The following conditions are frequently referred to the General Medicine (GM) clinic from the Emergency Department (ED). These have been included in GPNext as they can be comfortably managed at the primary care level for follow up.
By Dr Adeline Chin Mei Lin, Principal Resident Physician and Dr Teong Hui Hwang, Senior Consultant
Department of General Medicine, Tan Tock Seng Hospital
Patients with severe hypertension are not uncommonly referred to the ED by their GP. After evaluation and medication adjustment, if there is no evidence of progressive or new end organ damage, and blood pressure upon discharge from ED is not severe (less than 180/110mmHg), patients can be referred back to their GP for further management. With the use of home blood pressure monitoring devices, patients can be educated about the white coat phenomenon without the need for referral to a specialist. However, patients with resistant hypertension or onset at age less than 40 years old will still be evaluated at the GM clinic.
Lower Limb Swelling
Lower limb swelling is a common presenting symptom to the ED as patients are rather alarmed when it occurs. A common cause is venous insufficiency or stasis, which is suggestive if it resolves with recumbency or in the presence of varicose or prominent veins. Management is mainly nonpharmacological through weight reduction and compression stockings. Another common cause of lower limb swelling is the increased capillary permeability caused by the use of calcium channel blockers which will resolve upon withdrawal or dose reduction. Patients with these benign causes can be reviewed by their family doctors. However, if there is unilateral limb swelling, features of weight loss, limb pain or abnormal investigation results, such patients will not be directed to GPNext but should instead be followedup at the GM clinic.
Iron Deficiency Anaemia
Young women aged 25 and below with suspected iron deficiency anaemia (haemoglobin not less than 8g/dl) can follow up with their GP for therapy with oral iron. If iron replacement produces minimal response and there are no signs and symptoms that would warrant a direct referral to the gastroenterologist or gynaecologist, the patient can be referred back to the GM clinic for review.
Patients without cerebrovascular or cardiovascular risk factors or disorders who present to ED with non specific dizziness related to stress or poor rest may also be monitored at primary care. If these symptoms are persistent despite modification of stressors, the patient may then be referred back to a specialist for further evaluation.