When to Refer

Cold

Ear ache that is severe

Vulnerable patient groups e.g. very young, very elderly, heart disease, lung disease, asthma

Fever and cough that is persistent

Chest pain

Shortness of breath that can’t be explained

Cough

Longer than 2 weeks and not improving

Chest pain

Shortness of breath

Wheezing

Recurring cough present at night

Whooping cough/croup

Cough or wheezing that may be drug induced e.g. ace inhibitors and beta blockers

Yellow, green, brown or blood stained phlegm/sputum

Offensive or foul smelling phlegm/sputum

Sore throat

Dysphagia (difficulty in swallowing)

Longer than 7-10 days

Hoarseness persisting for more than three weeks

Sore throat with a skin rash

White spots, exudate or pus on the tonsils with a high temperature and swollen glands

Recurrent bouts of infection

Suspected adverse drug reaction e.g. carbimazole

Failed treatment

Breathing difficulties

Ear wax

Foreign body in the ear

Pain

Dizziness

Tinnitus

Treatment failure

Headache

Headache associated with recent head injury/trauma

Children under 12

Associated with stiff neck, fever and or rash

Sudden onset and or severe pain

Suspected adverse drug reaction e.g. oral contraceptive pill

Associated with drowsiness, blackouts, unsteadiness, visual disturbances or vomiting

Recurring headaches

Constipation

Blood in the stools

Pain on defecation

Suspected drug induced constipation e.g. opiates, antidepressants

With abdominal pain, vomiting or bloating

Weight loss

Failed treatment

Change in bowel habit of more than 2 weeks

Diarrhoea

Persistent change in bowel habit

Recent travel which was abroad

Presence of blood/mucus in the stools

Diarrhoea with severe vomiting and fever

Signs of dehydration e.g. dry mouth, drowsiness or confusion, passing little urine, sunken fontanelle and eyes

Longer than 3 days in older children and adults (longer than 1 day in babies under 1 years and 2 days in children under 3 years and elderly)

Suspected drug induced diarrhoea e.g. antibiotics

Severe abdominal pain

Dyspepsia

Unexplained weight loss

Suspected drug induced dyspepsia e.g. ferrous sulphate, NSAIDs

Persistent vomiting

Persistent symptoms (more than 5 days) or recurring

Black or tarry stools

Severe pain

Pain radiating to other areas of body e.g. arm

Symptoms developing for the first time in patients aged 45 years or over

Dysphagia (difficulty in swallowing)

Failed treatment

Haemorrhoids

Blood in the stools

With abdominal pain or vomiting

Weight loss

Persistent change in bowel habit

Longer than 3 weeks

Mouth ulcers

Lasting longer than 3 weeks

Suspected adverse drug reaction e.g. NSAIDS

Crops of 5-10 or more ulcers

Rash

Diarrhoea

With weight loss

Involvement with other mucous membranes

Cystitis

Diabetics

Immunocompromised patient

Pregnant

Men

Children

Elderly women

Vaginal discharge

Haematuria (presence of blood in the urine)

With fever, nausea and or vomiting

Pain or tenderness in the loin area

Recurrent cystitis

Failed treatment

Longer than 2 days

Primary dysmenorrhoea

Abnormal vaginal discharge

Heavy or unexplained bleeding

Showing signs of systematic infection e.g. fever

Symptoms suggesting secondary dysmenorrhoea

Vaginal thrush

Diabetics

More than two attacks in the last six months

Failed OTC treatment

Pregnant

Vulval or vaginal sores ulcers or blisters

Vaginal discharge that is green-yellow or blood stained

Vaginal discharge that is foul smelling

Under 16 or over 60 years of age

No improvement within 7 days of treatment

Previous history of STD (sexually transmitted infection) or exposure to partner with STD

Abnormal or irregular vaginal bleeding

Any associated lower abdominal pain or dysuria

Athlete’s foot

Not responded to the appropriate treatment

Nail involvement

Spreading to other parts of the foot

Diabetics

Signs of bacterial infection e.g. weeping, pus or yellow crusts

Cold sores

Longer than 2 weeks

Lesions inside the mouth

Eye is affected

Immunocompromised patients

Signs of secondary bacterial infection e.g. weeping, pus, yellow crust

Babies and children

Severe, widespread or worsening lesions

Painless lesion

Warts and verrucas

Anogenital warts

Facial warts

Diabetics

Immunocompromised patient

Bleeding or itching

Changed in size or colour

OTC treatment that has been unsuccessful following 3 months of treatment