Acute infections
| Acute Sore throat |
Do FeverPAIN score to aid antibiotic prescribing – can be done over the phone. Ask patients if they can see their tonsils/pus/exudate. Consider delayed abx prescribing. |
|
Acute Otitis Media |
If < 3 days, no need to treat unless discharge symptoms or < 2y with bilateral symptoms. Consider prescribing abx over the phone in these cases or if systemically very unwell – see NICE guidance below. |
| Acute Otis Extrena | If well and has itching/soreness/history of recurrent OE, prescribe topical drops after 3 days as delayed script. |
| Sinusitis |
If < 10 days – NO antibiotics unless significant systematic upset. If > 10 days – delayed or immediate abx + consider nasal steroid drops/spray. |
|
Acute Exacerbation of COPD |
Low threshold for oral steroids if any SOB above baseline. Ensure rescue packs are replenished. Remember if COVID+COPD – caution re steroids. Use functional baseline of mobility to assess sats as Roth score will not work. Relevant HSC Primary Care Guidelines |
|
Infective Exacerbation of Bronchiectasis |
Consider antibiotics based on previous sputum samples if available – 14 day courses |
|
Community Acquired Pneumonia |
Do rough CURB-65 over the phone: 1. Confusion 2. Cannot talk full sentences 3. Reduced UO 4. Dizzy on standing up (low BP) Low threshold to treat with abx |
| Lower UTI |
No need to send urine for culture routinely. Nitrofurantoin 1st line but check eGFR and ensure no signs of pyelonephritis! Review previous cultures if recurrent infections to help prescribing. |
|
Acute Pyelonephritis |
If loin pain/tenderness and NO vomiting/dizziness on mobilising/high temp then consider prescribing antibiotics over the phone – risk of Covid-19 by coming into surgery more than prescribing high dose abx, note use next day review and safety net is a must. Can you get obs done – devices the patient has, bp machine access. Escalation to a&e if vomiting and dizziness. |
| Gastroenteritis |
Mild, self-limiting in majority. Can take 10-14 days for bowels to settle in some cases. Emphasise importance of rehydration – Fluids++, Oral Rehydration Salts, foods rich in water for children (watermelon/ice lollies). Abdominal Pain and diarrhoea (often) green may be a symptom of COVID. Note elderly/HTN meds/AKI – consider next day telephone review for PU output in all age groups. |
| Cellulitis |
Video Consultation/Photo via Email may be helpful. If prescribing antibiotics, advise patients to mark area with a pen and arrange telephone follow-up 24-48 hours. Dizziness – must have obs check, consider if RR team needed for obs but remember their service is limited. |
| Conjunctivitis |
Self-limiting 7-14 days. Poor evidence base for topical antibiotics. Consider video consultation to reassure. Delayed abx. Note risk of preseptal cellulitis – video if swelling reported. |
Gynae
|
IMB/PCB |
Assess by telephone – may need face to face to assess cervix/take swabs |
|
Serious Gynae pathology: ?ectopic ?cancer |
If this is possible will need to refer |
|
Miscarriage |
Telephone – can usually be managed at home (as long as safety net re ectopic) |
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Endocrine
|
Diabetes & complications/unwell with fever |
Video/visit – need to remember could be Covid but equally sending unwell diabetic to hot site could have dire consequences |
|
Thyroid |
Video |
|
Other |
Telephone |
Cardiovascular
|
Chest pain |
Telephone/Video – detailed history and risk assessment. If concerned re cardiac cause/haemodynamic instability for hospital referral. Assess breathless, including Roth score. Consider Wells score. |
|
Vascular |
Any rash/skin changes → video consultation. If concerned re pulses/ischaemia, consider F2F assessment or hospitalreferral. |
|
Calf pain |
Telephone/video – assess as much of Well’s score as possible. If concerned re DVT for referral to ambulatory care. |
|
Palpitations |
Would suggest only significant if persistent with symptoms (breathlessness/chest pain) and if this the case need A&E. |
Gastrointestinal
|
General |
Video/Telephone consultation – can try and self-examine. Ask about associated symptoms/fever – video and may need face 2 face Strongly consider urine dip and pregnancy test. |
|
