Category: All Referrals

Colorectal General Referral

Scott McLaughlin

This protocol should only be used where there is no suspicion of malignancy

If there is a degree of suspicion please see the guidelines below and refer through the Lanarkshire Cancer Referral Centre

Colorectal Cancer Referral Guideline

Risk-Based guidelines for Investigating Patients with Colorectal Symptoms

Patients with any of the following symptoms and associated symptoms should be referred urgently through the Lanarkshire SCI Gateway Cancer Referral Services. This will ensure that a patient pathway co-ordinator tracks the referral from the day it is sent..

Patients over 75 will be seen at the clinic first and will not be appointed straight to test.

Main SymptomAssociated SymptomAgePatient will be booked for
Rectal bleeding for > 6 week
Frequent and/or loose stools for 6 weeks
Constipation

Constipation

in isolation
in isolation		>75
<75

>50-74

<50

>50-74
<50		Outpatient clinic
Colonoscopy

Flexible Sigmoidoscopy and Barium Enema
Please refer using Routine Colorectal Guideline (below)
Flexible Sigmoidoscopy and Barium Enema
Please refer using Routine Colorectal Guideline (below)
Diarrhoea 3 or more loose or liquid stools/day for > 4 weeks>75
>50-74
<50		Outpatient clinic
Colonoscopy
Please refer using Routine Colorectal Guideline (below)
Palpable mass, right sided Abdominal mass or Rectal massAnyOutpatient clinic appointment
Iron deficiency Anaemia. UnexplainedUpper GI symptoms

in isolation male or postmenopausal female
in isolation male or postmenopausal female
Pre-menopausal female

<75

>75
Please refer using the Upper GI Suspected Cancer Guidelines
Colonoscopy and gastroscopy

Outpatient clinic

Please refer using Routine Colorectal Guideline (below) or to Gastroenterology

Routine Colorectal Referral Guideline

Patients with any of the following symptoms and associated symptoms should be referred routinely through the Lanarkshire SCI Gateway to the colorectal specialty in the appropriate hospital.

Patients over 75 will be seen at the clinic first and will not be appointed straight to test

Main SymptomsAssociated symptomAgePatient will be booked for:
Rectal bleeding for > 6 weeksConstipation
in isolation		<50
<50		Flexible Sigmoidoscopy
Flexible Sigmoidoscopy
Diarrhoea 3 or more loose or liquid stools/day for > 4 weeks<50Outpatient clinic
Constipation recent change of bowel habit>75
>50-74

<50		Outpatient clinic
Flexible Sigmoidoscopy and Barium Enema
Outpatient clinic
Iron deficiency Anaemia. UnexplainedIn isolationPremenopausal femaleGastroenterology or Colorectal Outpatient Clinic

All patients who require direct referral to test should be:

  • Physically fit for bowel preparation
  • No Anal symptoms (pain, discomfort, itching, lump and prolapse)
  • No Large bowel investigations carried out in the last 2 years

Investigations

No examinations or investigations (other than abdominal and rectal examination ,Uamp;E (for patient safety with bowel prep) and FBC are recommended).

Chronic diarrhoea – recommended investigations are Uamp;E, FBC, CRP, TFT and faeces culture

FOB or CEA is not indicated and should not influence decision making in symptomatic patients.

Key Points:

Patients with the following symptoms are at very low risk of cancer and could be managed initially within Primary Care or referred non-urgently for assessment:

  • Rectal bleeding with anal symptoms
  • Change in bowel habit to decreased frequency of defaecation and harder stools.
  • Abdominal pain without clear evidence of intestinal obstruction.

