General Medicine

PLEASE NOTE THAT REFERRAL GUIDANCE FOR General Medicine SJH CURRENTLY BEING REVIEWED NOV 2018, BUT MANY OF THE APPROACHES BELOW WILL APPLY.

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.

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.

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 in the Emergency Department or via switchboard, all 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.

How to refer:

All referral letters are best sent via SCI Gateway

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
1. no clear underlying cause despite appropriate initial investigations AND
2. who do not meet criteria for Haematology referral (see link below):
  
  http://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 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 (see link below): http://apps.nhslothian.scot.nhs.uk/refhelp/Cardiology/DirectAccessAmbulatoryECGMonitoring
Dizzy spells in patients who are generally under the age of 65 years with no obvious
1. ENT cause – generic ENT: a specific pathway for dizziness is currently under development
2. cardiac cause (see link below): http://apps.nhslothian.scot.nhs.uk/refhelp/Cardiology/DirectAccessAmbulatoryECGMonitoring
3. 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 (eg dizziness, falls, non-specific symptoms) are better assessed by the Medicine for the Elderly team

Who not to refer:

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

There is currently no allergy service in NHS Lothian.
Allergy testing guidance: http://apps.nhslothian.scot.nhs.uk/refhelp/LaboratoryServices/Immunology
Dermatology colleagues may sometimes assess patients and offer skin prick tests, but NOT provocation testing, de-sensitisation or immunotherapy: http://apps.nhslothian.scot.nhs.uk/refhelp/Dermatology/Urticaria
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 consider referral to appropriate service: See RefHelp Page ME-CFS here

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: http://apps.nhslothian.scot.nhs.uk/refhelp/Haematology/NightSweats#tab

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 RefHelp Haematology Night Sweats guidanceSyncope 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 – primarily seizures disorders. Refer to general neurology or first seizure clinic:-http://apps.nhslothian.scot.nhs.uk/refhelp/Neurology/FirstSeizuresAndEpilepsy

Palpitations with a likely endocrine or cardiac cause. Refer to appropriate specialty. http://apps.nhslothian.scot.nhs.uk/refhelp/Cardiology/DirectAccessAmbulatoryECGMonitoring

General Gastrointestinal presentations e.g., microcytic anaemia, diarrhoea, altered bowel habit, dysphagia and dyspepsia: http://apps.nhslothian.scot.nhs.uk/refhelp/Gastrointestinal
Generalised musculoskeletal pains polyarthralgia, polyarthritis, and muscle stiffness: http://apps.nhslothian.scot.nhs.uk/refhelp/Rheumatology

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 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: http://apps.nhslothian.scot.nhs.uk/refhelp/FlowCentre