Dyspepsia |
Test and treat, consider if vomiting and severe pain – pancreatitis → A&E |
|
RUQ Pain |
No fever – biliary colic – order USS but note delays – diet and analgesia: Fever but no vomiting – Rx for cholecystitis – next day review. Consider how to get obs checked. Fever + vomiting – A&E May need to consider examination if lacking diagnostic clarity – discuss with 2nd doctor. |
|
Lower GI pain |
Review hx – diverticular symptoms/hx/constipation, DDx if diverticulitis – broad-spectrum abx and next day review call. Women – think pelvic pathology – severity may dictate investigation – remember delay in USS. May need to consider examination if lacking diagnostic clarity – discuss with gynae doctor in surgery. Consider UTI → urine can be left for MSU or dip depending on your clinical concern. Think access to obs |
|
RIF pain |
Video consult always – jump test. Might need examinationor escalate to A&E. Always discuss with 2nd doctor. |
|
LIF pain |
Pelvic/bowel symptoms – as for lower GI pain. |
|
Hernia |
Difficult to assess – may need examination – note routine hernias can’t wait. Ask for symptoms or strangulation/reducibility. |
|
Rectal symptoms |
Consider treating and follow up call for piles/haemorrhoids – always set up review. |
|
Bloating |
Consider ovaries – test first if concerns. Rv if ongoing. Most other symptoms without red flags can wait. |
|
PR Bleeding |
If heavy/dizzy → consider A&E; If risk significant pathology, consider 2ww/F2F cold clinic (assuming not in association couch/fever/Covid symptoms) |
|
Diarrhoea/Vomiting |
Hx to assess hydration status/PMHx/medications. ?unwell, altered responsiveness, e.g. irritable/lethargic, decreased urine output, pale/mottled skin, cold extremities. May benefit from video to eyeball patient. If persistent/unwell, need to consider F2F/2ww/A&E |
Neurology
|
General |
Consider neuro advice line if concerns |
|
Headache: Tension |
Telephone only |
|
Headache: Migraine |
Telephone only |
|
Headache: Meningitis |
Telephone/video-> Refer to hospital if suspected |
|
Headache: Subarachnoid |
Telephone/video-> Refer to hospital |
|
Headache: Suspected Tumour |
Telephone/video-> Refer to hospital |
|
Headache: Temporal arteritis |
Telephone/video-> Refer to hospital |
|
Dementia (Alzheimer’s) deterioration/new |
Telephone |
|
Parkinson’s Disease deterioration |
Telephone |
|
Stroke/TIA |
Telephone/Video-> refer to hospital |
|
Faints, Fits, Blackouts |
Telephone + Video -> will need F2F |
|
Multiple sclerosis flare ups |
Telephone |
|
Numbness & Tingling |
Telephone + Video – will need to be F2F (not urgent but will eventually have to be dealt with) for examination. |
|
Back Pain |
Telephone – red flags will need F2F |
|
Neurological symptoms in disease of other systems, including cancer |
Telephone – Realistically will probably need advice from a specialist. |
Musculoskeletal (MSK) conditions
|
General |
Always ask about trauma/injury/fall Ask the patient if the can weight bare when assessing foot/knee injuries and/or pain. X-rays often do not change management plans. Avoid unless suspected bony injury/diagnostic uncertainty. The majority of MSK conditions can be managed through self-help measures and adequate analgesia – ask specifically what they are taking, doses, timings etc. Encourage self-help exercises and signpost patients accordingly ohttps://www.circlehealth.co.uk/integratedcare/msk – good website with videos of each condition o https://www.hasantahir.com/exercise.php – basic exercise sheets Consider video consultations to access ‘active’ movements. |
|
Hot Joints |
Septic arthritis rare but mustn’t be missed; history and video will help |
Dermatology
|
General |
Hx may help e.g. recurrent cellulitis, tender/hot to touch, doesn’t blanch, mole that is weeping/itchy/bleeding Consider telephone review in 24-48hrs to assess if improving |
|
Petechial rash |
A&E |
|
Other rash /eczema/psoriasis |
Manage with video consultation (if elderly patients that do not have a mobile – ask if can use a family members mobile) |
Opthalmology
All routine General Ophthalmic Services have been suspended due to the current COVID – 19 pandemic. This means routine sight tests and eye examinations are no longer being provided by optometry practices.
