REFERRAL RECOMMENDATIONS : PAEDIATRIC SURGERY by i33O8b

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									REFREC009

                                           GYNAECOLOGY REFERRAL RECOMMENDATIONS

    Diagnosis / Symptomatology                        Evaluation                           Management Options                        Referral Guidelines
Gynaecology problems are addressed       A thorough history and examination is     Specific treatments depend on specific   These guidelines are provided (below)
under the following headings:            required to determine a specific          problems identified as noted below.      to give greater clarity in situations of
                                         diagnosis and its degree of urgency.                                               the primary/secondary interface of
   Amenorrhoea                          Some appropriate investigation by the                                              care. Clear telephone/fax
                                                                                   Be aware of molar pregnancies.
   Diseases of the vulva                referrer will facilitate the referral                                              communication would enhance
   Dysmenorrhoea                        process.                                                                           appropriate treatment.
   Excessive/irregular menstrual loss
   Infertility                          Pelvic examinations – GPs, specialists.
   Menopause/HRT
   Other bleeding problems
   Ovarian cysts
   Pelvic inflammatory disease
   Prolapse
   Urinary symptoms
   Vaginal discharge




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    Diagnosis / Symptomatology                         Evaluation                         Management Options             Referral Guidelines
Amenorrhoea
Primary                                     Age > 15 years.                       Counselling and support.    Where there are abnormal results or
                                            Weight history.                                                   significant patient stress/anxiety – refer
                                                                                                               to the appropriate specialist service –
                                            Dietary history.                                                  Category 4.
                                            Exercise history.
                                            Physical/secondary sexual
                                             development.
                                            Family history.
                                            Evidence of any congenital
                                             gynaecological abnormality/
                                             abdominal mass.
                                            Sexual history.

                                         INVESTIGATIONS:
                                            FSH/LH/HCG.
                                            Prolactin x 3*.
                                            Thyroid function test.
                                            Ultrasound.

                                         Chromosomal studies may be
                                         requested in consultation with the
                                         specialist service.

                                         *Note: Only one is necessary if initial
                                         test is normal.
Secondary (> 6 months)                   All of the above plus:                    Counselling and support.    Where there are abnormal results or
                                            Contraception history.                                            significant patient stress/anxiety – refer
                                                                                                               to the appropriate specialist service –
(Cross-refer to Endocrinology Referral      Drug history, eg psychotropic.                                    Category 4.
Recommendations.)
                                            Galactorrhea.
                                            Signs of masculinisation.                                         If associated with infertility.
                                            Hirsutism.

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                                    Significant stress and anxiety.
                                    Environmental factors.
                                    Past gynaecological
                                     history/surgery.

                                 INVESTIGATIONS:
                                    HCG.
                                    FSH/LH/E2/Prolactin x 3*.
                                    Testosterone/SHBG/DHEA (if
                                     Hirsute).




    Diagnosis / Symptomatology                 Evaluation                        Management Options                          Referral Guidelines
Diseases of the vulva
                                    Symptomatology – pain, swelling,    1. Antibiotic treatment of Bartholins         Bartholin's abscess – Category 2.
                                     pruritus, dyspareunia, localised       abscess is of no value. Acute              Bartholin's cyst – refer – Category
                                     lesions (pigmented or non-             referral for assessment                     4.
                                     pigmented lesions).                    recommended.
                                                                                                                       Older woman with localised lesion
                                    Current treatment to date.          2. Bartholins cyst, refer for specialist
                                                                                                                        – Category 2.
                                                                            management.
                                    Systemic dermatological problems.
                                                                         3. The older the patient and the more
                                                                            localised the lesion of the vulva,
                                 INVESTIGATIONS:                            the more urgent the assessment.
                                    Consider swabs/scrapings.
                                    Consider biopsy for a generalised
                                     skin condition.




