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