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 reactionviii. 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:
o 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
