NORTH WEST ARMED FORCES HOSPITAL

Family Medicine Administration

MANUAL OF CASES
ELIGIBLE FOR REFERRAl
TO SURGICAL SUBSPECIALITIES
BY FAMILY PHYSICIANS
NWAFH, TABUK

Reviewed by:
Scientific Committee
of Referral System
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TABLE OF CONTENTS
CONTRIBUTORS:
TOPICS PAGE

• Dr. Mahmoud Zakaria Consultant& Headof Urology

• Dr. TalalAlkindi, Consultant& Headof Orthopedics Preface
• Dr. Mohammad Homood Consultant& Headof Neurosurgery
• Dr. YahiaZedan, Consultant& Headof PlasticSurgery Introduction & Background P ••••••••••••••••••••••••••••••••••••• 2
• Dr. Hossam Hassan Consultantof VascularSurgery General Surgery 6
• Dr. Mohammed Alnuwagi, Consultantof PediatricSurgery
• Dr. Mohammed Abdullah, Consultant& Headof Ophthalmology Pediatric Surgery 10
• Dr. Essam Farhood, ConsultantENT Surgeon
Plastic Surgery p •••••• 12
- Dr. Yosuf Alalawi, SeniorRegistrarGeneralSurgery
• All Family Physicians in Family Medicine Department Urology 14

• Scientific Committee of Referral System Vascular Surgery 17

in Family Medicine Administration
Neurosurgery 18
• Dr. Tariq Shaqran Chairman
• Dr. Ayman Afifi Member Orthopaedic 20
• Dr. Tahani Khalil CPD Supervisor
• Dr. Saad AI Qahtani Member ENT 22
• Dr. Eyad Khalid Member Ophthalmology 28
• Dr. HishamEid Member(TOM)

• Advisors:

• Dr. Ali Faris AI Amri, Directorof FamilyMedicineAdmin,

- Dr. \IIiur MlJsawa, Directorof SurgeryDepartment

 PREFACE

- It is my pleasure to introduce this manual regarding referral process between

family medicine clinics and surgical subspecialty clinics.

- First of all, I would like to thank and appreciate all members sharing in the
preparation and outcome of this great work.

- Special acknowledgement should be given to the Family Medicine Depart-

ment for this unique initiative, the department of surgery represented
by the Director of the Department and the Heads of Surgical Subspecialties.
Their genuine cooperation to finalize the whole process is highly
appreciated.

- The methodology of this manual shows clearly that it was a real interactive
and cooperative team work.

- I believe that proper application of the instructions in this manual will

minimize time, cost and effort done by the triad of referral system i.e. the
patient, the referring physician and the referred consultant aiming finally
at professional development of services provided by our hospital.

- At the end, I hope all success to this effort and further more applications
with other specialties like Internal Medicine, Pediatrics and OB/Gyn.

- With best wishes.

Brig. Gen. Dr. Ghalib Ghalib Bin Huraib

Director of North West Armed Forces Hospitals
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INTRODUCTION AND BACKGROUND

Alms of this manu.al:

- The family physician and ofuer specialisls cannot function in isolation, This manual is mainly Intended fur Famny Physicians tl'lllieir daily ~clice te
as they are equal partners in providing heallh care to llie whole find III cl.ear and easily aC£:essible answer fur llie fallQwmg questicns:
oommunlty.
1} When to refer? Regarding ltIe medical condiuQl'\S
- The refellal prooess is not a supenodinferior or teacher/pupil 2} To whom to refer? appropriately
relationship BUT rrather 2 skilled physicians working together. 3) How to refer? regal'dlng ltIe type of refenal
The ultimate target ISprofessional develcpment of refenal system,
- The refellal system is defined in Rake!, textbool< of family medicine
4th ed as "a process m whiCh lhe beating physician at a lower level of Methodology of this manual:
health services, who has inadequate skills by virtue of his qualifications It was a real dynamic process between Family Medicine Department and
andror lesser facilities at his level to manage a clinical ronclition, seeks SUl'glcal Subspecialties.
the assistance of a better equipped and specifically trained individual
wilh be1l!erresources at a higher level to guide the treating physician 1) A brainstorming ~ done for aU Family Physicians in the department ~
in managing or talQng over the management of a parlioolar clinical anUst from their own Point of view the cases sup~~ to be eligible for
oollclitiOll~. referral to surgical subspecialties including ENT and EYE Clinics, The
collected data are gathered [n OM manuscript [nvl1lMngltle sug~stedl cases
- II sb001d be reoognized as a 2 way process of communication between per subsl*lalty_
the fami1y Physician and the Hospital Coosultanls. 2} The PfetiminafY list was sent to the Directol' of Surgery department to be
reviewed by the heads and teams of eacll sur9[cal su~ia.It¥'_
- For this process to sooceed, bolh parties (the referring physician and S) A feedback (reviewed Usts) was re~ed from surgical s~e for pllQllng in
~he oonsUltant) should have a mulllal understanding and recognition family practiQe to ass~ appllcability_
of their respeDlive roles. 4) A number of to Family Physicians was selected to follow up the ~back
list for 2 ~ and tQ mentton \MIl' oommeflts (if any) l\) be taltlNl (nto
ool'\~derattQn beiQffl printing the nnal Ust