All domiciliary eyecare services are also similarly suspended.
HSC Board is working with primary eyecare providers to continue to provide NI PEARS urgent eyecare, individually or within locality “clusters”. If a patient has an urgent eyecare problem, ask them to contact their own optometrist via phone for advice.
For the current list of NIPEARS provider practices click on link http://www.hscboard.hscni.net/eyes/
In addition, the regional eye casualty service is still currently available for emergencies or urgent sight threatening conditions:
- BHSCT Eye Casualty: RVH tel: 028 9615 5872 or RVH main switchboard 028 9024 0503 ask for Eye Casualty.
- WHSCT Eye Casualty: Altnagelvin Hospital tel: 028 7134 5171 ask for ophthalmologist on call.
Given the nature of the current situation things are changing rapidly so if you have any additional queries do not hesitate to contact ophthalmic services at HSCB via Ophthalmic.Services@hscni.net
|
Blepharitis and infection of eye lid |
Telephone/Video only |
|
Meibomian Cysts |
Telephone/Video only |
|
Entropion/Ectropion |
Video only (Non-urgent so really can wait a few months) |
|
Ptosis/Proptosis |
Telephone/Video only
|
|
Squint |
Telephone/Video only |
|
Conjunctivitis |
Telephone/Video only |
|
Dry Eye |
Telephone |
|
FB in the eye |
Telephone/Video and advice If not successful may need F2F for removal. High risk due to aerosol of eye fluids so will need full FFP3 Refer to A/E |
|
Corneal abrasions, ulcers/ minor trauma |
Telephone/Video – will need close up examination F2F with FFP3 due to contact with eye fluids Refer to A/E or Contact Local Eye Casualty for advice before referral |
|
Herpes Zoster and the eye |
Telephone/Video – will need close up examination F2F with (especially as elderly without video facilities) with FFP3 due to contact with eye fluids Contact Local Eye Casualty for advice before referral |
|
Iritis |
Telephone/Video – will need close up examination F2F with (especially as elderly without video facilities) with FFP3 due to contact with eye fluids Contact Local Eye Casualty for advice before referral |
|
Acute loss of vision Optic Atrophy, Retinal Detachment, Flashing Lights, Retinal Vein Thrombosis, Senile Macular degenerationacute on chronic |
Telephone/Video – Realistically GP will not be able to manage this so will need to go to hospital for proper assessment Contact Local Eye Casualty for advice before referral
|
|
Double vision |
Telephone only. Realistically many GP’s will not have the skills to manage this so no point F2F. Rarely an acute problem so probably needs A&G for safety and onward referral at some point. |
|
Cataracts |
Telephone advice – can wait a few months for review |
|
Retinopathy-diabetic |
Telephone consultation. IF sudden loss of vision as per acute loss of vision advice –> refer to hospital. Contact Local Eye Casualty for advice before referral |
|
Medication |
Telephone only. |
|
Eye Malignancies |
Telephone/Video (rare so unlikely to present without visual difficulties acutely. Will need a proper examination with a slit lamp so will need a referral to hospital so F2F not needed Contact Local Eye Casualty for advice before referral |
|
Contact Lens Problems. |
Telephone. Will we have access to local optician to ask advice? |
