Medical Red Flags For Acupuncturists

Front 1

Headache, eye pain, blurry or haloed vision, nausea, vomiting

Back 1

Acute closed-angle glaucoma
Total loss of vision
Urgent care referral or semi-urgent PCP
Symptoms closely resemble classic migraine

Front 2

Sudden cataclysmic headache in middle-aged hypertensive patient

Back 2

Nontraumatic subarachnoid hemorrhage (NTSAH)
Paralysis, death
If stable, PCP. Unstable, 911
"Worst headache of my life"

Front 3

Atraumatic, progressive, intermittent hip pain on movement and decreased hip ROM

Back 3

Avascular necrosis of hip, also Prrthese disease, "Legg-Calve-Perthes" or aseptic necrosis of hip
Disabling osteoarthritis of hip
Semiurgent PCP
Generally diagnosis between 4-10 years of age

Front 4

Hip, knee, groin pain with limp in obese adolescent with or without trauma, decreased ROM

Back 4

Slipped capital femoral epiphysis
Severe hip arthritis and loss of function
PCP or orthopedist

Front 5

Knee trauma with pain and immediate and severe swelling of the knee

Back 5

Internal derangement of knee (ACL, PCL, menisci)
Permanent pain and disability
PCP or orthopedist
Tests - Lachman, anterior and posterior drawer, Mcmurray

Front 6

Mid-abdominal pain followed by vomiting, then pain moving to lower right abdomen

Back 6

Acute appendicitis
Infection of abdominal cavity, sepsis and death
ER
McBurney's point

Front 7

Posterior calf pain reliably occurring after walking specific distance

Back 7

Intermittent claudication from peripheral artery disease
Loss of limb, increased risk of stroke and MI
Timely PCP or urgent care if no PCP

Front 8

Late teen to early adult with focal persistent shin pain after increasing running distance

Back 8

Stress fracture of tibia
Complete tibial fracture
Timely PCP
Shin splints tend to be bilateral, stress fractures tend to be unilateral

Front 9

Neck pain with tingling, numbness, or pain radiating down one arm

Back 9

Cervical nerve root radiculopathy
Permanent neuromuscular deficit in arm or hand
Timely PCP or orthopedic surgeon
Four grades from minimal sensory fiber compression to major compression of motor and sensory fibers with severe pain and numbness with weakness and muscle atrophy

Front 10

Neck pain and progressive sensory changes and weakness in both arms and legs (slower onset)

Back 10

Spinal cord injury
Paralysis and loss of function
Timely PCP if stable, avoid risk of fall or trauma

Front 11

Shoulder pain and progressive inability to abduct the arm due to shoulder stiffness

Back 11

Adhesive capsulitis of shoulder (frozen shoulder)
Longterm disability and pain
Timely PCP for further referral

Front 12

Severe sore throat, high fever, drooling, difficulty swallowing in an adult

Back 12

Peritonsillar abscess
Possible sepsis and death
PCP or ENT

Front 13

Pain on urination (dysuria) with high fever, chills, frequent urination, malaise, pain in back

Back 13

Kidney infection(acute pyelonephritis)
Kidney scarring, failure, abscess, sepsis, death
PCP, urgent care or ER if high fever, shaking chills, appears septic

Front 14

Chronic tenderness in anatomical snuff box, pain of wrist after fall on outstretched hand

Back 14

Occult fracture of scaphoid bone
Malunion, nonunion, avascular necrosis
Timely PCP or urgent care

Front 15

Bunion deformity (hallux valgus) of great toe displacing adjacent toes

Back 15

Hallux valgus deformity with subluxation of adjacent joints
Chronic pain, disability
PCP

Front 16

Abdominal pain and rigidity of abdominal muscles (general red flag)

Back 16

Irritation of inner lining of abdominal peritoneum from blood and or pus
ER

Front 17

Persistently inflamed joint (general red flag)

Back 17

Possible dz includes inflammatory arthritist, lupus, rheumatoid arthritis, gout, pseudogout
Permanent joint and soft tissue damage, damage to vital organs, deformity and disability

