Tuesday, September 18, 2012

Using Risk Factors and Red Flags to Rapidly Identify Potential Serious Disease Processes


Identifying high risk patients from common chief complaints is an endeavor that needs to be cultivated and will significantly enhance one’s clinical acumen.

High Risk Patients can present with very subtle findings. An acute MI with ST elevation becomes readily apparent but the patient with the dissection can easily be misdiagnosed. High risk also includes illnesses that need to be treated in a specific time frame and bad outcomes leads to high liability.

Risk Factors are a combination of historical associations through family history, social history, genetics and red flags are positive responses to goal directed questions and physical exam findings that can lead to a higher suspicion of serious illness. Risk factors that are historical have been determined by longitudinal clinical studies over many years. They are a helpful guide but do not exclude serious illness in an individual patient.

The converse is also true. The majority of back pain chief complaints are musculoskeletal. How does one rapidly identify the patient that needs a more extensive evaluation?

The #1 Risk Factor is abnormal vital signs. Each abnormal sign must be addressed. If cannot be explained, further evaluation or monitoring is required.

See index below for some examples of risk factors and red flags associated with the following chief complaints. They are not all inclusive.

Chief Complaint:

        i.           Chest Pain
      ii.            Shortness of Breath
    iii.            Ob-Gyn
    iv.            Back Pain
      v.            Headache
    vi.            Syncope
  vii.            Allergic reaction
viii.            Abdominal Pain
     ix.            Testicle pain


This list is extensive, however evaluating the patient with knowledge of these risk factors and red flags will limit your liability and allow benign processes (tincture of time) to heal most patients without extensive cost , radiation, side effects of unnecessary treatments.  When artificial intelligence is fully developed and placed in EHRs, these items will be sent to the provider in real time to enhance their clinical decision making.
More details available upon request.


Index:


i.                    Chest Pain

         Risk Factors for Acute Coronary Syndromes:
o   Past Hx of CAD
o   Family Hx of CAD
o   Age: Male >33 Female >40
o   Diabetes
o   Hypertension
o   Smoking
o   Increased Lipids
o   Sedentary lifestyle
o   Obesity
o   Postmenopausal
o   Drug use- cocaine

Risk Factors for Pulmonary embolism (PE):
o   Prolonged immobilization
o   Surgery >30 days 3 months
o   Prior DVT or PE
o   Pregnancy
o   Lower extremity trauma
o   Oral contraceptives
o   Smoking
o   CHF
o   Chronic obstructive pulmonary disease
o   Obesity
o   PMH or FH Hypercoagulability

Risk Factors for Aortic Dissection:
o   Hypertension
o   Congenital disease of the aorta or aortic value
o   Inflammatory aortic disease
o   Connective tissue disease
o   Pregnancy
o   Arteriosclerosis
o   Smoking


ii.                  Shortness of Breath

                          Risk factors for Acute Coronary Syndromes:
           See list above

                        Risk factors for Pulmonary embolism (PE):
o   See list above

 Risk factors for Pneumothorax:
o   Hx Pneumothorax
o   Valsalva maneuver
o   Chronic lung disease
o   Smoking


iii.                Ob-Gyn

             Risk Factors for Ectopic Pregnancy:
o   Abdominal pain
o   Abnormal tenderness
o   Positive hCG test

 Ovarian Torsion
o   Pregnancy
o   ovarian cysts
o   ovarison hyper stimulation syndrome
o   tumors

Pelvic Inflammatory Disease
o   STD exposure
o   Abdominal pain
o   Fever
o   Vaginal discharge
o   Pelvic pain
o   Multiple sex partners


iv.                Back Pain

          Risk Factors for Abdominal Aortic Aneurysm:
o   Abdominal pain
o   Back pain
o   Age >50

  Red flags:
o   Numbness
o   Dizziness
o   Motor Weakness
o   Syncope
o   Paresthesias
o   Fever
o   urinary retention


v.                  Headache

          Red flags:
o   Syncope
o   Loss of Consciousness
o   Mental State
o   Speech Difficulty
o   Seizure disorder
o   Focal weakness
o   Dizziness
o   Gait Abnormal
o   Numbness
o   Paresthesias
o   Fever
o   Polycystic kidneys
o   Osteopathic manipulative treatment


vi.                Syncope

            Risk Factors for ACS:
o   See above

Risk Factors for Pulmonary Embolism (PE):
o   See above

Risk Factors for Abdominal Aortic Aneurysm:
o   See below

Risk Factors for Drug Syncope:
o   Drug use
o   Polypharmacy
o   Drug interactions

Risk Factors for Ectopic Pregnancy:
o   See above

Family History of Sudden Death

CHF (Congestive Heart Failure)


vii.              Allergic Reactions

          Red flags:
o   Allergic to ace inhibitors
o   Allergen exposure
o   Allergic to bee stings
o   Bug bites / stings
o   Allergic to shellfish
o   Allergic to soap/detergent
o   Allergic to pets


viii.            Abdominal Pain

         Risk Factors for Ectopic Pregnancy:
o   See above

Red Flags for Abdominal Aortic Aneurysm:
o   Abdominal pain
o   Back pain
o   Age >50

 Risk Factors for Mesenteric Ischemia and Ischemic Bowel Disease:
o   Age >55
o   Hx Cardio Vascular Disease (CV)
o   Hx Congestive heart failure (CHF)
o   post-myocardial infarction mural thrombi
o   Congestive heart failure (CHF)
o   Shock
o   hypercoagulable state
o   pain is out of proportion
o   coagulable state
o   arrhythmias
o   Sleeping impairment

Risk Factors for Acute Coronary Syndromes:
o   Past Hx of CAD

 Red Flags for Acute Appendicitis:
o   Anorexia
o   Right lower quadrant pain
o   Fever


ix.                 Testicle Pain

             Age <40

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