Category: General Practice Referrals

General Practice referral guidelines

Podiatry Template

Scott McLaughlin

This is a dictation template to provide a reminder of the information required to complete the referral. The fields in red are mandatory and must be completed on the referral protocol.

Presenting Complaint

Which service is this referral aimed at:

  • General Podiatry
  • MSK Podiatry
  • Diabetes
  • Nail Surgery

Is this a request for a domicilliary visit:

  • Yes
  • No

Main Presenting Complaint: [Text – 98 character maximum]

Reason for Referral: [Text]

Date of Onset: [Date]

Priority:

  • Routine
  • Urgent

Priority Reason: [Text – 98 character maximum]

Podiatry Guideline

Podiatry Referral

Scott McLaughlin

MSK Podiatry (Biomechanic Clinic)

MSK podiatry provides diagnosis and treatment for a range of muscle and joint related foot and lower limb problems which may be due to development, posture, occupation and exercise, or due to long-term conditions such as Rheumatoid arthritis, Osteoarthritis.

Diabetes

The Podiatry Diabetes service provides assessment, diagnosis and treatment of low, medium and high risk patients with pathologies directly related to their Diabetes. This include active ulceration but excludes red flags such as Charcot foot, infection etc which should be directed to acute services which is found under the District Hospital in SCI Gateway.

General Podiatry

General Podiatry provides assessment, diagnosis and treatment for a range of foot pathologies and patients presenting with severe circulation problems with associated foot lesions.

Nail Surgery

General podiatry provides nail surgery procedures; partial or total nail avulsion.

Pain Service Referral

Scott McLaughlin

The pain clinic is held at the Buchanan Centre, Coatbridge.

The staff do not always have access to all hospital and electronic records and hence completion of the form will assist in patient management.

Please attach any relevant hospital clinic and investigation letters/reports from Docman

Please state if a patient requires ambulance transport. As there are no facilities for this at Coatbridge, ambulance patients will be seen at WGH.

ServicesLanarkshire Chronic Pain Service provides out-patient multi-disciplinary assessment and treatment for adults with chronic pain.
LCPS Aims & Objectives
The team consists of two consultants in pain medicine, two specialist nurses, one specialist physiotherapist and one clinical psychologist.

The Pain Management Programme is based at the Douglas Street Health Centre in Hamilton
Rehabilitative & psychological approach to pain self-management

The Pain Clinic, based at the Buchanan Centre (Coatbridge) and Wishaw General Hospital, has a more medical approach:
TENS, medication, acupuncture,
Diagnostic and medication advice and review
Occasionally other procedures will be arranged at the day surgery unit at Wishaw General Hospital
Who to referPatients over 16:

With pain for longer than 6/12
With a chronic painful condition

or

Whose pain is causing significant distress
Who have been fully investigated,
For whom no further investigation or treatment is planned,
Whose lifestyle is significantly disrupted,
Who find standard analgesia is ineffective and
Who accept, during discussion, that a cure may not be possible.

See Pain management algorithm
Who not to referPatients under 16 (without initial discussion with Yorkhill (Glasgow) paediatric chronic pain clinic
Patients who would not tolerate the journey reasonably well
Patients with back pain should initially be assessed through MSK or back pain service pathways

Patients with:

Red Flags
Pain for less than 6/12
Awaiting investigations or specialist opinion, or invasive treatment
Alcohol / drugs dependency
Somatisation disorder

Caution in relation to the following:-
Active mental health problems where initial referral to mental health service or medication may be more appropriate:

Depression: major
Post Traumatic Stress Disorder: major
Personality disorder: high level or primary
Somatisation Disorder
Bereavement: significant unresolved issues
Abuse: unresolved issues
Obsessive compulsive disorder: major
Eating disorder: major
Psychosis: active psychosis or delusions

See Pain management algorithm
ResourcesThe British Pain Society
The British Association Scotland
Pain Pathway Guidance for GPs
Pain Management manual
Patient information leaflets (PILs) See Patient support groups

Orthopaedic Referral

Scott McLaughlin

This referral will be vetted by a Lead Extended Scope Practitioner. The patient will then be seen by the most appropriate Health Care Professional. This may be, a Podiatrist, a Physiotherapist or a Doctor.