Front 18

Acute joint pain and or inflammation after surgery

Back 18

Possible sepsis and death within 24 hrs
ER

Front 19

Joint inflammation with no recent surgery or trauma (general red flag)

Back 19

Many serious conditions possible
Prompt referral

Front 20

Persistent and chronic joint inflammation with acute flare (general red flag)

Back 20

Possible permanent destruction of bone, cartilage, or tendon
Rheumatology consult

Front 21

Pain that worsens progressively over weeks to months (general red flag)

Back 21

Ongoing tissue damage

Front 22

Pain that steadily increases over weeks to months (general red flag)

Back 22

Treat of irreversible tissue damage from cancer, nerve damage, post-surgical pain syndromes, ischemia, etc

Front 23

Progressively worsening pain after surgery (general red flag)

Back 23

Never normal
Refer back to surgeon

Front 24

Increasingly painful area that turns numb (general red flag)

Back 24

Possible conditions include carpal tunnel syndrome, spinal radiculopathy
Total sensory nerve destruction

Front 25

Worsening of any stable chronically recurring pain (general red flag)

Back 25

New tissue necrosis or injury

Front 26

Progressive and unremitting bone pain (general red flag)

Back 26

Bone cancer

Front 27

Unexplained fracture caused by minimal or unidentified trauma (general red flag)

Back 27

Pathological deterioration of bone, possibly due to cancer, osteoporosis, Paget's disease, etc

Front 28

Pain or loss of function after trauma with severe immediate pain at the time of trauma, numbness, weakness and or loss of function (general red flag) (pain may diminish significantly after trauma in these cases)

Back 28

Fracture or disruption of vital structure
Note - any trauma severe enough to produce exquisiste pain at timeof injury can seriously damage tissues.

Front 29

Severe pain and swelling in joint immediately after trauma (general red flag)

Back 29

Ruptured arteriral or arteriolar vessels

Front 30

Intense pain and skin changes persisting many weeks after trauma (general red flag)

Back 30

Complex regional pain syndrome (reflex sympathetic dystrophy)
Notes - after initial decrease in healing process, pain begins to increase. Three stages post-injury. Symptoms of stage 1(right after injury to 3 mo) may include severe burning pain, muscle spasm, joint stiffness, fast hair growth, scalding or wire brush sensation on skin from light touch such as clothes. Stage 2 (3 months post injury) changes in the nails, localized osteoporosis, skin may become cold, pale, taut, smooth or glassy, weak muscle tone. Stage 3 irreversible changes in skin, joints, bones, unrelenting pain, dry scaly mottled skin, thick and ridged nails, tremors, involuntary contractions

Front 31

Upper abdominal pain and vomiting blood

Back 31

Upper GI hemorrhage from inner lining of stomach and or esophagus
Possible death
Semiurgent transport by other if stable, 911 if vomiting blood and unstable cardiopulmonary

Front 32

Daily heartburn for many years

Back 32

Chronic esophagitis
Barrett's esophagus or esophageal cancer
PCP, gastroenterologist
Test for H. pylori, possible endoscopy

Front 33

Severe abdominal pain better with leaning forward, nausea and vomiting

Back 33

Acute pancreatitis
Severe pain, possible fatality
ER

Front 34

Sudden lessening of appendicitis symptoms, followed by later worsening of pain, fever

Back 34

Honeymoon period in abdominal pain due to rupture of appendix, followed by peritonitis
Sepsis, shock, death
ER by family or friend, otherwise 911 if no other transport available

Front 35

Mid to lower abdominal colicky pain, vomiting, constipation, abdominal distention

Back 35

Bowel obstruction
Death
ER with advance call to triage nurse or doc or 911

Front 36

Low back pain with progressive leg numbness, tingling, weakness

Back 36

Compression neuropathy from pressure on lumbar nerve roots (radiculopathy), (possible disk involvement)
Permanent numbness, weakness, loss of function
Tests for patellar or Achilles tendon reflex, decreased strength in dorsiflexion, straight leg raise test (compression radiculopathy)

Grade 1- mild pain, no sensory impairment. Treat and monitor.
Grade 2- moderate pain, constant parasthesia, sensory loss objectively verified. Aggressive treatment and refer for eval.
Grade 3- very painful, parasthesia, constant numbness, weakness or loss of reflex, no atrophy evident. Aggressive treatment, semiurgent referral to PCP or specialist
Grade 4- severe pain, numbness, parasthesia, inability to move some muscles, atrophy. Semiurgent referral.

