CPAC GENERAL SURGERY GENERAL SURGERY REFERRAL RECOMMENDATIONS Diagnosis / Symptomatology Evaluation Management Options Referral Guidelines Problems may be categorised under A thorough history and examination is Specific treatments depend on specific Most general surgical diagnoses the following groupings: required to determine a specific problems identified as noted below require referral to specialist diagnosis and its degree of urgency management. However, these • Endocrine guidelines are provided (below) to give greater clarity in situations of the • Herniae Some appropriate investigation by the primary/secondary interface of care. • Ano-rectal referrer may facilitate the referral Clearly, telephone/fax communication process • Skin would enhance appropriate treatment. Diagnosis / Symptomatology Evaluation Management Options Referral Guidelines Endocrine Thyroid masses Painful mass (inflammatory) Complete head and neck exam Appropriate antibiotic trial (of ENT Referral indicated if mass persists for indicated for site of infection: referral recommendations) two weeks without improvement • FBE (phone surgeon) Where pathology is identified which • requires surgical intervention a surgical Cultures when indicated • referral is indicated Consider HIV/intradermal Semi Urgent referral if painless, TB/Paul Bunnell (if indicated) progressive enlargement or highly Non-surgical conditions should be • Consider possible cat scratch suspicious of malignancy – Semi- referred to Endocrinology disease/Toxoplasmosis urgent Painless mass (non inflammatory) Complete head and neck exam Refer to appropriate specialist – Semi- indicated for site of primary: urgent • TFTs if thyroid mass. • FNA may be appropriate Updated December 2014 Page 1 of 4 CPAC General Surgery Diagnosis / Symptomatology Evaluation Management Options Referral Guidelines Herniae Inguinal/femoral hernia • Pain in groin sometimes Conservative management may Herniae should be referred to a precedes lump. Pain may be possibly be considered in the very General Surgeon – Semi-urgent- colicky and associated with elderly +/- infirm Routine. vomiting (intestinal obstruction) If episode of irreduciblity Semi-urgent • Lump in groin – may be intermittent/ reducible Major social impact- Routine • Social impact Incisional hernia • Nature and time previous Weight reduction (reduces probability Refer – Routine operation of future occurrence) • Factors associated: poor wound healing (diabetes, malignancy, Corset if symptomatic, delay in repair, malnutrition, steroids, obesity). or treating conservatively • Co-morbidity Biliary Conditions Common Bile Duct Stone Charcot's Triad: Need U/S and LFT to discriminate If jaundice without fever Urgent • Pain (site, acute/chronic, • Charcot’s is the most urgent in continuous/episodic) If only abnormal LFT with dilated duct terms of referral. It can be a • Jaundice and gallstones, can be Semi-urgent surgical emergency • Fever • Fever and thick walled GB needs If resolving biliary pain and no more urgent referral thickening of GB, normal duct and LFT, Routine Cholecystitis Investigations: Known gallstones: Refer Semi-urgent-Routine • FBE • Low fat diet Cholelithiasis • Liver function tests • Short attacks of biliary colic can be • Lipase managed symptomatically • Hepatitis serology, if indicated • Ultrasound Gallstones, points for concern: • Increasing frequency and severity of pain • Documented jaundice or deranged liver function tests • Ultrasound evidence of duct dilatation Updated December 2014 Page 2 of 4 CPAC General Surgery Ano-rectal Diagnosis / Symptomatology Evaluation Management Options Referral Guidelines Pilonidal Disease Disease's incidence is increased with: Three categories that represent Acute cases to ED – for drainage . • sweating activity associated with different stages of the clinical course: sitting and buttock friction (1) acute pilonidal abscess • poor personal hygiene (2) chronic pilonidal disease (clinic), Refer to a General Surgeon – Urgent- • obesity, and and Routine based on clinical condition. • local trauma (3) complex or recurrent pilonidal disease (clinic). Diagnosis of a pilonidal sinus can be made by identifying the epithelialized follicle opening, palpated as an area of deep induration beneath the skin in the sacral region. Haemorrhoids History of bleeding (with motions or Lifestyle/dietary advice/modification Refer for exclusion of other underlying apart, mixed or on surface material). Proprietary creams/suppositories disease – Routine Prolapse and thrombosis. Injection sclerosant therapy (if Specialist management appropriately trained to perform Evaluation: procedure) • PR • Proctoscopy • Sigmoidoscopy • Age >40 years + possibility blood mixed with stools, family history colorectal cancer and delay > 4 weeks before clinic – barium enema Updated December 2014 Page 3 of 4 CPAC General Surgery Diagnosis / Symptomatology Evaluation Management Options Referral Guidelines Anal fistula History of recurrent perianal Refer for management and exclusion abscesses, discharging sinus, and of associated disease – Routine. previous drainage operation Evaluation: • PR • Proctoscopy/sigmoidoscopy Anal fissure History of pain with and/or after Xylocaine creams/suppositories. Refer for severity and chronicity Defaecation : Rectogesic (glyceryl trinitrate) applied reasons – Routine. tds. • Attacks may be intermittent or prolonged • Evaluation may be difficult due to spasm • Note anal tag Skin Ingrown toenail Refer – Routine. Carpal Tunnel Syndrome Neurovascular assessment Refer – Routine. Not all General Impact on activities of daily living Surgery departments accept these referrals Can be referred to orthopaedics, Plastics or general Surgery Updated December 2014 Page 4 of 4 .