Should you wish the patient considered for joint surgery the following X Rays are appropriate:

  • HIP – AP Pelvis

 

Should you require further information, please contact Janie Thomson, Lead Extended Scope Practitioner, Musculoskeletal Project, 01355 585447.

Please do not refer to a named Consultant unless your patient has been seen previously for the same condition. This prevents delays in appointment

Orthopaedic Back Pain

Scott McLaughlin

This referral will be vetted by a Specialist Physiotherapist

Back pain referrals will be vetted by a Lead Extended Scope Practitioner. If there are any RED FLAGS, the referral will be fast tracked to a orthopaedic consultant.

  • Only 1% of Low back Pain requires further investigation
  • Lumbar spine X-ray is inappropriate in mechanical low back pain and will not be routinely carried out

Should you require further information, please contact Janie Thomson, Lead Extended Scope Practitioner, Musculoskeletal Project, 01355 585447.

CCI Guidelines

The CCI Referral Guidelines can be found at Back Pain Referral Pathways

Vascular General Referral

Scott McLaughlin

General Vascular Referral

Please Note: This referral must only be used for general vascular referrals where no other referral form is available.

There are specific referral forms available for the following:

  • Aortic Aneurysm
  • Leg Ischaemia
  • Carotid Artery
  • Varicose Veins

Where any of these presenting problems are suspected, the relevant referral form should be completed.

Leg Ischaemia

Most patients with recent onset intermittent claudication will improve spontaneously – especially if they are encouraged to correct known risk factors (e.g. smoking, cholesterol, hypertension, obesity, low activity level). Furthermore timely attention to secondary prevention will reduce mortality and morbidity due to cardiac and cerebro-vascular disease in this high-risk group.

Patients with mild to moderate intermittent claudication do not require invasive vascular interventions.

Patients with suspected mild to moderate intermittent claudication may be referred to the local Community Claudication Clinic (via SCI Gateway) for confirmation of the diagnosis, cardiovascular risk factor assessment and appropriate counselling.

The Community Claudication Clinic

Our service has been set up in eight clinics across Lanarkshire for patients with suspected intermittent claudication (i.e. early peripheral arterial disease). We offer initial assessment and management by a Vascular Nurse and onward referral to the Vascular Physiotherapist and local services as appropriate.

NB We are unable to provide patient transport to the Community Claudication Clinic.

Fasting blood sugar, fasting lipids and full blood count, prior to referral, would facilitate patient management.

Patients with severe intermittent claudication, not improved by a regime of smoking cessation, walking exercise, antiplatelet treatment, statin, weight reduction etc. may be referred for Hospital Vascular OP Clinic assessment.

Patients with suspected critical limb ischaemia (rest pain, arterial ulcers, necrosis) should initially be discussed by contact with one of the Vascular Secretaries at Hairmyres Hospital in hours on Hairmyres 01355 584743. Appropriate arrangements will be confirmed by return call.

In the case of suspected ACUTE limb ischaemia with possible immediate limb threat (e.g. failed perfusion and sudden diminished sensation and movement): please refer as an emergency via ERC to the receiving surgical team.

Aortic Aneurysm

Patients with aortic aneurysm > 5cm, even without related symptoms, should be referred as an urgent case to the Hospital Vascular OP Clinic. Smaller aortic aneurysms may be referred as routine cases.

Patients with suspected symptomatic abdominal aortic aneurysm (i.e. recent onset or increasing back pain, acute tenderness of the aneurysm, distal embolism) should be referred as an emergency via ERC to the receiving surgical team

Carotid Artery Disease

Patients with suspected carotid artery disease should be referred urgently to the Stroke Service via SCI Gateway if they present with symptoms of stroke, TIA, or amaurosis fugax.

Varicose Vein Guideline

Scott McLaughlin

General Guidelines

Priority will be given to patients with critical limb ischaemia (rest pain, arterial ulcers, necrosis), symptomatic carotid stenosis and aortic aneurysm – who are likely to require surgical or radiological intervention.

 

Varicose Veins

NHS Lanarkshire does not offer treatment for thread veins or reticular veins or any cosmetic treatment for varicose veins.