Front 37

Back pain with insidious onset and progressive, unintentional weight loss

Back 37

Cancer of the spine
Disability and death
Semiurgent PCP

Front 38

Back pain, progressive bilateral leg weakness and erectile dysfunction in a man over 40

Back 38

Cauda equina syndrome (lower soinal canal narrowing - spinal stenosis)
Permanent weakness in lower extremities, anal incontinence, impotence
PCP

Front 39

Severe localized midline back pain with spinal process tenderness to percussion

Back 39

vertebral compression fracture with possible underlying osteoporosis or tumor
Extreme pain, disability, prolonged bedrest
PCP or ER if overwhelming pain

Front 40

Chest pain coming on reliably with physical exertion

Back 40

Angina pectoris - ischemic myocardial pain secondary to coronary artery disease
MI
Urgency proportionate to severity of symptoms

Front 41

Sarp chest pain, SOB, unilateral or bilateral assymetric ankle swelling

Back 41

Pulmonary embolus
Sudden death
911

Front 42

Sudden spontaneous sharp unilateral chest pain, SOB

Back 42

Pneumothorax
Death
If minor symptoms, semiurgent referral. If severe and unstable symptoms, 911. Smokers less likely to self-resolve.
Note - tension pneumothorax likely from major trauma

Front 43

Earache, ear drainage, fever, severe tenderness of mastoid process

Back 43

Acute mastoiditis
Oteomyelitis of mastoid bone, infection of nearby tissues causing thrombosis, abscess, meningitis, facial nerve damage, labyrinth destruction
Semiurgent PCP, urgent care, or ENT. Deep local needling contraindicated.
More common in very young

Front 44

Persistent elbow pain and stiffness after fall on outstretched hand

Back 44

Fracture of radial head of elbow
Permanent stiffness, deformity, arthritis, nerve damage
PCP semiurgent

Front 45

Elbow swelling and pain with diminished radial pulse and or hand numbness after fall

Back 45

Supracondylar fracture of humerus
Ischemic necrosis, permanent neurological impairment
ER, call to triage to notify of diminished radial, pulse

Front 46

Facial pain over sinuses, fever, purulent drainage from nose continuously for more than 3 months or recurrently fore more than six months

Back 46

Chronic bacterial sinusitis
Abscess formation possibly leading to meningitis, damaged vision, encephalitis, osteomyelitis
PCP if no urgent symptoms

Front 47

Severe sudden anxiety, smothering sensation, chest pain with complete recovery

Back 47

Panic disorder
If Treatment is not effective, consult with PCP

Front 48

Non-drug induced auditory hallucinations, delusions, tangential thinking

Back 48

Schizophrenia
Psychiatric consult, psychiatric emergency services or 911 if needed

Front 49

Patient who feels pessimistic, hopeless, helpless

Back 49

Major depression
Emergency psychological services if suicide risk, PCP or psychological/psychiatric consult otherwise

Front 50

Depression followed by episode of hyper-excitation and euphoria

Back 50

Bipolar disorder

Front 51

Personality change, social withdrawal, unstable relationships, evasiveness, decreased academic performance

Back 51

Drug abuse or addiction

Front 52

Palpitations that occur reliably with exercise and go away with rest (general red flag)

Back 52

Some type of heart disease

Front 53

Chest pain that occurs reliably with exercise and goes away with rest (general red flag)

Back 53

Coronary artery disease

Front 54

Resting heart rate over 100 beats per minute, hyper vigilance, warm skin

Back 54

Hyperthyroidism (thyrotoxicosis)
Thyroid storm leading to heart failure and death
PCP; throid storm requires ER