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    Diagnosis / Symptomatology                  Evaluation                          Management Options                      Referral Guidelines
Dysmenorrhoea
                                    Examination history.                   1.   Symptomatic analgesia/NSAIDS –     Unresponsive to treatment (no
                                    Symptomatology – pain                       Preferred NSAID preparation is     improvement in 90 days) or if
                                     (increasing with duration of period         Mefenamic Acid 500mgs TDS.         symptoms severe earlier. (?
                                     – suspect endometriosis),                   Days 1-3 of flow. Alternatively,   Endometriosis, sub-mucous fibroids) –
                                     vomiting, fever, fainting,                  Diclofenac 75-100mgs plus          Category 4.
                                     associated discharge, deep                  Paracetamol 1gm rectally 12
                                     dyspareunia.                                hourly may be helpful. Response
                                                                                 to NSAID can be idiosyncratic.
                                    Time off activities of daily living.
                                                                            2.   OCPs. Consider continuous
                                                                                 (bleed free) regimen
                                 INVESTIGATIONS:
                                 If PID suspected (see below).              Note: If no clinical abnormality
                                                                            demonstrable: treat pre-menstrual
                                                                            discomfort (relieved by flow)
                                                                            symptomatically whenever possible.
                                                                            This is rarely amenable to surgical
                                                                            correction.




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    Diagnosis / Symptomatology                       Evaluation                         Management Options                      Referral Guidelines
Excessive/Irregular menstrual loss
(Minimum of 3 months unless bleeding      Drug history (contraception, HRT).      Hormonal control, eg oral           Refer Category 3 for any of the
continues.)                               Symptomatology, eg pain, fatigue.        contraceptive/HRT.                  following:
                                          Family/personal history of              Non-steroidals, eg Mefenamic Acid   Anaemia Hb<80 g/l.
                                           haematological disorders.                500mgs TDS.                         Age > 37.
                                          Evidence of any genital tract           Treat anaemia (Hb<80 g/l and low    Pelvic mass.
                                           abnormalities/abdominal mass.            iron studies) for a minimum of      Abnormal smear.
                                                                                    three months. Dietary advice.
                                          Sexual/PID history.                                                          Non-response to other treatment
                                                                                   Manage other abnormal               modalities.
                                          Ability to cope with bleeding, eg        investigations, eg hypo/hyper
                                           time off work.                                                               Otherwise – Category 4.
                                                                                    thyroidism.

                                       INVESTIGATIONS:
                                          FBC/iron studies.
                                          Thyroid function test.
                                          Smear.
                                          Pelvic ultrasound (especially if
                                           clinically undiagnosable pelvic
                                           mass).
                                          Pregnancy test.




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     Diagnosis / Symptomatology                          Evaluation                           Management Options             Referral Guidelines
Infertility
Twelve months or longer, but                  Age                                    Counselling and support.      Refer to specialist service as
investigations may be initiated prior to      History of both partners including     Timing intercourse.           appropriate – Category 4.
this time.                                     drugs, lifestyle, number of children   Lifestyle modification.
                                              Sexual history.                        Weight loss if appropriate.
                                              Obstetric/gynae history.

                                           INVESTIGATIONS:
                                              Seminal analysis.
                                              Confirm ovulation (serum
                                               progesterone – day 21-23).
                                              Serum FSH/LH
                                              Menstrual calendar.
                                              Hystero-salpingogram for
                                               secondary infertility.

                                           Note: Imaging Referral
                                             Recommendations.




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    Diagnosis / Symptomatology                   Evaluation                     Management Options                      Referral Guidelines
Menopause/Commencement of Hormone Replacement Treatment (HRT)
                                  Full assessment with particular       – HRT counselling.                     Referral of any women with risk
                                  emphasis on menopausal symptoms.                                             factors:
                                  Past gynaecological history with                                                Breast disease – Category 4.
                                                                        – Cyclical regimens in women who
                                  particular reference to fibroids,
                                  endometriosis and breast disease.
                                                                          are still menstruating < 52 years.      Irregular bleeding – Category 2.
                                                                                                                  Embolic disease – Category 4.
                                                                        –   Combined regimens in women            Gallbladder disease – Category 4.
                                  INVESTIGATIONS:
                                                                            who have not menstruated for 12
                                     Cardiovascular risk evaluation.                                             Women who have abnormal
                                                                            months > 52 years.
                                                                                                                   bleeding in conjunction with HRT
                                     Fasting lipid profile.                                                       after six months – Category 4.
                                     FBC.                              –   Tertiary Menopause Clinic (KEMH)
                                     TFT.                                  for complex menopausal problems
                                                                            eg patients with a history of
                                     Mammogram.
                                                                            oestrogen sensitive tumours or
                                     Consider bone density – (c.f.         venous thrombosis
                                      National Health Committee’s
                                      guidelines for HRT). before
                                      treatment is commenced.




