referral

Question 1

Acne

Answer 1

• children under 6
• unclear diagnosis
• lack of response to treatment
• moderate to severe acne
• signs of androgen excess
• medicines that is causing/aggravating acne
• experiencing significant negative emotional or social impacts
• scarring or family history of severe scarring, from acne

Question 2

Vaginal Thrush

Answer 2

• 1st time symptoms
• > 4 episodes a year
• treatment failure
• bleeding
• pelvic or abdominal pain
• discharge not of BV or VCC
• sores
• urinary symptoms
• systemic symtpoms
• history suggestive of STI
• recent birth, miscarriage or abortions
• IUD
• <18yrs and >60yrs
• immunosupression
• diabetes

Question 3

BV

Answer 3

• 1st time symptoms
• > 4 episodes a year
• treatment failure
• bleeding
• pelvic or abdominal pain
• discharge not of BV or VCC
• sores
• urinary symptoms
• systemic symtpoms
• history suggestive of STI
• recent birth, miscarriage or abortions
• IUD
• <18yrs and >60yrs
• sx recurr within 2 weeks of treatment
• pregnancy

Question 4

Epi-pen

Answer 4

refer
- Clinical need for adrenaline auto-injector not confirmed by a medical or nurse practitioner
- Child <7.5 kg where clinical need for adrenaline auto-injector not confirmed by a clinical immunology or allergy specialist
Supply and refer
- poor asthma control
- taking a beta blocker
- no action plan

Question 5

Allergic Rhinitis

Answer 5

• tx failure
• quality of life seriously affected
• persistent unilateral nasal obstruction or discharge
• impaired sense of smell
• infection
• signs or sx of undiagnosed asthma
• signs or sx associated with medicines use

Question 6

common colds

Answer 6

• fever above 39 degrees or chills
• fever for >5 days or returning after a fever free period
• dyspnoea
• wheezing
• chest pain
• dehydration
• vomiting

Question 7

common colds - children

Answer 7

• fever above 38 in infants
• more than 2 days fever in children
• symptoms that do not improve or get worse
• ear pain
• excessive irritability
• lack of appetite or poor feeding
• drowsiness or lack of energy

Question 8

constipation

Answer 8

• rectal bleeding, dark, tarry stool; or passing mucus in stools
• rectal pain
• unexplained weight loss
• fever
• anorexia, vomiting
• severe abdominal pain
• > 50yrs with new or worsening symptoms
• constipation alternating with diarrhoea
• sudden change in bowel habits lasting >2 weeks or recurring over >3 months
• suspected laxative misuse
• daily use of laxatives (excluding fibre based)
• constipation persisting as a new symptom that is not attributed to changes in diet or lifestyle or medicines or medical condition
• persisting after a week after 1 week of laxative or 2 weeks of dietary modification
• change in, or persistent concern about, bowel habit in infants <3 months

Question 9

Cough

Answer 9

• cough persisting >2 weeks
• Haemoptysis
• Dyspnoea
• Systemic symptoms ( weight loss and fever)
• dicoloured or purulent sputum
• wheeze
• chest pain
• Persistent hoarseness
• feeding difficulties
• recurrent, productive cough in a child (particularly at night)
• nea/altered cough in a smoker ager >45 years
• New/altered cough in a person who is immunosupressed
• New/altered cough in a person who has visited a country where tuberculosis is endemic

Question 10

dermatitis

Answer 10

-Unclear diagnosis
-Signs of secondary or systemic infection
-Respiratory, gastrointestinal (abdominal pain, vomiting) or cardiovascular (loss of consciousness, persistent dizziness, hypotension) signs or symptoms
-Drug reaction is suspected
-Signs or symptoms persist despite appropriate treatment
-Signs or symptoms are widespread
-Signs or symptoms are severe
-Sensitive areas (e.g. genital area) are affected

Question 11

Diarrhoea

Answer 11

-Blood and/or mucus in the stools
- Severe abdominal or rectal pain
-Fever (≥39 °C)
-Severe vomiting
-Signs of severe dehydration (e.g. lethargy, loss of skin elasticity, sunken eyes, dry mouth, reduced urine output)
-Severe or worsening symptoms
-Diarrhoea lasting ≥14 days
-Unintentional weight loss
-Diarrhoea alternating with constipation
-Diarrhoea lasting >24 hours in an infant <1 year of age
-Diarrhoea lasting ≥2 days in a child
-Diarrhoea in an infant <6 months of age
-Pregnancy
-Chronic medical condition (e.g. heart failure, diabetes)
-Person is immunocompromised (e.g. chemotherapy, long-term corticosteroids, HIV infection)
-Suspected adverse drug reaction or laxative misuse

Question 12

EC - refer

Answer 12

-the patient does not have a mature understanding of what is proposed
-oral EC is not supplied within the required time after unprotected sexual intercourse (UPSI)
-the patient has severe asthma treated with oral glucocorticoids and UPSI was >96 hours ago (ulipristal EC is indicated but may worsen their asthma)
->120 hours (5 days) after UPSI.