Front 55

Irregularly irregular pulse with rate over 100 bpm

Back 55

Atrial fibrillation with uncontrolled ventricular response
Disability, stroke, heart failure, sudden death
Transport to ER by other; 911 if severe symptoms

Front 56

Persistent and progressive tingling numbness or weakness in any part of the body (general red flag)

Back 56

General red flag for progressive neuronal destruction
Total permanent numbness, weakness or paralysis

Front 57

Acute paralysis or loss of strength, balance or coordination (general red flag)

Back 57

General red flag for acute neuronal damage

Front 58

Fifteen minute episode of unilateral tingling/numbness that resolves completely

Back 58

Transient ischemic attack - temporary neurological dysfunction from ischemia due to vascular occlusion
Stroke risk
If in midst of neurological symptoms, urgent transport to ER with triage call. Resolved TIA same day PCP referral or ER.
May present with transient aphasia

Front 59

Slow onset of patchy numbness and weakness in more than one area of the body

Back 59

Multiple sclerosis
PCP
Tests for numbness with cotton ball, strengthof major muscles, limb reflexes, romberg's sign (ataxia), gait and coordination, vision test, vibration and position sense of toes, Babinski

Front 60

Growth or change in dark skin lesion

Back 60

Malignant melanoma
Semiurgent PCP
Melanomas are usually dark and a suspicious if
A - assymetry
B- borders are irregular or blurred
C- color is dark or mixed shades
D- diameter greater than 6 mm
E- evolving skin lesion different from others in sizenor shape

Front 61

Unilateral painless lymph node swelling in neck, groin or arm

Back 61

Lymphoma
Refer to PCP with solitary lymph node

Front 62

Painless and hard area within testicle, especially of young adult male

Back 62

Testicular cancer
Potentially rapidly fatal
Semi urgent PCP

Front 63

Oe-sided ankle/distal calf swelling or asymmetrical bilateral swelling with more than 3 cm difference

Back 63

Blood clot in deep vein of calf (deep vein thrombosis)
Pulmonary embolism and death
Same day ER; if symptoms of pulmonary embolus 911

Front 64

Bilateral, pitting ankle swelling with SOB

Back 64

Congestive heart failure
Disability and death
Mild symptoms, PCP. Mderate symptoms, ER with other driving. Severe symptoms 911.

Front 65

Swelling of one arm with shoulder and or armpit pain

Back 65

Subclavian artery deep vein thrombosis
Severe pain and dysfunction
Semi urgent PCP

Front 66

Swelling and itching of lips following insect sting or ingestion of drug, food, herb or supplement

Back 66

Impending anaphylactic shock reaction
Sudden death
Urgent care or 911 depending on presence of acute respiratory distress

Front 67

Sudden, painless loss of vision in one eye

Back 67

Detached retina
Permanent blindness
Semi urgent PCP or opthalmalogist

Front 68

Transient, painless "curtain" coming down over vision of one eye then lifting

Back 68

Amaurosis Fugax (AF) - brief and fleeting attacks of monocular partial or total blindness lasting seconds to minutes
Warning for stroke or MI due to atherosclerosis
PCP
Carotid doppler to determine extent of disease in internal carotid arteries

Front 69

Double vision following blunt trauma to one eye. Eye subsequently appears lower than the other eye.

Back 69

"Blowout fracture" of eye orbit with entrapment of inferior rectus muscle in fracture
Permanent loss of vision and removal of the eyeball
Urgent PCP or opthalmologist

Front 70

Blurry vision, frequent urination, increased hunger and fatigue in adult

Back 70

Adult onset diabetes mellitus (type 1)
Type 1- usually diagnosis in childhood
Type 2- more common in adulthood
Gestational
Disability, blindness, neuropathy, loss of lower limbs, renal failure, heart dz, death
If diabetic emergency ER
Note - known insulin-taking patients who present with anxiety, tremor, sweating and racing pulse should be assumed to be having a hypoglycemic reaction. Give glucose.
Hyperglycemic coma requires insulin - 911