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 REMEMBER
5) The feedback list with comments on each subspecialty from Family
Medicine side was resent again to Surgery Department for final
- Referral DOES NOT mean transferring the responsibility; it is indeed
corrections, additions, explanations and comments.
"sharing" the responsibility in patient care.
6) The finalized list was received from Surgery Department.
7) A panel discussion meeting was arranged including all doctors from
- The hallmark of the referral process is the appropriateness of referrals
Family Medicine and Surgery Departments to put the fine touches and NOT the referral rate.
before printing the finalized list. The attendants are divided into (6)
groups. Each group reviewed (2) lists of subspecialties in a period of - Avoid preoccupying your patient/client by something expected to be done
one hour. Then, Panel discussion iwas initiated for the final agreement
in the referred clinic. For instance, DO NOT tell the patient; "you are going
of each item in the different lists in another period of one hour.
to do specific investigation like MRI or specific procedure like laser treatment",
8) EBM hints were added to some lists to augment applicability on solid
This may break the communication between the patient and the referred
scientific ground. consultant.
9) The items of referral in some lists were put chronologically in
alphabetical orders to make it easily usable as a reference. - If the patient has appointment already in one clinic with certain Consultant,
10) Now, the printed manual is available on the desktop of each Family it is better to recommend referral to the same Consultant for proper medical
Physician in NWAFH for application. service

•. Further evaluation will be done after one year. - DO NOT refer before reviewing the medical file of your patient; surprisingly
• We are planning to do the same with other specialties like Internal you may find that he was given another referral to the same clinic (avoid
'Medicine and Pediatrics, etc. unnecessary duplication of referrals)

• Finaly, I would like to acknowledge everybody who shared in the - DO NOT hesitate to consult your Seniors in Family Medicine Department
preparation of this booklet. Also, special thanks to Jocelyn R. Mercado before referring your patient/client to other specialty (we are one team).
for her great effort to layout this manual.

Dr. Tariq Shaqran

Chairman of Scientific Committe of Referral System
Senior Consultant of Family Medicine

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CASES ELIGIBLE FOR REFERRAL TO GENERAL SURGERY
B. Anal Fistula or Perianal Sinus: ---+ Routine Referral.
l.ABDOMINAL HERNIAS: C. Internal Hemorrhoids:

A.lnguinal - 1st and 2nd degree can be treated in Family Medicine clinics.
B. Femoral Soften stool by bran, fybrogel and recommend analgesia like
C. Epigastric lignocaine
D. Umbilical/para-umbilical 5% ointment
E. Incisional - 3rd and 4th degree ~ Routine Referral.
• If uncomplicated ~ Routine Referral. • Complicated Hemorrhoids e.g. strangulated -> Emergency
Referral.
- If complicated (e.g. obstructed, irreducible, strangulated) --
Emergency Referral (arrange with the General Surgeon On call). - Patient> 40 years -> needs sigmoidoscopy to rule out malignancy.
So, refer to Gastroenterology before Surgery Clinic.
2. ACUTE ABDOMEN: D. Perianal Hematoma: (misnomer is thrombosed external pile)
• Only with suspected surgical cause needs emergency referral (Ref Murthagh's General Practice 4th ed. 2007; page: 359 with modification)
(arrange with General Surgeon On-calL) - Has been described as the five day, painful, self-curing pile.
- Within 3 days (5 days in the reference) of onset -> Emergency Referral.
3.ANAL PROBL.EMS; (arrange with the Sugeon On-call; evacuated by aspiration within 24 hours
A. Anal Fissure: (Ref: Murtagh's General Practice 4th ed.: page 358) of onset or by incision & squeezing from 24 hours to 3-5 days of onset)
- Treat conservatively for 2 months (complete healing in most cases). Note: Drainage may be done in Family Medicine Clinic if facilities are available
Options: - Day 4 (6 in the reference) onwards -> best left alone unless very painful
• Aim at soft bulky stool by laxatives and high residue diet to avoid or infected then, arrange with the General Surgeons On call for
constipation; Emergency Referral.
• Apply combined anesthetic and steroid ointment locally to provide E. Perianal Abscess, Ischiorectal Abscess, Pilonidal Abscess:

