FIRST EDITION
PRIMARY CARE REFERRAL GUIDELINES
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Primary Care Referral Guidelines All rights reserved. This material may be freely reproduced for educational and not for profit purposes. No reproduction by or for commercial organizations is permitted without the express written permission from the Family Medicine Specialists Association of Malaysia. You may complete your request online via our website.
First Edition 2014
Family Medicine Specialists Association of Malaysia Address: Room 14, Level 5, Malaysian Medical Association Building No 124, Jalan Pahang, 53000 Kuala Lumpur Email:
[email protected] Website: http://fms-malaysia.org ISBN: Designed by Publisher name Printed by Printing Company
Disclaimer The clinical advice, referral criteria and the organizational details contained in this book refer to the Malaysian setting, unless otherwise stated. The book is intended for use by primary care practitioners and not for patients. While efforts have been made to ensure the accuracy of the information in this book, it is the responsibility of the doctor who is caring for the patient(s) to make his or her own judgment on the best treatment for the patient at that time. Although efforts are made to maintain accuracy of the information, some of the information may be outdated by the time of printing. The authors, editors and publishers cannot accept liability for information that is subsequently shown to be wrong.
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List of Editors Dr Mastura Ismail Family Medicine Specialist Seremban 2 Health Clinic Negeri Sembilan
Dr Adina Abdullah Senior Lecturer Department of Primary Care Faculty of Medicine, University Malaya
Prof Dr Ng Chirk Jenn Consultant Family Medicine Department of Primary Care Faculty of Medicine, University Malaya
Dr Mimi Omar Family Medicine Specialist Kelana Jaya Health Clinic Selangor
List of External Reviewers Prof Dr Teng Cheong Lieng Department Family Medicine International Medical University
Dr Vickneswari a/p Ayadurai Family Medicine Specialist Medan Jaya Health Clinic Petaling Jaya
Prof Dr Khoo Ee Ming Department of Primary Care Medicine Faculty of Medicine University of Malaya
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Table of Contents Foreword Preface How to use the guideline Acknowledgements List of abbreviations List of tables Content Chapter 1 Chapter 2 Chapter 3 Chapter 4 Chapter 5 Chapter 6 Chapter 7 7.1 7.2 7.3 Chapter 8 8.1 8.2 8.2.1 8.2.2 8.2.3 8.3 8.4 Chapter 9 9.1 9.2 Chapter 10 10.1 10.2 10.3 Chapter 11 11.1 11.2 Chapter 12 12.1 12.2 Chapter 13
Introduction Aims & Objectives Methodology Good referral practices Medicolegal implications Implementation of referral guideline Paediatric Febrile convulsion Neonatal jaundice Acute gastroenteritis Cardiology Atrial fibrillation Coronary heart disease Angina Acute myocardial infarction Unstable angina/Non ST Elevation MI (NSTEMI) Heart failure Hypertension Nephrology Chronic kidney disease Nephrotic syndrome Endocrinology Diabetes mellitus Obesity Thyroid disorders Gastroenterology Dyspepsia Jaundice in adult Ophthalmology Acute visual loss Red eye Ear, Nose & Throat 4
13.1 13.2 13.3 Chapter 14 14.1 14.2 Chapter 15 15.1 15.2 15.3 Chapter 16 16.1 16.2 16.3 Chapter 17 17.1 17.2 17.3 Chapter 18 18.1 18.2 Chapter 19 19.1 19.2 Chapter 20 20.1 20.2 Chapter 21
Dysphagia Obstructive sleep apnoea Vertigo Orthopaedic Back pain Knee and hip pain (degenerative) Psychiatry Anxiety Depression Substance abuse Urology Haematuria Lower urinary tract symptoms Urinary calculi Haematology Anaemia Haemoglobinopathies Lymphadenopathy Neurology Headaches Cerebrovascular accident Obstetric Gestational diabetes in pregnancy Hypertensive disorder in pregnancy Respiratory Chronic cough Pulmonary tuberculosis Rheumatology
21.1 21.2 Chapter 22 22.1 22.2 22.3 Chapter 23 23.1 23.2 23.3 23.4 Chapter 24 24.1 24.2 Chapter 25 25.1 25.2
Osteoporosis Gout Gynaecology Menorrhagia Subfertility Vaginal discharge Infectious disease Dengue Hepatitis B Hepatitis C Human Immunodeficiency Virus Surgery Acute abdomen Thyroid nodule Dermatology Acne Psoariasis 5
Chapter 26 26.1 26.2
Child psychiatry Autism Learning disabilities
Appendices List of contributors
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Foreword
Congratulations to the Malaysian Family Medicine Specialists Association (FMSA), especially to the committee members, authors, reviewers and editors of the Primary Care Referral Guideline Handbook for their diligent effort to provide guidance to practitioners on the appropriate referral of patients from primary to secondary care. The decision to refer patients to specialist services in hospitals is a critical management issue. Despite its importance, there has been modest research in this area. Many retrospective evaluations of referrals seek to measure the level of appropriateness, often from one stakeholder’s perspective. Careful analysis reveals that referrals are more complex. They reflect the needs and expectations of individual patients and their families, the knowledge and experience of the individual health care providers, and the range, type and level of services available locally. The contents of this booklet are the result of sound evidence and professional consensus among representatives of key stakeholder groups, involving family medicine specialists, private general practitioners and relevant hospital specialists. Primary care practitioners may use this guideline as a tool to assist in determining the best approach to manage their patients, ascertain that referral criteria are met and decide when and where to refer depending on the availability of resources and specific care at the referral centre. The patients’ clinical presentation and circumstances will also influence their referral. It is my hope that this Primary Care Referral Guideline Handbook will be constantly used by primary care practitioners as reference to improve the referral of patients to secondary care.
Dato’ Seri Dr Noor Hisham bin Abdullah Director General of Health Ministry of Health, Malaysia
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