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    Diagnosis / Symptomatology                      Evaluation                        Management Options                         Referral Guidelines
Other abnormal bleeding
Post-menopausal.                        Drug history (contraception, HRT     Note: Cervical polyps associated with     Refer to specialist service – Category
                                         particularly oestrogen only          post-menopausal bleeding should be        2.
(Twelve months from last menstrual
                                         regimens).                           referred as frequently associated with
period.)
                                        Evidence of any genital tract        sinister pathology.
                                         abnormalities, eg cervical polyps/
                                         atrophic change or abdominal
                                         mass.
                                      Sexual/PID history.
                                     INVESTIGATIONS:
                                        Smear.
                                        HVS.
                                        +/– Pipelle.
                                      Pelvic ultrasound
                                     Preferably Transvaginal by specialist
                                     with expertise in Gynaecological
                                     Ultrasound
                                        Pregnancy test (unnecessary > 55
                                         years).
Post-coital bleeding.                   Examine.                                Support and counselling.              Recurrent, troublesome or
                                        Smear.                                  Report further episodes.              embarrassing – refer to specialist
                                                                                                                        service – Category 2.
                                        HVS.                                    Encourage return if symptoms
                                                                                  recur/change.
Postpartum bleeding (within six         Drug history, including                 Treat with Augmentin 500mg TDS        No response to treatment – refer –
weeks).                                  contraception.                           5-7 days.                             Category 2.
                                        Delivery history.                       Consult with specialist service and
                                       Symptomatology – pain, fever,             refer.
                                        uterine size, tenderness.
                                     INVESTIGATIONS:
                                        Endocervical swab.
                                        Chlamydia test.
                                        Consider scan for retained
                                         products.
                                        Hb.
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    Diagnosis / Symptomatology                 Evaluation                        Management Options                         Referral Guidelines
Ovarian Cyst
                                 HISTORY:
                                 Asymptomatic?                                                                     Refer as soon as possible – Category
                                    Incidental clinical or ultrasound                                             2 / 3.
                                     finding.

                                 Symptomatic?                            If 5 cm  size. Repeat scan after         Refer urgently if persistent or colicky
                                    Cyclical symptoms.                  menstrual period when applicable (can     pain, weight loss, anaemia, any
                                                                         exclude such as corpus luteal cysts).     suspicion of ascites or irregularly
                                    Pain.                                                                         contoured mass on abdominal or pelvic
                                    Dyspareunia.                                                                  examination – Category 2.
                                    Irregular cycle.
                                    Gastrointestinal.

                                 (Note: Ovarian pathology (eg torsion
                                 and not least carcinoma) may present
                                 with gastrointestinal symptoms.
                                 Risk of malignancy greater pre-
                                 pubertally and with increasing age to
                                 70.)

                                 INVESTIGATIONS:
                                 (a) Examination.
                                      Size.
                                      Consistency.
                                      Contour.                          Was the ultrasound both transvaginal
                                 (b) Ultrasound scan. (specialist        & abdominal
                                     experienced in Gynaecological       Ultrasound should comment as to
                                     Ultrasound)                         whether the cyst has any malignant
                                 (c) Tumour Markers (OMMA +/- AFP,       features, such as: Septae, solid areas,
                                     CEA, HcG)                           papillary projections, ascites or
                                                                         abnormal blood flow.