relief and pr-omote heali!Jg.
• Sitz baths can relax the !ntemal anal sphincter.
• If NOT Improved after 2 months or complicated by a degree of
fibrosis or anal stenosis -t Routine Referral.
Note: The mO$t promising COnSflfYatiVIiJtreatmflnt is diluted glyceryl
trlnltr-ate ointment (0.2 • 0.3%) " times dally to the lower anal
canal (transient headache in thliJmain adverse effeat).
- Emergency Referral (arranged with the Surgeon On call).
NOTE: Superficial skin abscesses can be drained by Family Physicians
F. Suspected Anal Cancer: usually squamos cell carcinoma
• Refer for urgent surgical review and confirmation of diagnosis.
G. Pilonidal Sinus (PNS) - Routine Referral

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4.BREAST MASS:
A. Breast abscess: 7. NECK SWELLINGS:
- Arrange with the General Surgeon On call for Immediate Referral.
A. Thyroid mass: request U/S and FNAB
B. Breast mass -->
- If suspected malignancy refer ASAP after arrangement with the
- If the patient is < 35 years of age --> request ultra-sonography
On call team otherwise Refer Routinely.
(U/S) + fine needle aspiration biopsy (FNAB) B. Thyroglossal cyst or sinus.
- If the patient is > 35 years of age --> request U/S + Mamography
+ FNAB
- If the patient >12 years of age -> Refer Routinely to General
Surgery Clinic
- If suspected malignancy (based on the above mentioned work up)
- If the patient < 12 years of age -> Refer Routinely to Peadiatric
--> refer ASAP after arrangement with the On-call team. Surgery Clinic

5.DIABETIC FOOT:
8. RECTAL PROLAPSE: (Ref: OHBGP 2nd ed.; page 475)
A. Simple diabetic foot can be dressed in Family Medicine Clinic.
- Occurs in 2 age groups: the very young and those> 60
B. If signs of gangrene dry/wet --> arrange with the On call team for years.
Emergency Referral.
- Refer adults Routinely to General Sugery.

Note: If the patient was seen before in Surgery Clinic please refer him
Note: The following needs referral to Gastroenterologist
to have appointment with the same Consultant. before Surgery:
a. Esophageal Disease
6. GALLBLADDER STONE:
b. Gastric Diseases e.g Hiatus Hernia, Pyloric Stenosis
A. If symptomatic without complication --> Routine Referral. c. Colorectal Disease
Note: 70% of gallstones are asymptomatic. d. Cases for Sigmoidoscopy
B. If complicated e.g.
- Acute Cholecystitis evident clinically plus stat U/S arranged with the
Surgeon On-call -->Emergency Referral
- Chronic Cholecystitis evident by U/S --> Routine Referral
Note: Cholecystitis is associated with gallstones in > 90% of cases.

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CASES ELIGIBLE FOR REFERRAL TO PEDIATRIC

SURGERY

1. FOR CIRCUMCISSION
4. Inguinal Hernias: Routine Referral as soon as diagnosed
A.AII patients should be examined for: 5. Retractile Testes: Routine Referral at the age of one year
- Meatus position 6. Thyroglossal Cyst/Sinus:
- Foreskin retraction
- Refer Routinely those below the age of 12 years.
- Inguinal swelling 7. Umbilical Hernias:
- Undescended testis - Refer Routinely at the age of :2 years,
B. Children less than 4 months of age, should be Referred If below 2 years of age -> conservative treatment.
Routinely to the circumcision clinic (with coagulation 8. Undescended Testes:
profile if familial history of bleeding disorder). - Refer Routinely at the age of 3 months
C. If the child is more than 4 months of age (up to 12 - If> 3 months of age arrange with the Peadiatric Surgeon
years), he should be Referred Routinely to the Pediatric On-call for appointment as soon as possibje.
Surgery Clinic. Note: Do U/S only if testicle/s is not palpated. '
D. If the child is more than 12 years, Refer Routinely to
Urology Clinic. 9. Tongue Tie -> Routine Referral
- If his tongue reaches the lower border of the lower lip,
2. Branchial Cyst/Sinus/Fistula: rare condition no need for referral.
Refer Routinely after 6 months of age.
3. Hydrocele: Note: the following is NOT for referral to Pediatric Surgery
if not changing in size, Refer Routinely after one year of - Rectal Bleeding - Pediatric Gastroenterologist -
age - Constipation - Pediatric Gastroenterologist
- if tense refer ASAP after arrangement with the Pediatric - All neck swellings should be referred to Pediatrician for
Surgeon On call. clearance
- If changing in size or associated with inguinal swelling ->
Routine Referral as soon as diagnosed.

