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Syncope / pre-syncope (General Medicine)

ADULT

If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region.


Anaemia

  • Severe anaemia (Hb <80g/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

Complex or undifferentiated medical problems

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

Complex paediatric patients transitioning to adult services

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

Falls

  • 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)

Medication review / poly-pharmacy

  • 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, corrected Ca >3.0, Mg <0.4)

Osteoarthritis, gout and joint pain

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

States of altered neurological function

  • 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 of sudden onset

Syncope / pre-syncope

  • Syncope / pre-syncope with any of the following concerning features
    • 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

Unintentional weight loss

  • Uncontrolled hyperthyroidism with risk of thyroid storm
  • Vomiting, dysphagia or odynophagia suggesting oesophageal or gastric outlet obstruction
  • 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)

Wounds of uncertain cause or non-healing ulcers

  • 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

Other

  • Any condition defined by other CPCs as requiring referral to emergency
  • If syncope thought likely to be of of cardiac origin see Cardiology syncope / pre-syncope CPC
  • If possible please identify an eye witness to any episode of syncope and request that the witness attends the specialist outpatient appointment with the patient.

Minimum Referral Criteria

  • Category 1
    (appointment within 30 calendar days)
    • Syncope with unclear aetiology (if cardiac aetiology is thought likely see Cardiology - syncope/pre-syncope CPC)
    • Vasovagal syncope occurring on a weekly basis
    • Syncopal episodes that have resulted in physical injury (but not so severe as to warrant ED presentation)
    • Symptomatic orthostatic hypotension (of more than 20mmHg decrease in systolic blood pressure)
  • Category 2
    (appointment within 90 calendar days)
    • Vasovagal syncope occurring on less than weekly basis but at least once a month
    • Asymptomatic orthostatic hypotension 
  • Category 3
    (appointment within 365 calendar days)
    • Vasovagal syncope occurring infrequently (less than once a month)

1. Reason for request Indicate on the referral

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can't order, or the patient can't afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

2. Essential referral information Referral will be returned without this

  • General referral information
  • Relevant medical history, co-morbidities and medications
  • Details of clinical presentations:
    • include 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

3. Additional referral information Useful for processing the referral

  • Any investigations relevant to co-morbidities (eg HbA1c if diabetic, spirometry  if COPD)
  • EEG results (if available)
  • Holter monitor or event monitor results (if available)
  • Echocardiogram results (if available)

4. Request

Patient's Demographic Details

  • Full name (including aliases)
  • Date of birth
  • Residential and postal address
  • Telephone contact number/s – home, mobile and alternative
  • Medicare number (where eligible)
  • Name of the parent or caregiver (if appropriate)
  • Preferred language and interpreter requirements
  • Identifies as Aboriginal and/or Torres Strait Islander

Referring Practitioner Details

  • Full name
  • Full address
  • Contact details – telephone, fax, email
  • Provider number
  • Date of referral
  • Signature

Relevant clinical information about the condition

  • Presenting symptoms (evolution and duration)
  • Physical findings
  • Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
  • Body mass index (BMI)
  • Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
  • Current medications and dosages
  • Drug allergies
  • Alcohol, tobacco and other drugs use

Reason for request

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can't order, or the patient can't afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

Clinical modifiers

  • Impact on employment
  • Impact on education
  • Impact on home
  • Impact on activities of daily living
  • Impact on ability to care for others
  • Impact on personal frailty or safety
  • Identifies as Aboriginal and/or Torres Strait Islander

Other relevant information

  • Willingness to have surgery (where surgery is a likely intervention)
  • Choice to be treated as a public or private patient
  • Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)
  • Please note that where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service.  Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.

  • A change in patient circumstance (such as condition deteriorating, or becoming pregnant) may affect the urgency categorisation and should be communicated as soon as possible.

  • Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.