Front 71

Mild weight gain with lethargy, dry hair and cold extremities

Back 71

Hypothyroidism
PCP

Front 72

Weight loss andor failure to maintain adequate body weight due to body image concerns

Back 72

Anorexia nervosa
PCP

Front 73

Progressively decreasing mental function at any age (general red flag)

Back 73

Degeneration and deathof brain neurons
Dementia and related sequelae

Front 74

Chronic or repeated dizziness occurring other than when standing up. (general red flag)

Back 74

Cerebral neuronal hypofunction from a variety of causes which can result in disability and death

Front 75

Chronic or repeated dizziness occurring other than when standing up with possible abnormal pulses, bradycardia or tachycardia, low blood pressure, weak pulse, or bilateral pedal edema

Back 75

decreased perfusion of blood to the brain from arrhythmia or heart weakness

Front 76

Chronic or repeated dizziness occurring other than when standing up with more chronic and less episodic dizziness and SOB

Back 76

Normal perfusion of blood to brain but decreased oxygen in the brain from pulmonary or decreased hemoglobin or RBCS

Front 77

Chronic or repeated dizziness occurring other than when standing up with dizziness, jittery, symptoms of low blood sugar 1-3 hours after eating

Back 77

Decreased blood glucose

Front 78

Chronic or repeated dizziness occurring other than when standing up with simple seizures

Back 78

Seizures

Front 79

Chronic or repeated dizziness occurring other than when standing up with neurological symptoms

Back 79

Intracranial mass

Front 80

Increasing confusion in an elderly person days, weeks or months after minor head trauma

Back 80

Chronic subdural hematoma
Mental deterioration, coma, death
If stable with neurological presentation, ER by other.

Front 81

Severe dizziness immediately after standing up

Back 81

Severe orthostatic hypotension
Possible syncope and falling
PCP

Front 82

Dizziness and slow heart beat<60bpm that does not increase with activity in an elderly person

Back 82

Sick sinus syndrome
Debility, falling, death
PCP by other

Front 83

Sudden unconsciousness followed by severe drowsiness in otherwise healthy adult

Back 83

Seizure
Disability, death
PCP

Front 84

Sudden leg weakness and possible unconsciousness in elderly person when turning head

Back 84

"Drop attack" from vertebrobasilar artery insufficiency (VBI)
Falling episodes, increased risk of stroke
Avoid extreme neck rotation, PCP or cardiologist

Front 85

Loud snoring, gasping during sleep, excessive daytime sleepiness

Back 85

Sleep apnea
- obstructive: respiratory effort normal, physical block to airflow
- central sleep apnea : breathing interrupted by lack of respiratory effort because brain centers are not functioning properly
- complex: features of both
Timely PCP
Diagnosis by polysomnography.

Front 86

Cat bite of finger with subsequent swelling and pain

Back 86

Serious infection of tendon and or bone (osteomyelitis)
PCP

Front 87

Bleeding from orifice (general red flag)

Back 87

Potentially serious tissue destruction

Front 88

Bright red rectal bleeding in those over 45

Back 88

Possible rectal or colon cancer

Front 89

Melena (black rectal blood)

Back 89

Upper Gi hemorrhage

Front 90

Vomiting blood

Back 90

Brisk upper GI from ulcer, cancer or ruptured blood vessels
Urgent

Front 91

Hemoptysis - coughing blood of 1/4 tsp or more

Back 91

Possible lung cancer, serious lung infection

Front 92

Cough with bloody sputum in patient without obvious respiratory infection

Back 92

Lung cancer
PCP

Front 93

Painless, bloody urination in man over 50 (gross hematuria)

Back 93

Urinary tract cancer (usually bladder)
PCP timely

Front 94

Vaginal bleeding years after last menses

Back 94

Uterine cancer
PCP

Front 95

New retraction of nipple or fixed lump in breast of male or female

Back 95

Breast cancer
Semi urgent PCP

Front 96

Sudden SOB in the middle of the night, cough, bilateral ankle swelling

Back 96

Paroxysmal nocturnal dyspnea from congestive heart failure
Disability and or death
Semi urgent to 911 depending on severity