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CASES ELIGIBLE FOR REFERRAL TO PLASTIC
SURGERY
1. Cicatricial alopecia (post burn or posttraumatic) --> Routine
Referral
If infected, treat infection first
2. Cleft lip and/or cleft palate
Once diagnosed after birth arranged appointment with the
Plastic Surgeon On-call within 3 months if unilateral or
within 1 month if bilateral.
3. Disfiguring scars or keloid on the face --> Routine Referral
4. External angular dermoid cyst on the face-->Urgent Referral
5. Gynaecomastia: (Ref: OHBHP 2nd ed.2005; page:515)
- If physiological ( neonatal or pubertal) --> reassure.
- If accompanying medical condition (e.g. liver cirrhosis,
hyperthyroidism or dug induced) --> treat the cause
- Otherwise, Refer routinely to Plastic Surgery after
requesting ultrasound and hormonal profile
Note: Always be alert to differentiate breast mass
(General Surgery case) from whole breast enlargement.
6. Hairy moles. (pre-malignant --> Urgent Referral)
7. HAND CONDITIONS:
* Cut tendons of the hand
- If old --> Routine Referral
- If recent --> Emergency Referral for repair otherwise
if not done within 2 weeks, reconstruction will be difficult
(arrange with the Plastic Surgeon On-call)
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* Congenitalhand anomalies(e.g.Constrictionring,
polydactyly,syndactyly,)refer as soon as possibleonce
diagnosedafter doing plain X-ray.
possible
* Hand deformities(post burn, postraumatic)-t ReferASAP
to avoid stiffness
* Hand foreign bodies -t ReferUrgentlyto avoid infection
after doing X-ray (arangedwith Plastic SurgeonOn-call
8. Hypertrophied scar or keloidelsewhere-t RoutineReferral
9. Localized Adeposity. for Liposuction -t RoutineReferral.
Important Note: There is always misunderstandingabout liposuction.
It should be clear that liposuctionis not for weight reduction.It is
indicatedonly for body contouringi.e. localizedfat collection.In this
sense morbidobese patient should not be referredto Plastic Surgery.
They should go to General Surgeryfor BariaticSurgeryand the role
of·PlasticSurgerycomes later on afterweight reductionfor removing
redundantskin.
10. Macro or Micro Mastia for Mammoplasty -t Refer Routinely after
mammogram
11. Peripheral nerve injuries and neuromas -t Refer Routinelyafter nerve
conductionstudy and arrangementwith PlasticSurgeonon-call.
12. Post burn contracture -t Refer Routinely
14. Protruding ears (BATEARS) -t Refer Routinely
13. Suspected Cutaneous carcinomas (Basal Cell Ca, SquamousCell
Ca, or MELANOMAS)-t Urgent Referralarrangedwith Plastic Surgeon
On-call
14. Tattoo Marks: Any where in the body -t Refer Routinely
Note: Treatmentby excision +/- skin graft, we do not have LASER
therapy at NWAFH.
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CASES ELIGIBLE FOR REFERRAL TO UROLOGY

