Red flags in medical practice

The signs and symptoms of serious disease may be easily overlooked by the non-specialist in both primary and secondary care. This conference, organised by the British Geriatrics Society in conjunction with the Royal College of Physicians (RCP), presented the ‘red flags’ of some of the major medical specialties, while highlighting cases that may present atypically. Rheumatology and geriatric medicine The term ‘red flag’ was originally associated with back pain. The first catalogue of red flags for back pain appeared in the literature in the early 1980s and since then numerous lists have been compiled. The opening lecture of the day highlighted that red flags are a helpful concept, but can often have limited practical value. Henschke and colleagues 1 demonstrated a low sensitivity of the red flag questions in picking up serious causes of back pain, suggesting that clinical expertise trumps formulaic rules. Falls in the elderly population are common, often multifactorial and misdiagnosis of the cause has implications for falls prevention. Injurious falls in particular should act as a warning for loss of consciousness. 2 Hospitalisation after falls in elderly patients with cognitive impairment puts them at high risk of developing delirium. Incident delirium can be reduced by 30% in such patients by addressing basic factors such as pain control, medications, sleep hygiene, cognitive stimulation, hearing, vision, mobility and hydration. Detection of dehydration in elderly patients is difficult since the collagen changes of aging reduce skin turgor and lead to sunken eyes. Examination for axillary moisture is therefore a useful tool and a dry axilla is a red flag for dehydration. 3 Hypoactive delirium is poorly detected in hospitals. Before labelling a patient as a ‘difficult historian’ the clinician should consider underlying delirium. Similarly, a ‘social admission’ may be a mask for a missed delirium or another medical problem in disguise. Certain behavioural symptoms, such as carphology (picking at bedclothes), can act as a marker of delirium. Failure to orient the body in line with the bed (known as a ‘positive oblique sign’) is a predictor of cognitive impairment 4 and can be assessed quite literally at the bedside.