General Medicine - public patients

Essential information (Referral will be declined without this)

• General Referral Information.
• Details of relevant signs and symptoms.
• Details of all treatments offered and efficacy.
• Relevant medical history, co-morbidities and medications.
• Duration of anaemia (if known).
• Medication history (especially NSAIDS, aspirin, corticosteroids, immunosuppressants).
• FBC, ELFT, ESR, TSH, iron studies, vitamin B12, folate results.

Additional referral information (useful for processing the referral)

• Serial FBC results (if available)
• History of alcohol and drug use
• History of menorrhagia
• CRP, Coombs test or haptoglobin results

Other useful information for management (not an exhaustive list)

• If dietary cause suspected, modify diet and/or refer to a dietitian
• If appropriate, treat with supplements (eg iron, vitamin B12, folate)
• Cease any aggravating medications if possible (eg NSAIDS)
• Referrals for Iron Deficiency should be directed to the Mater Gastroenterology Service

Categorisation

Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access.

Essential information (Referral will be declined without this)

• General Referral Information
• Relevant medical history, comorbidities and medications (and assessment of adherence), including previous discharge summaries or outpatient letters from treating paediatric service
• Details of all treatments previously offered and assessments of efficacy
• A clear indication of clinical issues that the specialist is required to address
• Details of any functional decline or cognitive impairment

Additional referral information (useful for processing the referral)

• Existing psychosocial issues and supports
• Patient or carer support services – eg disability or carer pensions, services provided by Disability Services Queensland, National Disability Insurance Scheme, or other support agencies and consumer groups
• CXR report
• ECG
• FBC and ELFt results (labratory results should be limited and dependent on the history and examination) 

Other useful information for management (not an exhaustive list)

• The Mater Young Adult Health Centre Brisbane aligns existing services as well as establishes new dedicated specialised services and environments for people predominately aged 16 to 25. It delivers the highest standards of clinical care and provides programs for adolescents and young adults to address their emotional, social and educational needs. The centre cares for patients with acute presentations including injuries and surgical conditions along with chronic and complex health conditions.
• Patients with cystic fibrosis should be managed by statewide cystic fibrosis services where possible.
• Ensure that patients with conditions for which patient support groups exist that those patients in need of simple advice or support are familiarised with these groups.

Categorisation

Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access.

Essential information (Referral will be declined without this)

• General Referral Information
• Relevant medical history, comorbidities and medications
• Details of all treatments offered and efficacy
• A clear indication of clinical question that the specialist is required to address
• Details of any functional decline or cognitive impairment
• FBC, ELFT, ESR and TSH results

In cases of suspected malignancy, pyrexia of unknown origin or generalised lymphadenopathy, also include:

• CT scan chest/abdomen/pelvis
• ANA plus full antibody profile if ANA > 1/640
• Serum protein electrophoresis

In cases of myalgia / arthralgia, also include:

• CPK results
• ANA plus full antibody profile if ANA > 1/640

In cases of poorly controlled diabetes, also include:

•  HbA1c

In cases of suspected rheumatological or systemic inflammatory conditions, also include:

• CRP, Rh factor and ANA results

In cases of suspected or known cardiorespiratory disease, also include:

• CXR

In cases of unexplained fatigue of recent onset, also include:

• Impact on daily life and work (including falling asleep while driving) 
• CXR
• Urinalysis results
• Calcium, ESP / CRP, iron studies, TSH, CPK (if muscle weakness or pain), vitamin B12 and folate results 

Additional referral information (useful for processing the referral)

• Existing psychosocial issues and supports
• Copies of discharge summaries and outpatient letters relating to encounters with other specialists
• ECG
• BNP (if available)
• Magnesium and phosphate results (if appropriate) 
• Documentation relating to past hospitalisations and clinic visits for anxiety / depression (if appropriate)
• Background information on occupational history and past infectious diseases (if appropriate) 

Other useful information for management (not an exhaustive list)

• Laboratory tests should be limited and dependent on the history and examination
  • PHQ-2 - 2 question screening tool
  • K 10 - 10 question screening tool
• Consider referral to dietitian if significant weight loss reported

Categorisation

Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access.