1. Benign Prostatic Hyperplasia (BPH)
(Ref.: OHBGP 2nd ed. 2005; page: 686)
- If complicated (10% at presentation); e.g. Recurrent
urinary tract infection (UTI), Bladder stones, Hematuria,
Acute retention of urine with or without prior obstructive
symptoms,
Chronic obstruction,
Overflow incontinence,
Obstructive nephropathy.
- Nodular/firm prostate on digital rectal examination-CORE).
.i prostatic specific antigen (PSA)
In the above mentioned cases, arrange with the Urologist
On call for urgent referral.
- Severe symptoms (obstructive or irristative) --->refer ASAP
Note: • 10-30% of men in their early 70s have symptomatic
BPH.
• There is no clear relation between prostatic
volume and symptoms.
• Failure to respond to drug therapy; e.g.
after 3-12months. (a blocker) or 6-12months (5 a
reductase inhibitor).---> Refer Routinely
2. Cases for Circumcjsion (Ages 12 years & above)
3. Erectile Dysfunction (Impotence):
Referral Options: (Ref. OHBGP 2nd ed. 2005; page 703)
- Urologist: If the patient has never had an erection, has
a·severe vascular problem, lack of success in general
practice, or severe psychological distress due to impotence.
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- Endocrinologist: Hormone abnormalities (e.g. androgen,
i prolactin) treatment does not always restore potency.
- Psychiatrist/psychosexual counselor: Age < 40 years
and no evidence of organic cause; psychosexual problem.
Note: In our practice refer to Urologist, and leave the 2nd and 3rd
options to him.
4. Hematuria (Postglomerular)
- In patients < 20 years of age, GN & UTI are the most common causes
between 20-40 years; consider UTI, Stone, Trauma & Neoplasia of UT
Age 40-60; the most common cause is CA, fol!-owe('J by Kidney stones
& the BPH (Ref: .Blueprint 2006)
Differentiate Nephro from Urological causes by differentiating"
microscopy on urine detailed report.
- If Microscopic Hematuria i.e. 5~10 RBC on 2 r.epeatedurine detailed
report 1 month apart -t ReferASAP
- If painless .& frank hematuria, -t Urgent Refer arragned with Urologist
On-call
5. Hypospadias (Pediatric Urology)
7. Infertility with suspected urological problems and after doing work
ups: semen analysis, U/S testes, hormonal essays.
6. Penile swellings.
- If inflammatory -+ Urgent Referral
- If long standing -t Routine Referral
7. Retention of Urine: (Ref. OHBGP 2nd ed.2005; page. 690-1)
-If acute, catheterize (record initial volume drained) or refer urgently
to Urology for catheterization further assessment and treatment
(usually done in ER)
- If chronic, refer routinely BUT refer urgently or acutely if pain;
UTI, or renal failure (urea >12mmol/l). Do not catheterize in the
community
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- If recent Urosurgery send to the concerned Urologist as
possible.
-In all cases, do mid stream urine (MSU) to exclude infection,
urine dipstick for blood, CBC, U&E, Creatinine before
referring.
9. Renal Stones: (male to female ratio 3: 1)
- If the calculus is <5 mm, it is likely to pass spontaneously.
- If >5mm, intervention by lithotripsy or surgery is usually
required, so refer to Urology.
- If severe symptoms -> Refer urgently
Note: (90% renal stones are radio-opaque; only urate
and xanthine stones are radio-transluscent);
10. Scrotal swelling e.g. hydrocele, varicocele.-> Routine
Referral
Note: Varicocele is found in 15% of adult men. Refer if
1. Decrease sperm count and infertility
2. Testicular pain or discomfort
3. Isolated rt. sided varicocele or bilateral lesion that
doesn't disappear when patient assumes supine
position. Ref:Bratton's F.M. Board Review 2007
11. Suspected torsion of testes -> emergency referral
12. Suspected urological malignancy: e.g.
cancer bladder, testicle, prostate, hypernephroman,
Wilm's nephroplastoma and carcinoma of the penis.
Note: Arrange with the Urologist On call to refer all
cases urgently for histological confirmation and
advice on management.
13. Uretheral stricture after uroflow study -> Refer Routinely
unless retention.
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CASES ELIGIBLE FOR REFERRAL TO VASCULAR
SURGERY
1)VARICOSE VEINS
- In Middle and Old Age, treat conservatively by:
i 0 Daflon 500mg SO for 6 month
o Elastic stocking (or tube-grip if obese patient) during
walking and standing to be removed during sleep.
o Gradual compression bandage & excercise has level
:r.-- A evidence.
o Reassess periodical checking progress and surface area
& educate patient about measure to decrease recurrence.
- In Young Age (cosmetic problems) - Refer Routinely to
Vascular Surgery
- If Thrombosed Varicosities, treat by low dose Aspirin +
NSAID for 2 weeks. Then Refer Routinely to Vascular
Su~e~ -
2)VENOUS ULCER
Dressing by Aqacell silver in Family Medicine Clinic + Routine
Referral to Vascular Surge~ for study of venous system for
possible surgew
3)GANGRENE
IF Wet -> refer to General Surgery.
IF Dry with non-palpable Distal pulses -> refer to the next
clinic in vascular surgery (ASAP arranged with Vascular
Surgeon On call).
4) LEG ULCER
If Diabetic -> refer to General Surgery (routine)
If Venous -> dress in FMC + Routine Referral to
Vascular Surgery
If Ischemic -> refer to Vascular Surge~ ASAP.
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CASES ELIGIBLE FOR REFERRAL TO NEUROSURGERY
1)Abnormal skull shape (e.g. scaphocephaly in children)
Better to be referred before the age of 6 months -> arranged
with the Neuro Surgeon On-call for urgent referral
2)Abnormal midline back swelling e.g. midline lipoma, port
wine stain -> Routine Referral
3)Any fracturels of Skull/s.
4)Any fracturels of Spine (Cervical, Thoracic, Lumbar or Sacral)
Note: Recent fracturels only, NOT old healed ones.
Any recent fracture needs arrangement with the Neuro
Surgeon On-call for urgent referral.
5)Carpal Tunnel Syndrome -> Routine Referral
6)Cervical rib with neurological manifestations -> Routine
Referral
7. Headache more than 2 weeks not responding to medical
treatment -> request CT Scan'
- If abnormal finding e.g. space occupying lesion -> arranged
with the Neuro Surgeon On-call for urgent referral
8) Hydrocephalus.-> arranged with the Neuro Surgeon On-call
for urgent referral.
9) Low back pain not responding to conservative treatment
(NSAID + PHYSIOTHERAPY) for 6 to 12 weeks
RED FLAG SIGNS: (Ref. OHBGP 2nd ed. 2005 page 550)
< 20y. or >55y.- Non-mechanical pain - Thoracic pain -
Past history of carcinoma, HIV - Taking steroids - Unwell
Weight 1- Widespread neurology - Structural deformity
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Note: Acute Low Back Pain maybe Mechanical (Lumber
Strain 70%, Degenerative 10%, Disc 4%),
Non-Mechanical 1% (lnfection/ Neoplasm 2%),
Visceral (referred) 2% .
Ref. Blue print Family Medicine, 2006)
10) Meningocele -> arranged with the Neuro Surgeon On-call
for urgent referral.
11) Prolapsed Inter-vertebral Disc/s evident by radiograph' +
objectively detected neurological manifestations -> Routine
Referral
12) Suspected spinal tumors -> arranged with the Neuro
Surgeon On-call for urgent referral
13) Tuberculosis of the spine. -> refer ASAP
Note: All nerve injuries should be referred to Plastic Surgery.
'There will be 4 assigned Senior Consultants in Family Medicine
2 males and 2 females eligible for requesting MRI or CTScan.
Please do not hesitate to contact them.
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CASES ELIGIBLE FOR REFERRAL TO ORTHOPAEDIC