Referral Criteria For Varicose Veins
(MANDATORY FIELDS AT LEAST ONE REQUIRED)

  • Open or healed varicose ulcer
  • Active varicose eczema (unresponsive to topical steroids and compression)
  • Recurrent superficial thrombophlebitis requiring NSAID therapy and compression
    • (* Phlebitis/thrombophlebitis is defined as acute onset, tender, hard, lumpy veins due to thrombosis. It is Not just painful veins. Standard treatment is NSAIDs and compression, not antibiotics. Patients should not be referred on first episode unless there is clinical evidence of thrombosis extending up to the groin)
  • A history of venous haemorrhage where there is a likelihood of further bleeding

Aortic Aneurysm

Patients with suspected aortic aneurysm, even without related symptoms, should be referred as an urgent case to the Vascular OP Clinic.
Patients with suspected symptomatic abdominal aortic aneurysm (i.e. recent onset or increasing back pain, acute tenderness of the aneurysm, distal embolism) should be referred as an emergency to the Receiving Surgical Team.

Leg Ischaemia

Most patients with recent onset intermittent claudication will improve spontaneously – especially if they are encouraged to correct known risk factors. Furthermore timely attention to secondary prevention will reduce mortality and morbidity due to cardiac and cerebro-vascular disease in this high-risk group. Patients with mild to moderate intermittent claudication do not require invasive vascular interventions. If you have access to ABPI measurements, then that may help confirm the diagnosis.

Patients with severe intermittent claudication, not improved by a regime of smoking cessation, walking exercise, antiplatelet treatment, statin, weight reduction (as required) should be referred for vascular OP Clinic assessment.

Carotid Artery Disease

Patients with suspected carotid artery disease should be referred urgently if they present with symptoms of stroke, TIA, or amaurosis fugax.

Urology General Referral

Scott McLaughlin

The introduction of cancer and general diagnostic waiting time targets have lead us to look at how we can better deal with referrals to the urology departments in Lanarkshire and so minimise waiting times.

Patients with suspected urological malignancy should be referred through the SCI Gateway, Lanarkshire Cancer Referral Services These conditions include:

  • Palpable renal mass
  • Incidental renal tract mass on radiology
  • Frank haematuria
  • Symptomatic occult haematuria
  • A scrotal lump which cannot be sparated from testes
  • Suspected prostate cancer because of abnormal rectal examination or PSA outwith the age reference range
  • Suspected penile tumour

All other referrals should be marked Routine. An explanation in the text of the referral such as chronic retention or severe colic will be treated urgently, even if marked routine. Referrals for conditions other than described above marked urgent may be down graded to routine.

The following referral guidelines are based on specific presentations likely in general practice. Not all patients will fit these broad categories, but we hope the suggestions will ease the initial decision in many cases.

