal reflux

 When a patient presents with low backache,

What are the symptoms and signs you have to look for in
the history and examination(Red flags) to decide whether
the patient needs investigations and/or referral?
 Red Flags - Backache
Age over 50 years – Malignancy, Abdominal pathology
Age less than 20yrs – Congenital defect, tumor, infection
Previous cancer – Metastasis
Weight loss – Malignancy
Fever– Infection
History of trauma – Vertebral fracture
Neurological symptoms – Nerve root involvement
What are the red flags we should look for when
a patient presents with redness in the eye?

.
 Red Flags – Red Eye

Reduced visual aquity –A. glaucoma

Severe pain – A glaucoma, corneal ulcer
Corneal opacity – Corneal ulcer
 Red Flags – Red Eye

Circumcorneal redness Redness in periphery

Corneal ulcer Conjunctivitis

A. glaucoma
Iritis
 Red flags – Red eye

Irregular pupil

Iritis
 Red Flags - Headache
Onset after 50 years -Tumor/Temporal arteritis
Sudden onset “thunderclap” – Subarachnoid Haemorrhage
Focal neurological signs – Tumor
Neck stiffness – Meningitis
Papilledema – Tumor/ Meningitis
Pregnancy - PIH
Red Flags – GORD symptoms

Onset after 45 years – Gastric carcinoma

Dysphagia – Gastric/esophageal CA
Weight loss – Gastric CA
Loss of appetite – Gastric CA
Haematemesis/malena –Peptic ulcer
Epigastric mass - Carcinoma
 Red Flags - Limitations
• Different guidelines have produced a different set of red flags for
the same presentation..

• Guidelines generally provide no information on the diagnostic

accuracy of a particular red flag, which limits their value in
clinical decision-making.

• It is essential to use the clinical acumen to overcome the

deficiencies
 Conclusions
Evaluation of red flags does not need sophisticated equipment
or money.
You only need knowledge and skill and a few extra minutes.
Even though there are limitations evaluation of red flags is of
immense value in marginalizing the risk of missing serious
illnesses.
This is one of the main tasks of a primary care doctor !
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