The 1st On-call should be contacted for: All the following routine referrals( after X-rays):
1. Recent Fractures: 1. Advanced Osteoarthritis (if the patient is keen for operation)
- if confirmed by X-ray in our hospital 2. Baker's Cyst
3. Blount's disease (Tibia Vara)
- if confirmed outside our hospital and the patient had POP,
4. Bone cysUs
request an X- ray film to check if the fracture is not reduced
or the callus is not formed. 5. Club foot or Talipes
t:< 6. Flat foot
Note: Request for X-ray with cast if within 3 weeks of trauma,
otherwise remove the cast before doing X-ray. 7. Ganglion
8. Old fractures with complications e.g. deformity, mal-union
2. Congenital dislocation of the hips
9. Pes Cavus (High arched feet)
3. Foreign body in the upper or lower limb
10. Tenosynovitis
4. Osteomyelitis
11. Trigger Finger
5. Septic arthritis
12. Gamekeeper thumb (skier's thumb)
Note; In items 4 & 5, do full investigation (CBC, ESR, CRP,
Note: Items 9, 10 & 11 need routine referral unless they are acute
plain X-ray)
6. Slipped capital femoral epiphysis evident by X-ray
7. Susptected Bone Tumours, e.g., osteochondroma

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CASES ELIGIBLE FOR REFERRAL TO ENT
The main reference in this Chapter is derived from Oxford hand
book of General Practice (OHBGP) 2005 2nd ed. ENT Section
A. EAR CONDITIONS:
Otitis Externa
Except in mild cases, need to remove infected material.
Gentle syringing may work; if not, needs aural toilet refer
to ENT.
If diabetic -> Refer urgently (arrange with ENT Surgeon On-call)
Wax in the ear canal and syringing
Wax can be removed by syringing provided perforation of
the drum is not suspected. For hard wax, soften with 5%
sodium bicarbonate drops or olive oil tds for 5d. prior to
syringing Do not syringe ears after mastoid operations.
If blocking wax not responding -> Refer in many cases wax will
be removed just with ear drops sodium bicarb! olive oil.
Haematoma ot the pinna
Usually after trauma.
Arrange referral ASAP with the ENT surgeon on call.
Foreign bodies in the ear
Most common in children. Try to remove under direct vision
with forceps but avoid pushing objects deeper into the
canal and causing damage. Don't poke around with forceps
in an uncooperative child. Removal under GA may be needed.
Insects can be drowned in oil and syringed out.
Disc battery needs urgent referral
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Otitis Media:
Refer Routinely
If not responding to medical treatment -> (Systemic antibiotic
for 7-10 days at least)
If recurrent attacks (3 episodes in 6 months or> 4 episodes per
year) or if acute perforation does not heal in < 1 mo.
Ret. Uptodate, May 2009
Glue Ear: (otitis media with effusion)
Natural history: 75% resolve in <3mo.
Watchful waiting can be used in asymptomatic or mild cases.
Refer to audiology service or ENT if not resolving, especially
if speech or language delay.
Perforated Ear Drum
A. Central perforation: safe disease. Treat as for otitis
externa to dry discharge and encourage drum healing. Refer
Routinely, if persistent discharge, deafness, vertigo, or earache,
B. Attic or marginal perforation: unsafe disease. May
indicate cholesteatoma (stratified squamous epithelium
invades the middle ear and can cause local damage leading
to deafness, vertigo, facial nerve palsy, cerebral abscesses,
and meningitis). Refer Routinely, may need surgery to remove
invasive tissue,
Deafness
Refer to ENT if:
- Conductive deafness of unknown cause;
- Sudden deafness if no wax visible;
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- Asymmetrical deafness to exclude rare dangerous
diagnoses e.g. acoustic neuroma, cholesteatoma,
nasopharyngeal carcinoma
- Suspected Otosclerosis or presbyacusis
Vertigo (exclude systemic causes)
Benign positional vertigo (BPV):
Natural history: Usually self-limiting (few weeks) although in
a few cases, may continue intermittently for years.
Reassure. Labyrinthine sedatives are not helpful.
Teach the patient to minimize symptoms by sitting and lying
in stages. Habituation may occur by maintaining trigger
position until vertigo settles. If not settling, refer to ENT for
physiotherapy or for Epleys' manoeuvre (rapid repositioning
of head to move otoliths out of the labyrinth).
Note:Vertigo + Tinnitus + 1 hearing = Mennier's disease