Essential information (Referral will be declined without this)

• General Referral Information
• Relevant medical history, comorbidities and medications (including an assessment of adherence) 
• Number of falls in the previous 12 months
• Assessment of cognitive function (MMSE or MOCA or other validated tool) in patients ≥ 65 years of age
• Chronological profile of the impact of symptoms on ability to function
• FBC and ElFT results
• MSU results 

Additional referral information (useful for processing the referral)

• Existing psychosocial supports (family, carers, home services, etc)
• Copies of discharge summaries and outpatient letters relating to hospitalisations for falls, or visits to fall clinics, or home assessments for falls risk
• Bone mineral densitometry report, vitamin D assay (if performed)
• Home medications review report if available

Other useful information for management (not an exhaustive list)

• A history of falls in the past year is the single most important risk factor for falls and is a predictor for further falls
• Older people reporting a fall or considered at risk of falling should be observed for balance and gait deficits.  They should be considered for interventions that improve strength and balance
• Consider referral to clinical pharmacist for home medication review if evidence of polypharmacy 
• Consider referral to specialist falls clinic (if available) if patient has suffered multiple falls with no cause found
• Depending on specialist availability, patients with falls can be referred to either general medicine or geriatric medicine. In the setting of multiple geriatric syndromes, referral to geriatric medicine may be preferred 
• The following links to cognitive assessment tools may be useful:
  • General screening information
  • Montreal Cognitive Assessment (MOCA)
  • Standardised mini-mental state examination (MMSE)
  • Standardised mini-mental state examination (MMSE)
• Evidence for fall prevention strategies:
  • Exercise
  • High dose vitamin D
  • Psychoactive medication withdrawal (particularly antidepressants, antipsychotics and benzodiazepines)
  • Occupational therapy home visit
  • Restricted multifocal spectacle use
  • Expedited cataract surgery (where required)
  • Podiatry intervention
  • Multifactorial assessment with targeted interventions (including referral to physiotherapist and/or dietitian as appropriate)

Categorisation

Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access.

Essential information (Referral will be declined without this)

• General Referral Information
• Relevant medical history and comorbidities 
• Full list of medications including over the counter medications and complementary medicines, and indications for each one
• Past history of drug allergies or adverse reactions or medication-related hospitalisations
• History of attempts to wean or cease specific medications
• Details of any home medications review undertaken by pharmacists
• FBC, U&E, creatinine and LFT results 

Additional referral information (useful for processing the referral)

• List of all other doctors (specialists, GPs) who prescribe drugs for the patient, and their contact details
• Contact details for patient’s regular community pharmacist

Other useful information for management (not an exhaustive list)

• Refer to Drug de-prescribing guidelines
• Refer to the STOPP criteria

Categorisation

Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access.

Essential information (Referral will be declined without this)

• General Referral Information
• Relevant medical history, comorbidities and medications
• Description of joints affected (swelling, pain, morning stiffness)
• Details of treatments offered and assessments of efficacy
• Interference with activities of daily living and working ability
• FBC, ELFT, ESR, Urea, creatinine 

Additional referral information (useful for processing the referral)

• Imaging of joints (XR / CT / MRI results) 
• Urinalysis results
• If suspected inflammatory or crystal arthopathy include ESR / CRP, uric acid, rheumatoid factor, anti CCP and ANA results 

Other useful information for management (not an exhaustive list)

• If appropriate, encourage weight loss and regular exercise.

• For management of gout: 

  • Consider NSAIDs or colchicine for acute symptoms

  • Consider prophylaxis with allopurinol or probenecid (caution with slow up-titration in CKD and close monitoring)
  • Dietary modification (particularly alcohol intake)
  • Modify medications that may contribute to gout where possible (eg. thiazide diuretics)
  • Increase fluid intake
  • Consider referral to a physiotherapist or occupational therapist for functional assessment.
• Please note that CPCs have been developed for knee pain (acute) and knee pain (chronic) by orthopaedics 

Categorisation

Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access.

Essential information (Referral will be declined without this)

• General Referral Information
• Relevant medical history (including past surgical history), comorbidities and medications
• Details about planned procedure, surgeon, and informed consent of procedure
• Usual exercise tolerance and level of physical activity
• ECG (for patients with past cardiac history or multiple cardiac risk factors)
• Bedside spirometry (for current smokers and patients with known COPD)
• Results of any past echocardiograph (in patients with known heart disease)
• INR levels (for patients receiving warfarin)
• FBC, ELFT (for high-risk patients or patients undergoing moderate to high-risk surgery, or known renal or liver disease)

Additional referral information (useful for processing the referral)

• Copies of correspondence received from surgeons, anaesthetists
• Scheduled date of surgery (if known)
• Nutritional status / report from dietitian review (where appropriate)
• Pre-operative functional status and any other psychosocial factors that identify the patient as potentially requiring increased care needs at home at the time of discharge following the operation

Other useful information for management (not an exhaustive list)

• Refer to guidelines regarding pre-operative cardiac assessment
• Consider referral to a dietitian if the patient’s nutritional status impacts on surgery

Categorisation

Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access.