Question 13

EC give and refer

Answer 13

• BMI >30 kg/m2 or weight >85 kg
  -CYP3A4 enzyme inducer or griseofulvin used within the previous 4 weeks
  -malabsorption disorder (e.g. Crohn’s disease, acute vomiting, severe diarrhoea)
  -insufficient time interval between use of ulipristal EC and a progestogen
  -ulipristal EC is required more than once in the same menstrual cycle (possible risk of hepatotoxicity)
  -a victim or suspected victim of sexual assault

Question 14

Gastroenteritis in children

Answer 14

-Severe abdominal pain
-High fever (≥39 °C)
-Minimal oral intake (e.g. due to persistent vomiting)
-Persistent diarrhoea
-Bloodstained vomit or stools
-Bilious (green) vomit
-Persistent vomiting (>2 days) or vomiting without diarrhoea
-Pre-existing disease/condition
-Immunocompromised
-Age <6 months
-Poor growth or nutrition
-Use of fortified feeds (concentrated feeds or caloric additives)
-Recent use of potentially hypertonic fluids (e.g. Lucozade)
-Signs of severe dehydration
-Recent overseas travel
-Recurring symptoms

Question 15

GORD

Answer 15

-Dysphagia
-Painful swallowing
-Gastrointestinal bleeding—dark, tarry stools; haematemesis
-Recurrent vomiting
-Unexplained weight loss
-Severe chest pain or pressure, especially if accompanied by radiating pain in the shoulder/arm/neck/jaw, sweating or difficulty breathing; or exacerbated by exercise (requires immediate medical attention)
-New symptoms in person aged >55 years
-Changing, severe or frequent (>twice/week) symptoms
-Symptoms not adequately controlled or continuing after a 2-week trial of H2-antagonist or proton pump inhibitor (PPI)
-Prolonged or recurrent use of PPI without medical investigation
-Epigastric pain

Question 16

headache and migraine

Answer 16

New or different type of headache
​Speech difficulties, confusion, memory problems, balance problems, drowsiness, seizures
Neurological symptoms (e.g. paraesthesia, hypoaesthesia)
Ocular symptoms (e.g. blurred/impaired vision, pain exacerbated by eye movement)
Neck stiffness, fever, vomiting
Recent head or neck trauma
Temporal artery tenderness
Sudden-onset, unprovoked, severe pain (‘thunderclap headache’)
Headache that wakes the patient
Headache triggered by reading or watching television for 20–30 minutes
Recent-onset headache triggered by coughing, sneezing, straining, bending over, exertion or sexual activity
Recent-onset headache in a person who:
has cancer or a history of cancer
is immunocompromised
is >50 years old
is <5 years old
is <18 years old and obese
Headaches with rapidly escalating frequency or severity
Suspected medication over-use headache
Suspected drug reaction
Headache not responding to treatment
Isolated aura (i.e. without headache)
Migraine symptoms increasing in frequency or occurring on >2 days a month
Symptoms of dehydration and/or electrolyte disturbance as a result of vomiting

Question 17

headlice

Answer 17

Diagnosis is unclear
Signs of secondary infection (e.g. weeping or crusting of skin, swollen glands, fever)
Insecticides and physical methods have failed, and systemic treatment may be required

Question 18

nappy rash

Answer 18

Severe or unusual rash
Lack of response to appropriate treatment
Other areas of the body affected
Signs of secondary infection (e.g. fever, pustules, erosions, ulcers

Question 19

Insomnia

Answer 19

Suspected chronic insomnia (insomnia disorder)
Comorbid conditions associated with insomnia (including other sleep disorders) that require treatment
No response to evidence-based management options
Melatonin needed for longer than 3 weeks and use is not being managed by a medical practitioner (i.e. last medical review >13 weeks ago)
Contraindications to non-prescription treatment options

Question 20

NRT - refer

Answer 20

Pregnancy
Nicotine replacement therapy contraindicated or unsuitable
Patient wishes to use a prescription medicine for smoking cessation (e.g. bupropion, varenicline, subsidised nicotine replacement therapy, nicotine vaping products)
A medicine the patient uses may require a dose change when they stop smoking (e.g. clozapine)

