FIRST EDITION

PRIMARY CARE REFERRAL

GUIDELINES

Primary Care Referral Guidelines

All rights reserved. This material may be freely reproduced for educational and not for profit
purposes. No reproduction by or for commercial organizations is permitted without the express
written permission from the Family Medicine Specialists Association of Malaysia. You may
complete your request online via our website.

First Edition 2014

Family Medicine Specialists Association of Malaysia

Address: Room 14, Level 5,
Malaysian Medical Association Building
No 124, Jalan Pahang, 53000 Kuala Lumpur
Email: fms_association@yahoo.com
Website: http://fms-malaysia.org
ISBN:
Designed by Publisher name
Printed by Printing Company

Disclaimer
The clinical advice, referral criteria and the organizational details contained in this book refer to
the Malaysian setting, unless otherwise stated. The book is intended for use by primary care
practitioners and not for patients.
While efforts have been made to ensure the accuracy of the information in this book, it is the
responsibility of the doctor who is caring for the patient(s) to make his or her own judgment on
the best treatment for the patient at that time. Although efforts are made to maintain accuracy of
the information, some of the information may be outdated by the time of printing.
The authors, editors and publishers cannot accept liability for information that is subsequently
shown to be wrong.

List of Editors
Dr Mastura Ismail
Family Medicine Specialist
Seremban 2 Health Clinic
Negeri Sembilan

Dr Adina Abdullah
Senior Lecturer
Department of Primary Care
Faculty of Medicine, University Malaya

Prof Dr Ng Chirk Jenn

Consultant Family Medicine
Department of Primary Care
Faculty of Medicine, University Malaya

Dr Mimi Omar
Family Medicine Specialist
Kelana Jaya Health Clinic
Selangor

List of External Reviewers

Prof Dr Teng Cheong Lieng
Department Family Medicine
International Medical University

Dr Vickneswari a/p Ayadurai

Family Medicine Specialist
Medan Jaya Health Clinic
Petaling Jaya

Prof Dr Khoo Ee Ming

Department of Primary Care Medicine
Faculty of Medicine
University of Malaya

Table of Contents
Foreword
Preface
How to use the guideline
Acknowledgements
List of abbreviations
List of tables
Content
Chapter 1
Chapter 2
Chapter 3
Chapter 4
Chapter 5
Chapter 6
Chapter 7
7.1
7.2
7.3
Chapter 8
8.1
8.2
8.2.1
8.2.2
8.2.3
8.3
8.4
Chapter 9
9.1
9.2
Chapter 10
10.1
10.2
10.3
Chapter 11
11.1
11.2
Chapter 12
12.1
12.2
Chapter 13

Introduction
Aims & Objectives
Methodology
Good referral practices
Medicolegal implications
Implementation of referral guideline
Paediatric
Febrile convulsion
Neonatal jaundice
Acute gastroenteritis
Cardiology
Atrial fibrillation
Coronary heart disease
Angina
Acute myocardial infarction
Unstable angina/Non ST Elevation MI (NSTEMI)
Heart failure
Hypertension
Nephrology
Chronic kidney disease
Nephrotic syndrome
Endocrinology
Diabetes mellitus
Obesity
Thyroid disorders
Gastroenterology
Dyspepsia
Jaundice in adult
Ophthalmology
Acute visual loss
Red eye
Ear, Nose & Throat
4

13.1
13.2
13.3
Chapter 14
14.1
14.2
Chapter 15
15.1
15.2
15.3
Chapter 16
16.1
16.2
16.3
Chapter 17
17.1
17.2
17.3
Chapter 18
18.1
18.2
Chapter 19
19.1
19.2
Chapter 20
20.1
20.2
Chapter 21

Dysphagia
Obstructive sleep apnoea
Vertigo
Orthopaedic
Back pain
Knee and hip pain (degenerative)
Psychiatry
Anxiety
Depression
Substance abuse
Urology
Haematuria
Lower urinary tract symptoms
Urinary calculi
Haematology
Anaemia
Haemoglobinopathies
Lymphadenopathy
Neurology
Headaches
Cerebrovascular accident
Obstetric
Gestational diabetes in pregnancy
Hypertensive disorder in pregnancy
Respiratory
Chronic cough
Pulmonary tuberculosis
Rheumatology

21.1
21.2
Chapter 22
22.1
22.2
22.3
Chapter 23
23.1
23.2
23.3
23.4
Chapter 24
24.1
24.2
Chapter 25
25.1
25.2

Osteoporosis
Gout
Gynaecology
Menorrhagia
Subfertility
Vaginal discharge
Infectious disease
Dengue
Hepatitis B
Hepatitis C
Human Immunodeficiency Virus
Surgery
Acute abdomen
Thyroid nodule
Dermatology
Acne
Psoariasis
5

Chapter 26
26.1
26.2

Child psychiatry
Autism
Learning disabilities

Appendices
List of contributors

Foreword

Congratulations to the Malaysian Family Medicine Specialists Association (FMSA), especially

to the committee members, authors, reviewers and editors of the Primary Care Referral
Guideline Handbook for their diligent effort to provide guidance to practitioners on the
appropriate referral of patients from primary to secondary care.
The decision to refer patients to specialist services in hospitals is a critical management issue.
Despite its importance, there has been modest research in this area. Many retrospective
evaluations of referrals seek to measure the level of appropriateness, often from one
stakeholders perspective. Careful analysis reveals that referrals are more complex. They reflect
the needs and expectations of individual patients and their families, the knowledge and
experience of the individual health care providers, and the range, type and level of services
available locally.
The contents of this booklet are the result of sound evidence and professional consensus among
representatives of key stakeholder groups, involving family medicine specialists, private general
practitioners and relevant hospital specialists.
Primary care practitioners may use this guideline as a tool to assist in determining the best
approach to manage their patients, ascertain that referral criteria are met and decide when and
where to refer depending on the availability of resources and specific care at the referral centre.
The patients clinical presentation and circumstances will also influence their referral.
It is my hope that this Primary Care Referral Guideline Handbook will be constantly used by
primary care practitioners as reference to improve the referral of patients to secondary care.

Dato Seri Dr Noor Hisham bin Abdullah

Director General of Health
Ministry of Health, Malaysia