General Medicine ELCH

How to refer:

All referrals are best sent via SCI Gateway:

• FOR ADVICE ONLY: East Lothian Community Hospital >> General Medicine >> Advice Only
• FOR OUTPATIENT APPPOINTMENT: East Lothian Community Hospital >> General Medicine >> Basic Sign Referral

(For admissions / same day urgent assessment then referral should be Flow Navigation Centre to RIE / WGH).

Who to refer:

It is appropriate to refer patients with:

• Weight loss without specific features to suggest a particular sub-specialty referral, after appropriate initial investigations
• Multisystem symptoms and/or abnormal blood results with an unknown diagnosis, despite appropriate initial investigations
• Raised Inflammatory markers with multiple constitutional symptoms, not suggestive of an underlying rheumatological or infectious disease process
• Patients who require a second medical opinion
• Normochromic normocytic anaemia with
  • no clear underlying cause despite appropriate initial investigations AND
  • who do not meet criteria for Haematology referral
• Syncope or pre-syncope where the presumed cause is orthostatic hypotension, situational syncope or vasovagal syncope, which is frequent or persisting despite conservative management AND where cardiogenic or neurological causes have been excluded or are thought to be unlikely.  See ‘Who Not to Refer’ section for details.
• Palpitations in patients with no obvious endocrine cause and who do not meet referral criteria for Cardiology Referral
• Dizzy spells in patients who are generally under the age of 65 years with no obvious
  • ENT cause – generic ENT: a specific pathway for dizziness is currently under development
  • cardiac cause
  • neurological cause

We recognise that there are many patients who are over the age of 65 years who are fit and independent with few comorbidities and often a general medical referral is appropriate for them.  Those over the age of 65 with multiple comorbidities and multifactorial conditions (e.g. dizziness, falls, non-specific symptoms) are better assessed by Medicine for the Elderly ELCH

Who not to refer:

Patients known to (or who have already been referred to) other services and have ongoing specialty specific issues.

Patients with organ specific complaints e.g. poorly controlled asthma, should be referred to the relevant organ specialty and not General Medicine. Please note that not all specialties offer clinics in East Lothian so you may need to refer to RIE or WGH. In the case of symptoms such as breathlessness where the most appropriate specialty is not clear, please initiate appropriate tests from primary care such as CXR, NT-Pro-BNP, ECG etc and only refer to General Medicine if the diagnosis is still unclear.

Patients with rapidly declining symptoms.  Please consider admission or discuss with the Medical Interface Team consultant on-call (available via switchboard) or the on-call Consultant for General Medicine (on weekends or bank holidays).

Allergy Issues

1. There is currently no allergy service in NHS Lothian.
2. Please see this link re Allergy testing guidance
3. Dermatology colleagues may sometimes assess patients and offer skin prick tests, but NOT provocation testing, de-sensitisation or immunotherapy: see Urticaria page
4. Otherwise consider an out of area referral, which can only be done by secondary care.

Primary Immune Deficiency and C1 inhibitor deficiency (hereditary angioedema) – refer to Immunology

Chronic  fatigue – please see guidance on Chronic Fatigue Syndrome page

Night Sweats – patients with:

1. abnormal FBC – please refer to Haematology
2. normal FBC – please consult RefHelp guidelines for night sweats and consider referral to appropriate specialty

We are amenable to reviewing patients who have night sweats in the context of normal FBC and constitutional symptoms that suggest a non-haematological malignancy.  Please ensure that the recommended primary care investigations are followed prior to referral

Syncope likely to be – Cardiogenic cause – refer to Cardiology. 

Suspect if:

• Abnormal ECG: symptomatic heart block, bradycardia <40bpm, pauses >3s, AF, LVH changes, Q waves suggestive of IHD or cardiomyopathy, conduction abnormalities, BBB, long or short QTc
• Structural or ischaemic heart disease or heart failure
• Syncope while supine
• Syncope on exercise (nb syncope after exercise is often vasovagal)
• Syncope without prodrome (esp. >65yrs)
• Syncope preceded by palpitations 
• Family history of sudden cardiac death

Syncope likely to be – Neurological cause – primarily seizures disorders: Refer to general neurology or first seizure clinic

Palpitations with a likely endocrine or cardiac cause.  Refer to appropriate specialty. 

General Gastrointestinal presentations e.g., microcytic anaemia, diarrhoea, altered bowel habit, dysphagia and dyspepsia – Please see Gastroenterology guidance

Generalised musculoskeletal pains polyarthralgia, polyarthritis, and muscle stiffness – Please see Rheumatology guidance

Alternatives to Admission:

There is always a General Medical Interface Team consultant who operates out of Accident & Emergency at the RIE on all working weekdays between 8am and 8pm.  We carry an Interface Team mobile phone which can be accessed via switchboard which allows a senior to senior discussion for patients who are not clear cut.  We endeavour to either review patients on the same day or advise on whether clinic or ambulatory care, are suitable alternatives to admission.

The Flow Navigation Centre also helps to support the flow of patients across the acute sites and can discuss alternatives to admission.

Other alternatives are:-

1. Ambulatory Care
2. Hospital at Home
3. East Lothian Community Respiratory Pathway
4. Rapid Access Chest Pain Clinic at RIE
5. Stroke/TIA Hotline