Question 21

NRT - supply and refer

Answer 21

Cardiovascular disease, diabetes, mental illness
Breastfeeding
Age <18 years

Question 22

mouth ulcers

Answer 22

Frequently recurring mouth ulcers
Large mouth ulcers (>1 cm in diameter)
Mouth ulcers lasting >2 weeks
Extremely painful mouth ulcers causing difficulty eating or drinking
Signs of infection or systemic illness (e.g. fever)
Suspected underlying cause (e.g. immunocompromise, medical condition

Question 23

threadworm

Answer 23

• under 12 months old
• signs of secondary infection
• lack of response to treatment
• unclear diagnosis

Question 24

Naloxone - refer

Answer 24

• naloxone contraindicated (

Question 25

naloxone - overdose signs

Answer 25

choking, snoring or gurgling sounds slow, shallow, erratic or no breathing extreme drowsiness being unresponsive cold, clammy skin pale face bluish-purple skin (in lighter-skinned people), or greyish or ashen skin (in darker-skinned people) blue or purple–black lips and fingernails limp body small or pinpoint pupils slow, erratic or no pulse vomiting.

Question 26

naloxone - supply and refer

Answer 26

Pre-existing cardiovascular disease Using medicines that cause adverse cardiovascular effects <18 years old Pregnant or breastfeeding

Question 27

Tinea

Answer 27

Extensive, severe or persistent infection Infection of the scalp, beard or nail matrix Lack of response to topical therapy Prior treatment with a topical corticosteroid Signs of secondary bacterial infection (e.g. swelling, purulent drainage, fever) Patient with diabetes or immune deficiency

Question 28

chlorsig

Answer 28

Severe eye pain or swelling Reduced, blurred or loss of vision Restricted eye movement Cloudy cornea Abnormal-looking pupils Injury to the eye or suspected foreign body in the eye A history of welding without adequate eye protection Generally unwell Experienced similar symptoms in recent weeks Glaucoma Dry eye syndrome Use of other eye drops or eye ointments Eye surgery or laser treatment in the past 6 months History of bone marrow problems Recently travelled overseas Photophobia Copious purulent (yellow–green) discharge Contact lens user age <2 yrs old

Question 29

cold sores (famciclovir)

Answer 29

Painful mouth ulceration with poor oral intake Signs of bacterial skin infection Systemic symptoms present Lesions on other parts of the body Outbreaks occur more than three times a year Aged <18 years Lesion present for >14 days immunocompromised

Question 30

glucagon

Answer 30

Clinical need for glucagon not confirmed by a medical or nurse practitioner, or diabetes educator If a patient with severe hypoglycaemia is taking beta-blockers, an ambulance should be called immediately, because they may not respond to glucagon and will require intravenous (IV) glucose

Question 31

hypoglycaemia sx

Answer 31

sweating shaking pallor anxiety palpitations nausea. hunger confusion blurred or double vision impaired intellectual function difficulty speaking irritability seizures coma

Question 32

neutrafleur

Answer 32

- Clinical need for high-concentration fluoride toothpaste not confirmed by a registered dental practitioner or medical practitioner

Question 33

orlistat

Answer 33

Aged <18 years Previous or suspected eating disorder cholestasis major gastrointestinal (GI) surgery chronic malabsorption syndrome pancreatic enzyme deficiency chronic pancreatitis significant cardiac, renal, hepatic, GI, endocrine, chronic psychiatric and/or neurological disorders bulimia or anorexia nervosa laxative abuse fat-soluble vitamin deficiency (vitamins A, D, E and K) gallstones, renal stones active peptic ulcer disease postsurgical adhesions pregnant

Question 34

SABA

Answer 34

Clinical need for a SABA not confirmed by a medical or nurse practitioner Using a medicine that can interact with salbutamol and terbutaline∗ Three or more SABA inhalers used in previous 12 months∗ Using SABA >2 days per week (not including before exercise)∗ Asthma symptom control not good within the previous 4 weeks∗ Last medical review >6 months ago∗ Patient with asthma does not have a current personalised written asthma action plan

Question 35

Uticaria

Answer 35

Unclear diagnosis Signs of secondary or systemic infection Signs or symptoms persist despite appropriate treatment Wheals are not transient, are painful, occur with bruise-like staining Undiagnosed underlying condition is suspected Food allergy or drug reaction is suspected