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Clinical Triage

Symptom-based Triage Guide

A guide to triaging common symptoms in clinical practice.

Headache

  • **RED FLAGS**: Worst headache of life, sudden onset (thunderclap), with neck stiffness, fever, altered consciousness, focal neurological signs, or papilloeodema
  • **URGENT**: Severe, persistent, with visual changes or vomiting
  • **NON-URGENT**: Mild to moderate, tension-type, responds to simple analgesia

    • Chest Pain

  • **RED FLAGS**: Crushing retrosternal pain, radiating to left arm/jaw, with diaphoresis, nausea, shortness of breath; or tearing pain radiating to back
  • **URGENT**: Atypical chest pain with risk factors, pleuritic pain with fever
  • **NON-URGENT**: Well-localized, reproducible on palpation, no cardiac risk factors

    • Abdominal Pain

  • **RED FLAGS**: Severe, generalized peritonitis (rigid, board-like abdomen), with shock, haematemesis, or melaena
  • **URGENT**: Localized tenderness, vomiting, fever, obstipation
  • **NON-URGENT**: Mild, diffuse discomfort, with normal vitals and soft abdomen

    • Dyspnoea

  • **RED FLAGS**: Severe respiratory distress, unable to speak in sentences, SpO2 <90%, cyanosis, stridor
  • **URGENT**: Moderate SOB, wheezing, with fever or chest pain
  • **NON-URGENT**: Mild, chronic, well-controlled on current treatment

    • Fever

  • **RED FLAGS**: >40°C, with petechial/purpuric rash, neck stiffness, altered mental status, hypotension
  • **URGENT**: High fever with focal symptoms, immunocompromised patient, recent travel or hospitalization
  • **NON-URGENT**: Low-grade fever with mild cold or flu symptoms