Vertigo +/-.1. hearing = periph. vertigo (BPV, Vestibular
neuritis, etc
Vertigo + any neurological symptom = Central Vertigo. =
Vestibulo basilar insufficiency (VBI)
Tinnitus
Indications for referral to ENT
Objective tinnitus (noise can be heard by an observer, rare
and may be due to vascular malformations or
tempromandibular joint problems); unilateral tinnitus
(especially if associated with deafness exclude acoustic
neuroma).
If pulsating -t Refer ASAP
24
Viral Labyrinthitis:
Natural history: Usually resolves in 2-3 weeks.
Try Labyrinthine sedatives e.g. cyclizine or prochlorperazine.
If persists> 6 weeks. Refer.
Menieres Syndrome:
Refer: All suspected cases for confirmation of the diagnosis.
B. NOSE CONDITIONS:
Deviated Nasal Septum:
Common in adults usually secondary to injury.
Refer routinely if uncontrolled symptoms. (chronic nasal
obstruction, snoring, mouth breating.
Nasal Polyps:
Most common in men age> 40 years
Associated with asthma, allergic rhinitis, and chronic sinusitis.
Try medical treatment: steroid nasal drops e.g. beclometasone
0.1 % bd until polyps shrink (max 1 month) and then
maintenance on steroid nasal sprays. Swab and give antibiotics
if purulent nasal discharge.
Refer for assessment and consideration of surgical treatment
(polypectomy) if medical treatment fails. Polyps often recur
after surgery.
Refer unilateral polyps with an unusual or irregular appearance,
especially if ulcerating and/or bleeding, for exclusion of
malignancy.
25
 4. Recurrent quinsy
5. Unilateral tonsillar enlargement: to exClude malignancy.
Foreign bodies in the nose: * Quinsy (peritonsillar abscess):
Common in young children. Refer all children with unilateral - Usually occurs in adults.
offensive discharge for exploration under GA. Do not try to - Arrange with ENT surgeon on call for Urgent Referral
remove a foreign body yourself unless the object is very
superficial and the child cooperative. You might push the ,. Retr-opharyngealabscess:
object further in and cause trauma. - Occurs in children.
- Arrange with ENT surgeon on call for Urgent Referral
Sinusitis
If ACUTE (Usually follows URTI, though 1 Q% due to tooth *Hoarseness of Voice:
infection), treat medically e.g. steam inhallation; short course URTI is the most common local cause
decongestants (local and systemic); antibiotics for 10 days at Refer aJJpatients with hoarseness lasting> 3weeks for ENT
at least (limited evidence of benefit); steroid nasal spray. assessment to exclude carcinoma.
If CHRONIC, Treat as for acute sinuslti~. Refer to ENT if Note: Hysterical paralysis of the vocal cord adductors due to
symptoms are interfering with life; surgery may herp. psychological stress can cause the voice to a whisper or be
lost completely. More common amongst young women.
Epistaxis if recurrent (no obvious systemic cause) _ Refer Refer for laryngosoopy to exClude organic cause.
routinely * Acute epiglottitis
If acute - Refer urgently Can potentiaJJy obstruct the airway.
Much rarer since introduction of HIS immunization.
C. THROAT CONDITIONS: If suspected, DONT examine the child's throat as this can.
precipitate complete obstruction. Refer urgently
~ Indications for referral for tonsUlectomy: (OHBGP; PAGE
915) '. '. D. OTHER HEAD AND NECK CONDlTtONS:
1, Recurrent acute tonsillitis: Young children have a lot of throat 1. Lymph Node for excision biopsy
infections and most will grow out of the problem without U~e 2. Facial palsy
need for surgery, Tonsillectomy is only considered if children 3. Any swelling (except thyroid) -'> Refer to GS
miss a lot of school: e,g, > 5 attacKs causing school absenceJ 4. Any sinus or fistula
year for :2 years, . 5. Cystic Hygroma
2",Airwa'l obstruction: Verylar-ge tonsils causing sleep apnoea, 6. ungual Thyroid
3, Chronic t~msillitis: >3mo, •. halit~ls,
27
 CASES ELIGIBLE FOR REFERRAL TO OPTHALMOLOGY B. As Soon As Possible (ASAP):
(Arrange with the opha/m%gist on call for appointment within 1 to 2
• The content of this list is based upon that one mentioned in OHBGP* weeks)
2nd ed. 2005 page 933 with some modifications discussed with the head - Central visual loss
of ophthalmology department. - Sinister floaters
1) Emergency & urgent cases came together under urgent referral. - Flashing lights without a field defect
2) Some cases are added. - Chronic glaucoma with pressure >35mmHg