Colorectal Cancer and Family History

Individuals who have a family history of colorectal cancer but who are asymptomatic may warrant investigations if their history meets the criteria outlined in the following table. If any of the criteria are fulfilled patients should be referred for risk assessment to:

Regional Genetics Service

Management of High Risk Groups

RiskCriteria for ScreeningScreeningAge of Screening
HighAt least three family members affected by CRC and one with endometrial cancer in at least two generations; one affected relative must be age ?50 years at diagnosis; one of the relatives must be a first degree relative of the other two

Gene carriers (HNPCC genes)

Untested primary relatives of gene carriers		Colonoscopy every 2 years

Discuss gynaecological screening for endometrial and ovarian cancer

Offer 2 yearly upper GI endoscopy for gastric cancer

Consideration needs to be given to other screening for other cancers which may occur in specific families and are part of the HNPCC spectrum		From 30 to 70 years (or 5 years younger than the youngest affected relative)

For stomach cancer from 50 to 70 years or 5 years younger than the youngest stomach cancer
MediumOne first degree relative affected by colorectal cancer when aged < 45 years;

or

Two affected first degree relatives (one less than 55 years);

or

Two (one CRC less than 55 years) or three affected individuals with colorectal or endometrial cancer who are first degree relatives of each other and one a first degree relative of consultand.		Single colonoscopy if normal findings

Single repeat colonoscopy		At 30-35 years and again at 55 years
LowAnyone not fulfilling medium or high risk criteriaReassure and encourage healthy lifestyle

GP to monitor		N/A

Hereditary Nonpolyposis Colorectal Cancer (HNPCC)
Sign revised edition – in press

HNPCC is an autosomal dominant condition caused by a mismatch repair gene mutation. Individuals carrying a mismatch repair gene mutation or fulfilling high risk criteria for HNPCC should be offered endoscopic screening starting in the twenties if possible and repeated every 2-3 years taking into account the patient’s general condition and uptake. Diagnosis requires:

At least three relatives with a HNPCC-associated cancer (colorectal, endometrial, small bowel, ureter or renal pelvis) (one of whom should be a first degree relative of the other two)

At least two consecutive generations should be affected

At least one should be diagnosed before age fifty years

Referral should be made to the Regional Genetics Service for consideration of Mismatch Repair Gene mutation analysis

Familial adenomatous polyposis (FAP)
Sign Revised edition – in press

FAP is an autosomal dominant condition caused by an APC gene mutation and characterised by the development of multiple adenomatous colorectal polyps and the subsequent development of one or more colorectal cancers. In patients with FAP, referral should be made to the Regional Genetics Service for consideration of APC Gene mutation analysis. For those at risk of FAP, determined either by a positive family history or on the basis of mutation analysis should be offered:

At least three relatives with a HNPCC-associated cancer (colorectal, endometrial, small bowel, ureter or renal pelvis) (one of whom should be a first degree relative of the other two)

Colonoscopy every 2-3 years and yearly sigmoidoscopy

Patients should be offered proctocolectomy with or without ileoanal reconstruction or total colectomy with ileorectal anaastomsis once adenomas have developed. Subsequent management should include lifelong survey

Other High Risk Groups

A number of chronic conditions require structured surveillance. These include:

Chronic Inflammatory Bowel Disease

Acromegaly

Peutz-Jeghers Syndromme

Juvenile Polyposis Coli

Reference: Scottish Referral Guidelines for Suspected Cancer. Scottish Executive 2007
SIGN Guideline 67 -Management of Colorectal Cancer
Lead Clinician Mr Alistair Brown, NHS Lanarkshire
Review Date Dec 2010

Chronic Leg Ulcer

Scott McLaughlin

This protocol should only be used where the following conditions apply:

  • Ulcers of unknown cause
  • Venous ulcers and / or dermatitis unresponsive to first line treatment (SIGN guideline No 26)
  • Please include details of contact allergies and recent topical treatment

Ulcers which are clearly arterial should be referred to a vascular surgeon or interventional radiologist

Diabetic foot ulcers should be referred to podiatry

Ophthalmology Cataract Referral Guideline

Scott McLaughlin
Disclaimer

Please note that this protocol is only for referrals from Community Optometry to Health Boards.

One Stop Cataract Clinic E-Referral Criteria

One Stop Cataract Clinic E-Referral Criteria

Only patients with a Lanarkshire postcode can be referred to the Lanarkshire Cataract Service.

This is a One Stop Service therefore it is ESSENTIAL that the patient understands the outcome of this referral is surgery.