Essential information (Referral will be declined without this)

• General Referral Information
• Relevant medical and psychiatric history, comorbidities and medications
• Details of treatments offered and efficacy
• FBC & ELFT results
• ECG

Additional referral information (useful for processing the referral)

• Psychosocial supports
• Work or life stressors, sleep deprivation
• Results of previous EEG, CT or MRI-head, carotid arterial duplex scan (if performed)
• Results of audiometry (if associated hearing loss)

Other useful information for management (not an exhaustive list)

• Patients with known epilepsy that present with single seizures do not necessarily require a specialist referral if there are no injuries, focal neurological symptoms or signs or any other new concerns such as non-compliance with medications or avoidance of triggers.

Categorisation

Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access.

Essential information (Referral will be declined without this)

• General Referral Information
• Relevant medical history, comorbidities and medications
• Details of clinical presentation:
  • Timeline since onset of symptoms
  • Precipitating factors
  • Any warning pre-syncopal symptoms
  • Loss of consciousness (complete vs partial; duration; nature of recovery)
  • Witnessed signs (including seizures, pallor, incontinence, cyanosis, irregular or absent pulse during attack, associated injury)
• Lying and standing BP
• Drug and alcohol history
• FBC, ELFT, TSH results
• ECG

Additional referral information (useful for processing the referral)

• Any investigations relevant to comorbidities (e.g. HbA1c if diabetic, spirometry if COPD)
• EEG results (if available)
• Holter monitor or event monitor results (if available)
• Echocardiogram results (if available)

Other useful information for management (not an exhaustive list)

• If syncope thought likely to be of cardiac origin, please refer to Mater Cardiology Services
• If possible, please identify an eyewitness to any episode of syncope and request that the witness attends the specialist outpatient appointment with the patient.

Categorisation

Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access.

Essential information (Referral will be declined without this)

• General Referral Information
• Relevant medical history and comorbidities
• Full list of current medications including non-prescription medications
• Weight, height and BMI
• Exact weight loss and time period of loss
• Any associated symptoms (e.g. cough, abdominal pain, change in bowel habits)
• Alcohol and drug history (including smoking)
• Assessment of mood and social situation (depression is a common cause of weight loss)
• Appetite, recent dietary changes, food intolerances or avoidances, and abnormal eating behaviours
• FBC, ELFT, ESR/CRP, TSH, iron studies, vitamin B12 & folate results
• Antitransglutaminase antibodies, IgA for coeliac disease in younger patients (aged < 40 years old) with associated iron deficiency

Additional referral information (useful for processing the referral)

• HbA1c results (if diabetic)
• CXR report (if indicated)
• Food intolerances or avoidances and abnormal eating behaviours
• Gastrointestinal or oral symptoms especially dysphagia, diarrhoea, gum disease, poor dentition, loss of taste

Other useful information for management (not an exhaustive list)

• Unintentional weight loss <5% can be managed in primary care
• If patient has anaemia please refer to Anaemia in the General Medicine Referral Guidelines or the Iron deficiency anaemia  within the Gastroenterology Referral Guidelines
• Available depression tools include:
  • PHQ-2 – 2 question screening tool
  • K-10 – 10 question screening tool
• If an eating disorder is suspected or confirmed, consider referring to the Queensland Eating Disorder Service document: A guide to admission and inpatient treatment for people with eating disorders in Queensland
• Consider referring to the NWHHS Refeeding Syndrome Identification and Management in Adults guideline

Categorisation

Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access.

Essential information (Referral will be declined without this)

• General Referral Information
• Relevant medical history, comorbidities (particularly diabetes, neuropathy, peripheral arterial disease, cognitive impairment, drug abuse, mental health problems) and medications
• Wound history
  • Duration
  • Description and size
  • Wound initiating event
  • Presence of peripheral pulses if limb wound
• Investigations (if performed)
  • Any biopsies of the wound
• For leg ulcers include
  • Arterial studies / Ankle Brachial Pressure index
  • Venous incompetence studies (note NOT venous ultrasound for acute DVT)
• Treatment history – including
  • Wound care provided to date (including antibiotics, topical ointments etc)
  • Service provider (i.e. GP, practice nurse or domiciliary nursing service
• FBC, ELFT, U&E, creatinine 

Additional referral information (useful for processing the referral)

• Residential status (lives alone, support networks, etc.) 
• Access to wound care services, domicillary nursing
• Smoking status
• Nutritional status / dietary intake / serum albumin
• HbA1C / blood sugar (if patient has diabetes) 

Other useful information for management (not an exhaustive list)

• The Wounds Australia Standards for Wound Prevention and Management may provide additional management guidance
• Consider using the Tissue, Infection/Inflammation, Moisture, Epithelial/Edge (T.I.M.E.) model
• Consider referring to the eTG section on Cellulitis particularly for appropriate antibiotic management
• Consider using the Bates-Jenson Wound Assessment Tool
• Consider referral to a dietitian to optimise nutritional status for wound healing

Categorisation

Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access.

