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. 

Relevant HSC Primary Care Guidelines

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. 

NICE – Otitis media (acute): antimicrobial prescribing 

Acute Otis ExtrenaIf 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. 

Relevant HSC Primary Care Guidelines

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 

Relevant HSC Primary Care Guidelines

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. 

Relevant HSC Primary Care Guidelines

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. 

Relevant HSC Primary Care Guidelines

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. 

Relevant HSC Primary Care Guidelines

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 [email protected]

 

 

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?