Before completing this e-referral please ensure the following:

  1. Patient is symptomatic due to significant cataract. Patient should actually complain that their sight is not good enough for day to day activity, working, driving etc. Optometrists must ensure that the cataract is causing visual problems. In absence of Posterior Subcapsular Cataract, Visual Acuity should normally be 6/10 or worse to warrant referral. However all cases of cataract induced visual loss should be considered, and the case for unusual referrals e.g. glare, poor contrast etc., should be made in the “Patient History and Details” section.
  2. Patient is keen to have cataract surgery. Patients must have been informed that the cataract can only be dealt with by surgery. Do they feel their sight is affected enough to have an operation?
  3. Patient agrees to take 5% risk of complications and 1:1000 risk of blindness related to cataract surgery
  4. If the cataract is affecting the “only” or “better seeing” eye, does the patient accept the risk of complications/blindness to that eye?
  5. Patient does not have significant ocular co-morbidity. The following conditions are unsuitable for One Stop Referral:
    • Suspicion of Glaucoma
    • Macular Hole
    • Diabetic Retinopathy or Maculopathy
    • Macular lesions that may require OCT e.g. Wet AMD
    • Vitreous Haemorrhage
    • Lid problems, Entropion, Ectropion, Ptosis, Chazion etc.
    • Corneal Scarring / Opacification / Oedema
    • Endothelial Dysfunction (not endothelial pigment)
    • Anterior Uveitis (or signs of past inflammation)
    • Amblyopia / Squint / Recent Onset Dipolopia
  6. Patient does not have significant Medical Pathology such as Diabetes, Angina / IHD, Hypertension, COPD, Tremor
  7. Patient is not taking Steroids, Anti-Coagulants or Prostate Medication e.g. Tamsulosin
    Please refer any of the above (sections 5, 6 and 7) to other Ophthalmology clinics as indicated, noting that patient is NOT SUITABLE for Direct Referral to One Stop Cataract Clinic.
  8. Patient with significant dry macular changes has sufficient cataract that surgery will be beneficial. These patients should be counselled with regard to limited improvements in VA after surgery and the reality of their expected visual outcome. Use the “Ocular Examination” section to inform the receiving ophthalmologist.
  9. Patient does not have Wet AMD: Refer patients to AMD clinic using the appropriate e-referral or paper form.
  10. Patient is not already attending the local eye unit with ocular co-morbidity. In these cases a letter should be sent to the consultant in charge of the patient informing them of findings or changes.
  11. All IOP readings have been made with contact tonometers such as the Perkins or Goldman. In addition, fundus examination should have been carried out by binocular slit lamp technique using an appropriate condensing (Volk type) lens
  12. ALL information requested on the referral template should be provided, including visual acuity and applanation tonometry.
For patients who fit the above criteria:
  1. Give eyelid hygiene instruction and Blepharitis leaflet
  2. Give Cataract Consent Form information leaflet
  3. Contact lens wearers should be advised to remove contact lenses 2 weeks (soft lenses) or 4 weeks (GP lenses) prior to their appointment, to enable accurate pre-assessment
  4. Ensure that the following items are recorded in the “Patient History and Details” section
    • Reason for referral e.g Blurred vision / Glare / Essential Driver / Poor contrast sensitivity / Carer
    • Relevant social history e.g. Working/Driver / Lives alone / Hearing impaired / Mobility impaired
  5. Ensure that the following items are recorded in the “Ocular Examination” section:
    • Do pupils dilate well?
    • Presence of Blepharitis and if treatment started
    • Type of cataract e.g. Nuclear / Cortical / Posterior Subcapsular
    • Presence of an IOL in the other eye
  6. If this is the second eye referred for cataract surgery, please ensure that the “Administrative Information” section is completed with the date of surgery of the first operation.
  7. Send e-referral.
  8. Print a copy of the completed e-referral and send to GP marked “For Information”

Reference:
Lead Clinician:
Review Date:

Carotid Artery Disease

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.

Carotid Artery Disease

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

  • 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

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.

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.

 

Breast, Suspicion of Cancer Referral

Scott McLaughlin
Breast Cancer

Breast symptoms are a relatively uncommon presentation in primary care. It is estimated that between 0.35% and 0.6% of all consultations in Scotland are for breast symptoms. Many of these consultations will be in young women, whereas the biggest risk factor, after gender, is increasing age. Incidence of breast cancer in women aged 30-35 is 33 per 100,000 population and approximately 81% of breast cancers occur in women over the age of 50.