Front 97

Cough with severe episodic shortness of breath and expiratory wheezing

Back 97

Moderate to severe chronic asthma
Disability and death
Grade 1- mild wheezing, no significant SOB, no hx of ER or hospitalization. Semi urgent within 2 days.
Grade 2 - mild to moderate wheezing, mild SOB, hx of ER or hospital visits - same day PCP or pulmonary specialist.
Grade 3- moderate wheezing and SOB and hx of ER or hospital visits - to PCP if office nebulizer or to ER.
Grade 4- severe wheezing, SOB, bluish lips and chest tightness - 911

Front 98

Unexplained or poorly explained trauma or failure to thrive in toddler or young child

Back 98

Child abuse or neglect
Psychological, sexual and or physical trauma or death
Same day CPS

Front 99

Noncentering of reflected light in one pupil, crossed eye

Back 99

Strabismus
Permanent loss of vision in one eye
Timely PCP

Front 100

Child with severe sore throat, high fever over 102, inspiratory stridor, drooling

Back 100

Acute epiglottitis
Respiratory arrest and death
ER urgent

Front 101

Crying child holding one arm flexed against body with hand pronated

Back 101

Nursemaid's elbow - elbow dislocation
Refer to family practitioner, pediatrician or orthopedic surgeon

Front 102

New onset constipation and weight loss in person over 40

Back 102

Carcinoma of colon and rectum
PCP
Earlier symptoms may include persistent change in bowel habits, constipation preceded by diarrhea, persistent feeling of incomplete defecation, bright red blood in stool or melena, persistently narrower or thinner stools

Front 103

Persistent unexplained diarrhea (>3-5 stools daily) over months or years (general red flag)

Back 103

Parasitic enteritis or significant malabsorption syndrome

Front 104

Acute bloody diarrhea with 6-8 stools per day and fever over 101.5

Back 104

Either acute inflammatory enteritis from bacteria, virus or parasite OR inflammatory autoimmune bowel disease such as Crohn's or UC
Disability and risk of death from severe dehydration or electrolyte balance
PCP same or next day

Front 105

Chronic fatigue with SOB and or chest pain (General red flag)

Back 105

General red flag for significant cardiopulmonary disease resulting in decreased blood flow to the brain
Semi urgent to urgent referrral depending on severity of symptoms

Front 106

Chronic fatigue with enlarged lymph node and or abdominal mass (General red flag)

Back 106

Possibility of widespread cancer

Front 107

Chronic fatigue in patient with jaundice or enlarged liver (General red flag)

Back 107

Serious liver disease, liver cancer or cancer metastasized to liver
Semi urgent PCP

Front 108

Chronic debilitating fatigue, muscle pain and sleep disturbance

Back 108

Chronic fatigue syndrome
Symptoms may also include impairment of short term memory or concentration, recurrent sore throat, tender lymph nodes and headache

Front 109

Fever over 105

Back 109

Risk of Brain damage
Urgent care

Front 110

Persistent fever over 101.5 for more than two weeks, "fever of unknown origin"

Back 110

Red flag for occult infection, metabolic or autoimmune disease

Front 111

Fever over 103.5 plus severe sore throat

Back 111

Streptococcal throat infection

Front 112

Progressive unilateral loss of hearing, loss of balance

Back 112

Acoustic neuroma - benign tumor of vestibulocclear nerve (CNVIII)
Permanent deafness, loss of balance, disability
Slow growing tumors, timely PCP

Front 113

Indigestion, RUQ pain, feeling of fullness following a meal

Back 113

Acute gall bladder inflammation (acute cholecystitis)
Possible ileus (bowel obstruction), empyema (gallbladder infection), sepsis, death
Asymptomatic patient - timely PCP
ER if persistent symptoms

Front 114

Hx of no menstruation, late menarche with skipped menses and extremely light flow

Back 114

General red flag for hypoestrogenemia, low estrogen

Front 115

Amenorrhea, anorexia, athleticism in young women

Back 115

Female athletic triad
Osteoporosis
Timely PCP