PresentationPreparation and Initial Management
Asymptomatic non visible haematuriaIf dipstick positive, send same sample for microscopy. Casts or abnormal forms indicate requirement for referral to renal physician. Investigate if 2+, or if consistently 1+ (as defined as 2 out of 3 samples) On flow cytometry of MSU, 1+ is defined as 40-100 rbc, 2+ is 100-250 rbc. Arrange MSSU. BP. biochemistry/haematology bloods. Book USS. Patient will be booked for direct access flexible cystoscopy. Manage positive results as indicated.
Symptomatic non visible haematuria In patients < 40 yrsMSSU, BP Biochemistry/Haematology bloods, USS with post-mic residual. Patient will be booked for direct access flexible cystoscopy. Treat/refer positive results as indicated.
Testicular Lump If lump distinctly separate and feels benign, then can be treated symptomatically. USS of scrotum if uncertain or there is a lot of anxiety. If patient fit and symptoms justify surgery refer to general urology clinic. In Wishaw and Monklands there is a separate scrotal lumps clinic for rapid assessment of all such lumps, but not non specific pain.
Testicular Pain Examine for local causes including rectal. Check MSSU. Think of referred causes. If negative reassure. If suspicion or anxiety persists, arrange ultrasound. If normal reassure. Urological referral unlikely to be useful but if in doubt, Patient will be seen at the general urology clinic.
Positive uti in male SIGN guidelines suggest men should be investigated if they have symptoms of upper tract infection, fail to respond to antibiotics or have two or more episodes in three months MSSU, BP, Biochemistry/Haematology bloods. Arrange an USS+KUB with post micturation residual. Patient will be booked for direct access flexible cystoscopy.
Recurrent cystitis in female / urinary tract infection in females Persisting pyuria There are no clear guidelines for investigation. In young males, consider urethritis/ STI. In all, consider atypical infection. Check 3 EMUs. In over 40s, it may be worth excluding underlying abnormality. BP, biochemistry/haematology bloods. Book USS, with post-micturation residual. The patient will be booked for direct access flexible cystoscopy.
Persisting pyuria Although there are no specific SIGN guidelines for referral, indications for referral could be as for males.MSSU, BP, Biochemistry/Haematology bloods. Book an USS, with post-mic residual. In those < 40 yrs, that may be enough but, if troublesome and in those > 40. The patient will be booked for direct access flexible cystoscopy.
Haematospermia Chlamydia urine (white top container) in younger patient MSSU. PR/testicular exam to exclude obvious malignancy Check PSA in older age group. Dipstick urine for haematuria. Trial of quinolone for 2 weeks if investigations negative. Patient will be booked for routine general urology clinic only for difficult cases.
Suspected stone disease MSSU, BP, Biochemistry/Haematology bloods, Arrange USS. If abnormal or history highly suggestive despite negative result. Patient will be booked for routine general urology clinic appointment.
Outflow obstruction in males > 50 yrs MSSU, BP, Biochemistry/Haematology bloods. Fill in symptom score and fluid chart. For mild/ moderate symptoms give trial of alpha blocker. If fails to respond or symptoms severe patient will be booked for prostate clinic.
Stress incontinence Examine for distended bladder/ pelvic mass. MSSU Address concomitant factors such as obesity, smoking. Refer for physiotherapy with pelvic floor exercises/ interferential bladder training. Refer to Continence Advisory Service, Lomond Road, Coatbridge, ML5 2JN.
Overactive bladderExamine for distended bladder / pelvic mass. MSSU. Address concomitant factors such as obesity, smoking, fluid / caffeine intake. Fluid balance chart. Refer to physiotherapy for bladder exercises. Consider trial of anti-cholinergic. If fails conservative management, refer to Continence Advisory Service, Lomond Road, Coatbridge, ML5 2JN.
Erectile dysfunctionCheck routine bloods including PSA and testosterone. Look at lifestyle and general issues such as obesity, smoking / alcohol intake, general fitness, medication and other diseases such as vascular, neurology, diabetes and psychology. Manage as appropriate. Next line of treatment if patient wishes this is with phosphodiesterase inhibitors such as Viagra/ Cialis/ Levetra. If this fails despite 8 doses, try another PDE5 inhibitor. If still fails or is contra-indicated and patient wishes to be considered for more interventive treatment, Patient will be booked for E.D clinic. If significant psychological component, consider referral to clinical psychologist.
Peyronies DiseaseThis may present with a penile lump and erectile deformity. There is no overlying skin problem.

There may be an acute phase with pain and a changing deformity that may last up to a year. This phase can be treated symptomatically. It may be worth a trial of phosphodiesterase inhibitor for flaccidity.

Once this has been settled, if the degree of penile deviation is such to make penetrative intercourse difficult enough to justify surgery with the side effects of penile shortening and impotence, refer routinely to general urology clinic.
Family planningWe do not offer a vasectomy reversal service. If a patient requests a vasectomy for family planning, they should be referred to local services , or to Sandyford Place in Glasgow for a local anaesthetic procedure. If a patient is deemed unsuitable by Sandyford place for a local anaesthetic procedure on medical grounds, and not just preference, they can be referred for a general anaesthetic vasectomy to the general urology clinic.
Paediatric conditions The lower age limit for the urology service is thirteen years. We will see referrals above this age with mainly surgical conditions such as phimosis, and inguino-scrotal problems. The paediatricians will continue to see referrals upto fifteen with medical conditions such as uti, abdominal pain, enuresis. Surgical problems in children below thirteen years old can be marked paediatric surgery and sent to J McGowan, who is the secretary in Wishaw to the eye dept and the paediatric surgeons (Mr M. Flett and Mr Walker). Emergency cases in children upto thirteen should be directed to Yorkhill.