What is the best course of action for a patient who is not feeling well and presents with non-specific symptoms?

Immediate Assessment and Action for Non-Specific Symptoms

When a patient presents with non-specific symptoms and reports "not feeling well," immediately assess for life-threatening conditions by obtaining vital signs, performing a focused physical examination for signs of distress, and determining if emergency evaluation is warranted—particularly if symptoms include chest discomfort, severe dyspnea, hemodynamic instability, or altered mental status. 1, 2

Critical Red Flags Requiring Emergency Evaluation

Immediately transport to the emergency department if any of these features are present:

• Chest pain or discomfort lasting >20 minutes at rest 3, 1, 2
• Severe dyspnea or respiratory distress 1, 2
• Hemodynamic instability (hypotension, tachycardia, signs of shock) 1, 2
• Syncope or presyncope 3, 1
• Altered mental status or confusion 4
• Severe pain of acute onset 3, 2

For patients with these high-risk features, call emergency medical services (9-1-1) rather than having the patient self-transport, as mortality increases significantly with treatment delays in acute coronary syndrome and other life-threatening conditions. 3, 1

Systematic Triage Approach

Step 1: Rapid Visual and Auditory Assessment

Immediately assess the patient's appearance, work of breathing, and circulation status:

• Appearance: Is the patient alert, anxious, diaphoretic, pale, or in obvious distress? 4, 5
• Breathing: Look for tachypnea, accessory muscle use, stridor, or labored breathing 3, 5
• Circulation: Assess skin color, capillary refill, and signs of poor perfusion 4, 5

This initial assessment takes less than 1 minute and categorizes the patient as stable versus unstable. 5

Step 2: Focused History for Life-Threatening Conditions

When the patient can communicate, rapidly assess:

• Onset and duration: Sudden onset suggests acute vascular events (MI, PE, aortic dissection) 3, 2
• Associated symptoms: Diaphoresis, nausea/vomiting, and pallor strongly suggest acute coronary syndrome 4
• Cardiac risk factors: Age, male gender, prior cardiovascular disease, diabetes 3, 2
• Recent trauma or surgery: Consider pulmonary embolism 2

Critical pitfall: Women, elderly patients, and those with diabetes frequently present with atypical symptoms including fatigue, nausea, or vague discomfort rather than classic chest pain—maintain high suspicion in these populations. 1, 2

Step 3: Differential Diagnosis Framework

The most common life-threatening causes requiring immediate action include:

Cardiovascular emergencies:

• Acute coronary syndrome (unstable angina, MI) 3, 2
• Aortic dissection or expanding aneurysm 2
• Pulmonary embolism 2
• Pericarditis with tamponade 2

Pulmonary emergencies:

• Pneumothorax 3, 2
• Severe pneumonia 2
• Acute respiratory failure 3

Other critical conditions:

• Sepsis 3
• Diabetic emergencies 2

Step 4: Immediate Interventions While Arranging Transfer

If acute coronary syndrome is suspected:

• Administer aspirin 162-325 mg (chewed, non-enteric coated) unless contraindicated 3, 2
• Consider sublingual nitroglycerin if no bradycardia or hypotension present 3
• Place on continuous cardiac monitoring with defibrillator readily available 2
• Establish IV access 4
• Obtain 12-lead ECG within 10 minutes if equipment available 1, 2

Stay with the patient until emergency medical services arrive if you suspect a life-threatening condition. 3

Management of Lower-Risk Presentations

For patients without high-risk features who have non-specific symptoms:

Assess for Common Non-Emergent Causes

• Musculoskeletal pain: Most prevalent diagnosis in chest pain presentations; look for reproducibility with palpation, movement-related symptoms 3, 2
• Gastrointestinal causes: GERD, peptic ulcer disease—consider if symptoms relate to meals 2
• Anxiety/panic attacks: Sudden onset with trembling, dizziness, paresthesias 3
• Viral illness: Fever, myalgias, upper respiratory symptoms 3

When Outpatient Management is Appropriate

Patients with clearly non-cardiac, non-life-threatening symptoms may be managed with:

• Symptomatic treatment based on specific diagnosis 2
• Clear return precautions: Instruct patient to call 9-1-1 if symptoms worsen or don't improve within 5 minutes, or if new concerning symptoms develop 3, 1
• Follow-up within 24-48 hours to reassess 6

Critical caveat: If diagnostic uncertainty exists or the patient appears uncomfortable with the assessment, err on the side of emergency evaluation rather than outpatient management. 1, 6

Patient Communication and Safety Planning

Explicitly instruct the patient and family members on when to seek emergency care:

• Call 9-1-1 immediately if chest discomfort lasts >20 minutes 1
• Call 9-1-1 if symptoms are unimproved or worsening after 5 minutes 3, 1
• Do not wait for symptoms to disappear, as these are poor indicators of risk 3
• Include family members or caregivers in these instructions to ensure rapid action 1

Document the rationale for your management decision, the specific return precautions given, and the patient's understanding of these instructions. 3

Special Considerations

For patients with baseline confusion or communication barriers: Rely heavily on objective findings (vital signs, physical exam, ECG if available) rather than history alone, as these patients have higher mortality risk from delayed diagnosis. 4

Telephone triage limitations: Patients with potentially life-threatening symptoms should not be evaluated solely by telephone—they require facility-based evaluation with ECG and biomarkers. 1