Breast cancer accounts for 30% of cancers in women and around 4,400 people are diagnosed with breast cancer in Scotland each year; approximately 20 of these are men. The following recommendations seek to improve the referral and effective management of breast symptoms in women and men in primary care. Guidance for referral to regional genetics centres for those with a family history of breast cancer is available at Health Improvement Scotland website.

Urgent suspicion of cancer referralRoutine ReferralPrimary care management
Issue relevant advice leaflet
LumpAny new discrete lump (in patients over 35 years)
New asymmetrical nodularity that persists at review after menstruation (in patients over 35 years)
Unilateral isolated axillary lymph node in women
Cyst persistently refilling or recurrent cyst 		Any new discrete lump in patients under 35 years with no other suspicious features
New asymmetrical nodularity that persists at review after menstruation (in patients under 35 years) 		Women with longstanding tender lumpy breast and no focal lesion
Tender developing breasts in adolescents
Nipple symptomsBloodstained discharge
New nipple retraction
Nipple eczema if unresponsive to topical steroids (such as 1% hydrocortisone) after a minimum of 2 weeks 		Persistent discharge sufficient to stain outer clothes Transient nipple discharge which is not bloodstained
Check prolactin levels when discharge present
Longstanding nipple retraction
Nipple eczema if eczema present elsewhere
Skin ChangesSkin tethering
Fixation
Ulceration
Peau d'orange		Obvious simple skin lesions such as sebaceous cysts
Abscess/infectionMastitis or breast inflammation which does not settle after one course of antibiotics Abscess or breast inflammation even after settled in patients over 35 years Abscess* or inflammation - try one course of antibiotics to cover staphylococcus and streptococcus (also consider possible anaerobic infection as per local guidelines)
PainUnilateral persistent pain in post menopausal women
Intractable pain that interferes with the patient's lifestyle or sleep 		Women with moderate degrees of breast pain and no discrete palpable lesion
GynaecomastiaExceptional aesthetics referral to plastic surgery pathway if required
Exclude or treat any endocrine cause prior to referral 		Examine and exclude abnormalities such as lymphadenopathy or evidence of endocrine condition
Review to exclude drug causes
Measure hormones (oestrogen, testosterone, prolactin, human chorionic gonadotropin and alpha-fetoprotein)
Reassure

* Any acute abscess requires immediate discussion with secondary care.

Reference:
Scottish Referral Guidelines for Suspected Cancer. Scottish Government, August 2014
SIGN Guideline 134 – Treatment of Primary Breast Cancer
Clinical Lead Dr Juliette Mitchell, Consultant Surgeon, Wishaw General Hospital
Review Date March 2017

Suspicion of breast cancer dictation template

Beating the Blues (Mental Health) 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

Main Presenting Complaint: [Beating the Blues Referral]

Has this been discussed with the patient:

  • Yes
  • No

If not discussed, please give explanation. (See Guidelines for contact details): [Text]

Date of Onset: [Date]

Priority: [Routine]

Is the patient currently taking anti-depressants:

  • Yes
  • No

Please indicate the persons education level:

  • Primary
  • Secondary
  • Higher and/or University
  • Other

Preferred method of communication:

  • Email
  • Phone or Text
  • Letter

Please provide details if not complete:

Mobile phone number: [Text]

Email Address: [Text]

Beating the Blues Guideline

Audiology Paediatric

Scott McLaughlin

General Information

Patients referred to this service will be seen by Specialist Paediatric Audiologists but may not be seen by medical staff within the Audiology Department. The Clinical responsibility for patient?s treatment will remain with the General Practitioner, unless there is onward referral to an Associate Specialist in Audiology or to an ENT Consultant for further management.

Referral Guidelines

Patients must meet the following criteria before the Audiology department will accept the referral.

Please see vetting guidelines.

The following patients are suitable for direct referral to ENT:

 

Child referred with concern re hearing: From 8 months to 4 years

Paediatric ENT Clinics

Any child with referral mentioning significant snoring, nasal obstruction, obstructive sleep apnoea, frequent ear infections or tonsillitis should be redirected for ENT appointment.