• Severe anaemia (Hb <80gm/l) with risk of cardiovascular and/or syncopal collapse
• Anaemia associated with definite clinical features of overt gastrointestinal bleeding
• Severe cytopaenias if patient is unwell (ie infection, symptomatic anaemia, active bleeding)
• Neutrophils < 0.5x109/L
• Haemoglobin < 80g/L
• Platelets < 20x109/L 

• Very rapid onset of cognitive +/- other neurological symptoms 
• Suspected delirium deemed unsafe to manage in the community by the treating medical practitioner
• Imminent safety risk to self or others

• Any sudden decompensation in clinical condition that carries risk of death or serious adverse events

• Any sudden decompensation in clinical condition that carries risk of death or serious adverse events
• Pyrexia of unknown origin with temp ≥ 39ºC
• Pyrexia with neutropaenia
• Delirium
• Suspected systemic vasculitis associated with symptoms, signs or investigation results suggestive of vital organ involvement
• Suspected temporal arteritis (giant cell arteritis) with markedly elevated ESR (>100) and/or jaw claudication and/or visual disturbance

• Any fall occasioning serious trauma (including fractures, major soft tissue injury, head strike or concussion) that cannot be managed in primary care.
• Frequent falls (more than one every few days)

• Anaphylactic or other serious adverse drug event
• Markedly prolonged heart rate adjusted QT interval which may herald pro-arrhythmic event
• Marked drug induced electrolyte abnormality (Na <120, K <3.0 or >6.0, Ca >3.0, Mg <0.4)

• Acute non-traumatic monoarthritis causing severe pain and/or incapacitating loss of function and/or marked constitutional symptoms
• Suspected septic arthritis

• Witnessed tonic-clonic (grand mal) seizures
• Suspected transient ischaemic attack or stroke on the basis of focal neurological deficits
• Delirium or acute confusional state
• Severe headache or altered level of consciousness with sudden onset

• Syncope / pre-syncope with any of the following red flags:
  • Exertional onset
  • Chest pain
  • Persistent symptomatic hypotension (systolic BP < 90mmHg)
  • Severe persistent headache
  • Focal neurological deficits
  • Preceded by palpitations
  • Associated significant physical injury (e.g. fractures, extreme soft tissue trauma, intracranial bleeds) or causing motor vehicle accident
  • Family history of sudden cardiac death

• Associated severe electrolyte abnormalities (K+ <3.0 mmol/l, corrected Ca+ <1.6 or >3.0 mmol/l, Mg+ <0.4 mmol/l, PO4- <0.4mmol/l) 
• Vomiting, dysphagia or odynophagia suggesting oesophageal or gastric outlet obstruction
• Uncontrolled hyperthyroidism with risk of thyroid storm

• Severe cellulitis with ongoing or worsening systemic symptoms or fevers despite oral antibiotics for 48 hours
• Foot ulcer in diabetic patient that is not responding to oral antibiotics and regular wound cleaning
• Any infected ulcer associated with systemic inflammatory response symptoms (SIRS) or excessive pain or features suggestive of abscess formation, osteomyelitis or deep tissue infection (necrotising fasciitis)
• Acute Charcot arthropathy
• Ulcers or wounds in a limb with markedly compromised circulation 

• Any condition defined by other state-wide referral guidelines as requiring referral to emergency 

• Clearly evident mental health disorders requiring psychiatric consultation
• Genetic testing / counselling
• Requests for respite care, ACAT assessments or other forms of assessment or supportive care in the presence of established diagnoses and management plans, or where patients with established mental capacity to make decisions refuse such assessments or care
• Reviews relating to workers’ compensation claims, NDIS eligibility, disability pensions, driving license renewals, or other legal and administrative procedures
• Reviews relating to drug withdrawal or detoxification 
• Cognitive impairment and dementia
• Outpatient follow-up of adults for acquired brain injury or neuro developmental disorder 
• Presentations that would be more appropriately assessed and managed by specialist mental health services e.g. where a primary psychiatric diagnosis (e.g. major depression, generalised anxiety disorder, schizophrenia) is the most likely cause of the patient’s presenting symptoms, assessments of financial and testamentary capacity
• Formal occupational therapy driving assessments