General Medicine

General Medicine RIE

The following guidelines are aimed at ensuring effective and efficient use of services, so that patients get seen promptly in the “right place by the right person, the first time”

Sometimes we review patients in the General Medical Outpatient Clinic and then refer directly on to another more appropriate specialty. We recognise that this decision is often not clear cut at time of referral and that these onward referrals are sometimes inevitable because of the complex nature of our caseload and the type of service we provide. These guidelines have been devised to help this process and hopefully allow the most appropriate referrals from the outset. We are always happy to discuss grey areas and complex cases. See details regarding how to contact the on-call consultant by phone and how to seek email advice below.

Our Services:

General medical clinics are held in OPD 2 at the Royal Infirmary of Edinburgh.

We aim to see urgent referrals within two to four weeks

Routine referrals are seen within the 12 week guarantee

More urgent referrals (e.g. rapid deterioration in a patient’s condition), which may require inpatient assessment should be referred for assessment via the Flow Centre.

Telephone advice

Any cases that are not clear cut or require a second medical opinion can always be discussed with:

General Medical Interface Team consultant on-call, available via switchboard or via Interface consultant phone 0131 242 1735 working weekdays 8am to 8pm, or
On-call consultant for General Medicine at weekends or bank holidays via switchboard

General Medical E-mail Advice Service: RIEacutemedicine@nhslothian.scot.nhs.uk

We aim to respond within two working days.
Commonly used for any queries related to recent inpatient discharges or if correspondence with a named General Medical Consultant is required.
It may also be used as a means of emailing for advice on management, if required.

Admission and Alternatives to Admission – see below under Who not to refer section.

D.I & B.I – 06-04-26

How to refer:

All referrals should be made via Sci-Gateway:

RIE > General Medicine > LI Basic Sign Referral

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. If malignancy is suspected please refer as Urgent Suspicion of Cancer and consider if GP Access to CT for Suspected Cancer (No Clinically Obvious Primary) – RefHelp is appropriate prior to referral.
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
1. no clear underlying cause despite appropriate initial investigations AND
2. who do not meet criteria for Haematology referral (see link below):
  https://apps.nhslothian.scot.nhs.uk/refhelp/Haematology/Anaemia/AnaemiaNormocytic
Syncope or pre-syncope where the presumed cause is orthostatic hypotension, situational syncope or vasovagal syncope, that is frequent or persisting despite conservative management (see PIL in ‘resources’ section) AND where cardiogenic or neurological causes have been excluded or are thought to be unlikely. See ‘Who Not to Refer’ section for details.
Dizzy spells in patients who are generally under the age of 65 years with no obvious

ENT cause – See ENT Dizziness and Balance – RefHelp
Cardiac cause – See Arrhythmia and palpitations – RefHelp
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.

Who not to refer:

Those over the age of 65 with multiple comorbidities and multifactorial conditions (eg dizziness, falls, non-specific symptoms) are better assessed by the Medicine for the Elderly team

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

Patients with rapidly declining symptoms. Please consider admission or alternatives to admission listed below 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

There is currently no allergy service in NHS Lothian.
Allergy testing guidance:Allergy Test Request – RefHelp
Dermatology colleagues may sometimes assess patients and offer skin prick tests, but NOT provocation testing, de-sensitisation or immunotherapy: Urticaria – RefHelp

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

Mast Cell Activating Syndrome

MCAS has been characterised by episodic signs and symptoms of systemic anaphylaxis / symptoms associated with mast cell degranulation that concurrently affect at least two organ systems.

MCAS tends to be a patient-led diagnosis characterised by a variety of ill-defined criteria with no specific diagnostic tests to support a formal diagnosis. Some patients benefit from anti-histamines which should be trialled if this is a potential diagnosis, but there is limited treatment beyond this option and as there are no formal diagnostic tests. Further investigation is not warranted.

A detailed consensus document on MCAS can be found at AAAAI Mast Cell Disorders Committee Work Group Report: Mast cell activation syndrome (MCAS) diagnosis and managementopens a new window (2019)

Chronic fatigue – please consider referral to appropriate service: Chronic Fatigue Syndrome: ME-CFS – RefHelp

Night Sweats – patients with:

abnormal FBC – please refer to Haematology
normal FBC – please consult RefHelp guidelines for night sweats and consider referral to appropriate specialty: Night sweats – RefHelp

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 (see link here to Night sweats – RefHelp)

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

Neurological cause – primariy seizure disorders. Refer to general neurology or first seizure clinic:- First Seizures and Epilepsy – RefHelp

Palpitations with a likely endocrine or cardiac cause. Refer to appropriate specialty.
Arrhythmia and palpitations – RefHelp

General Gastrointestinal presentations e.g., microcytic anaemia, diarrhoea, altered bowel habit, dysphagia and dyspepsia: https://apps.nhslothian.scot.nhs.uk/refhelp/Gastrointestinal

Generalised musculoskeletal pains polyarthralgia, polyarthritis, and muscle stiffness: Rheumatology and Bone disease – RefHelp

Alternatives to Admission:

There is always a General Medical Interface Team consultant who operates at the RIE on all working weekdays between 8am and 8pm. We carry an Interface Team mobile phone 0131 242 1735 or can be accessed via switchboard and are happy to support a prof-to-prof 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 there are useful links to alternatives to admission on their RefHelp page: Flow Navigation Centre – RefHelp