 

Child referred with concern re hearing: From 4 to 6 years

Paediatric ENT Clinics

Referral directed to ENT if history of significant snoring, nasal obstruction, obstructive sleep apnoea, catarrhal, frequent ear infections or tonsillitis.

Referral where there is history of recent ENT surgery within past year with recurrence of symptoms or related complaints.

 

Children referred re hearing concern: From 6 to 18 years

ENT Clinics

Those whose referral indicates significant history relating to OME, tonsillitis, snoring or obstructive sleep apnoea as previously.

Referral where there is history of recent ENT surgery within past year with recurrence of symptoms or related complaints.

Audiology Hearing Aid Referral

Scott McLaughlin

General Information

Patients referred to this service will not be seen by medical staff within the Audiology Department. The Clinical responsibility for patients treatment will remain with the General Practitioner.

The Audiology Department can offer travel to Hairmyres Hospital, Stonehouse Hospital, MDGH or Wishaw General Hospital if required –please indicate that transport is required

Housebound/Nursing home patients who are unfit to travel can be seen on a domiciliary visit. (Use separate template)

Referral Guidelines

Patients must meet the following criteria before the Audiology department will accept the referral:

  • Patient must be over 50 (under 50 if learning disabilities)
  • Hearing loss is not of short duration
  • Hearing loss is not of sudden onset
  • Hearing loss is not asymmetric or unilateral There is no rotary vertigo
  • There is no severe tinnitus
  • There is no external or middle ear infection There are no perforations
  • There is no recent discharge
  • Both ears are free from wax at time of referral

Please note: Wax Removal may be arranged by the department if necessary

Hearing Aid Repairs

Please advise patients that there is a walk in service available for hearing aid repairs and battery replacements, as follows:

Audiology Services,
Douglas St Clinic,
Hamilton, ML3 0BP.
Tel: 01698 368700
Tuesday – Friday, 1.30 – 4 pm
Central Advice Line
01698-456556

 

Hairmyres Hospital,
Eaglesham Road,
East Kilbride,
Tel: 01355 585000.
Mon, Tues, Wed 9.30 – 11.30
Tues 2.00pm – 4pm

 

Stonehouse Hospital,
Stonehouse,
Tel: 01698 794015
Tuesday 1:30 – 4pm
Thurs only 9.30am – 11.30am

 

Audiology Clinic,
Wishaw General,
Wishaw.
Tel: 01698 361100
Mon, Tues, Wed, Frid,
9.30am – 11 30am

 

Audiology Clinic OPD,
Monklands Hospital,
Airdrie, ML6 0JS
Tel: 01236-712028
Mon – Thursday
1.30-4pm

 

Lanark Health Centre,
Lanark.
Tel: 0155661534
2nd and 4th Friday
9.30am – 11.30am

 

Central Health Centre
North Carbrain Road,
Cumbernauld, G67 1BJ
Tel: 01236 731771
Mon only 9.30am – 11.30am

Audiology Domiciliary

Scott McLaughlin

General Information

Patients referred to this service will not be seen by medical staff within the Audiology Department. The Clinical responsibility for the patients treatment will remain with the General Practitioner

NB: The Audiology Department can arrange travel to Hairmyres Hospital, Stonehouse Hospital, MDGH and Wishaw General Hospital if this would be a suitable alternative.

Referral Guidelines

Patients must meet the following criteria before the Audiology department will accept the referral:

  • Patient must be over 50 (under 50 if learning disabilities)
  • Hearing loss is not of short duration
  • Hearing loss is not of sudden onset
  • Hearing loss is not asymmetric or unilateral
  • There is no rotary vertigo
  • There is no severe tinnitus
  • There is no external or middle ear infection
  • There are no perforations
  • There is no recent discharge
  • Both ears are free from wax at time of referral

 

OR

If the patient is an existing hearing aid user that requires to have a new hearing assessment.

NB: Patients that require a hearing aid repair may contact directly to arrange a Domiciliary visit.

Please note: Wax Removal may be arranged by the department if necessary