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    Diagnosis / Symptomatology                  Evaluation                      Management Options                         Referral Guidelines
Pelvic Inflammatory Disease
Acute                               Symptomatology – pain,             1. Antibiotics for PIDs. Triple           Acutely unwell, pelvic mass,
                                     discharge, pyrexia.                   therapy:                               unresponsive to treatment (12-16
                                    Out of phase bleeding.                – Augmentin 500mgs TDS 10              hours). Refer for admission –
(c.f. Sexual Health Referral
                                                                             days.                                Category 1.
Recommendations.)                   ? Presence of IUCD.
                                                                           – Flagyl 400mgs TDS 7 days.            Positive pregnancy test with pelvic pain
                                                                           – Doxycycline 100mgs BID               + - fever (consider septic abortion).
                                 INVESTIGATIONS:                                                                  Refer for admission – Category 1.
                                                                             minimum 14 days.
                                    FBC/ESR.
                                    HVS/chlamydia smear/swabs.
                                                                        2. Link and liaise with STD clinic as
                                    Urine specimen - Chlamydia            appropriate.
                                    Endocx/urethral/rectal swab.
                                    HCG.                               (Note: Erythromycin may be used as
                                    ? Smear.                           an alternative to Augmentin in cases of
                                                                        penicillin allergy.)
Chronic                             Symptomatology – chronic pain,     1. Symptomatic after treatment – refer.   Unresponsive to treatment – Refer
                                     discharge, erratic bleeding,                                                 Category 2.
                                     recurrent episodes of acute PID,
                                     dyspareunia.

                                 INVESTIGATIONS:
                                    See acute.
                                    Ultrasound scan.




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    Diagnosis / Symptomatology                Evaluation                         Management Options                         Referral Guidelines
Prolapse
Pelvic anatomical relaxation.       Symptomatology – lump, difficulty   1. Symptoms of prolapse without           Symptomatic prolapse – Category 4.
                                     with defaecation/micturition,          signs may resolve on treatment
                                     dyspareunia.                           with local oestrogen, which is
                                                                            worth a try before referral (ie, 3
                                                                            months).
                                 INVESTIGATIONS:
                                                                         2. Consider ring pessary.
                                  MSU.
                                 Consider:
                                    FBC.
                                    Renal biochemistry.



    Diagnosis / Symptomatology                Evaluation                         Management Options                         Referral Guidelines
Urinary symptoms
                                    Stress incontinence + - prolapse.   1. Refer to specialist physiotherapy/     Where indicated, refer for urodynamic
                                    Hesitancy associated with              continence nurse.                      assessment.
                                     prolapse.                           2. HRT/local oestrogens if post-
                                                                            menopausal.
                                    Other associated pressure                                                     Refer to Gynaecology or Urological
                                     symptoms, eg on bladder, on                                                   Service as appropriate – Category 4.
                                     bowel, pelvic pain.                 Note:
                                    Urge incontinence.                  1. Pelvic floor exercises by trained
                                    Frequency.                             continence therapist if available
                                                                            (and local oestrogens if post-
                                    Previous gynae, surgery/obstet         menopausal) should be tried for
                                     history.                               three months before referral in any
                                                                            event.
                                 INVESTIGATIONS:                         2. If stress incontinence associated
                                    MSU.                                   with urgency, frequency, nocturia
                                                                            etc (ie, a mixed picture) persists,
                                    FBC.
                                                                            then primary referral to the Urology
                                    Renal function biochemistry/blood      Service is recommended.
                                     sugar.
                                    Imaging if warranted.
                                    Pregnancy test.
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    Diagnosis / Symptomatology                 Evaluation                         Management Options                       Referral Guidelines
Vaginal Discharge
(c.f. Sexual Health Referral     –   Sexual and PID history.              1. STDs – treat patient and partner.    STD Services.
Recommendations.)                                                            Referral to STD clinic for contact
                                                                             tracing and counselling.
                                                                          2. Thrush (incl recurrent), local
                                 –   Characteristics – odour, quantity,
                                                                             treatments – cyclical local
                                     irritation, bloodstaining.
                                                                             treatments, oral therapy.
                                                                          3. Physiological – counselling and      Recurrent, failed treatment – refer to
                                 INVESTIGATIONS:                             education.                           specialist services – Category 4.
                                    Smear.
                                    Swab, HVS, chlamydia, viral.
                                    Blood glucose.




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