Diagnosis

PCP Evaluation/Management Options

PCP Guidelines for Referral to Specialist

Acute Abdominal Pain

1. Refer for pain associated with fever, leukocytosis, peritoneal signs, or palpable abdominal mass.

Acute GI Bleeding

1. Initiate early GI consultation.
2. Consider early surgical consultation if active bleeding continues.

Breast Masses

If stable, follow small breast lumps every three months for at least two visits.

For screening, order mammography according to an approved schedule (see attachment). Mammography should be accompanied by clinical breast exam.

Aspirate breast cysts if trained. Send for pathological exam on bloody fluid or if aspiration results in incomplete resolution of the cyst on physical exam.

1. Refer any suspicious breast mass, persistent breast cysts and areas of thickening, breast lesions with associated skin or nipple changes.
2. Refer suspicious and indeterminate mammograms.

Gallbladder Disease

Evaluate with history, physical exam, ultrasound

1. Refer is symptomatic
2. Refer for extrahepatic bile duct obstruction.

Hernias (other than Hiatal)

1. Refer symptomatic inguinal and abdominal hernias, and all femoral hernias.

Inflammatory Bowl Disease

After initial consult, manage uncomplicated disease.

Manage acute exacerbation in cooperation with consultant.

1. Consult for a cooperative effort between the primary care physician, GI, and surgeon.
2. Consult surgery for complications such as obstruction from stricture, persistent bleeding, periectal disease, toxic megacolon, and consideration for surgical resection in patients with long-standing UC.

Nausea, Vomiting, Constipation

1. Consult for gastric outlet, small bowel or colonic obstruction.

Pancreatitis

1. Consult GI and Surgery for patients with acute pancreatitis or sever abdominal pain and complications of hemorrhagic or necrotizing pancreatitis.

Peptic Ulcer Disease, Hiatal Hernias

1. Consult for perforation or obstruction, persistent or recurrent bleeding or intractability.
2. Refer hiatal hernias with symptoms of GERD unresponsive to medical treatment, and for gastroenterology evaluation.

Perirectal Disease

Diagnose with DRE and anascopy.

Treat hemorrhoids and anal fissures with diet, suppositories, sitz baths.

If trained, treat thrombosed external hemorrhoids surgically.

1. Refer for any perirectal abscess, fistula in ano, persistent bleeding or prolapsing hemorrhoids, persistent fissure.
2. Refer for thrombosed external hemorrhoids if ulceration, necrosis or bleeding is present.

Soft Tissue Infection

Perform incision and drainage if trained and procedure is simple.

1. Refer refractory non-responding soft tissue infections, especially in diabetics or immunocompromised hosts.
2. Refer complex infections on the hand and fingers.

Abdominal Aortic Aneurysms

Evaluate with examination and ultrasound.

1. Refer is symptomatic, enlarging or 4.5 cm in diameter or greater.

Arterial Problems

1. Refer gangrene, ischemic ulcers, or ischemic rest pain.
2. Refer incapacitating claudication.

Claudications

Early telephone consult with radiologist and vascular surgeon can aid in coordination of an appropriate treatment plan.

1. Refer patients with significant disability.

Deep Venous Thrombosis

Evaluate with history, examination, duplex Doppler scan.

Treatment with anticoagulation as appropriate.

1. Refer for uncertain diagnosis and complications.

Thoracic Aneurysms

Evaluate with examination, CXR , CT exam.

1. Refer those 4cm or greater.
2. Refer patients with aortic insufficiency or aortic dissection.

Transient Ischemic Attacks

Evaluate with history and examination.

Obtain carotid imaging whether or not symptomatic bruit is present.

1. Refer if a classic ischemic attack or recurrent attacks are associated with a carotid lesion appropriate to neurologic deficit and for surgery.
2. Consider neurology consult.

Varicose Veins

Evaluate with history, evaluation and possible duplex Doppler.

Treat conservatively with weight loss and support stockings.

1. Refer for severe pain, intractable ulceration, or current bleeding.