A. Urgent Referral: C. Routine Referral:

(lmmediate/y inform and arrange with the ophthalmologist on call) - Gradual loss of vision
- Sudden loss of vision - Chronic glaucoma (unless press6re >35mmHg)
- Acute glaucoma - Chronic red eye conditions
- Congenital glaucoma - Painless diplopia or squint
- Perforating injury; intraocular foreign body Chalazion/stye/cyst
- Chemical burns - Ptosis, Entropion, Ectropion
- Retinal detachment
- Corneal ulcer, foreign bodies or abrasions Note: Ptosis in child < 7 years of age needs urgent referral (arrange
- Sudden onset of diplopia or squint + pain with Ophthlamologist On-call)
- Temporal arteritis with visual symptoms
- Hyphema or vitreous haemorrhage -- Cataract
- Ophthalmia Neonatorum « 1 month age) Ref ABC of Eyes 2009 - Pterygium
- Orbital fracture - Lacrinal duct blockage, if fails to clear by 1 year (4%)
- Orbital cellulitis - Routine checkup (annual screening) for OM
- Sudden onset of ocular inflammation e.g. iritis or - Routine checkup (annual screening) for Hypertension
ophthalmic herpes zoster
- Scleritis Note:
!
1) Signs of a potentially dangerous red eye: visual acuity, pain deep
in the eye (not surface irritation as with conjunctivitis), absent or
sluggish pupil response, corneal damage on fluorescein staining,
history of trauma. Get the patient seen by a specialist the same
day if in doubt particularly post-operatively.

28 29
 iii

2) Consider referral in subconjunctival haemorrhage if it follows

trauma especially if the posterior edge of the haemorrhage can't
REFERENCES
be seen (may be associated with orbital haematoma, penetrating
injury, or orbital fracture). 1) Murtagh's General Practice 4th ed. 2007.
3) If red reflex in a child is not red, suspect tumor -- arrange with 2) Oxford Handbook of General Practice (OHBGP) 2nd ed.2005.
Opthalmologist On-call for urgent referral 3) Swanson's Family Practice Review 5th ed. 2005.
4) Refer school children with error of refraction or having old or 4) Principles & Practice of Primary Care 2nd ed. MOH, Saudi Arabia.
broken eyeglass to Optometry not to Opthalmology.
5) Rakers Text book of Family Practice 4th ed. 2001
5) There will be a mini eye clinic for quick 2nd opinion, measurement
6) Bratlons's F.M. Board Review, 2007
of eye pressure, urgent fundoscopy
7) Blueprints Family Medicine, 2006
8) EBM websites: Uptodate, May 2009, GAC. 2009.
CASES ELIGIBLE FOR REFERRAL TO MAXILLOFACIAL
SURGERY

- Salivary gland swelling (non-inflammatory)

- Salivary gland stone
- Sinus or facial soft tissue infection! cellulities after tooth extraction
or any dental procedure.

::J.'

30
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Please forward any comments to the e-mail address of:

DR. All FARIS AL AMRI
Director of Family Medicine Administration,
dr.amri@hotmail.com

PRINTED 2010