عيادات الباطنية

Routine

Urgent (<5 days)

Immediate (ER referral)

Resistant hypertension: BP remains ≥140/90 mmHg despite adherence to 3 antihypertensive drugs (one ideally a diuretic).

Secondary hypertension suspicion → unexplained or early-onset hypertension (<30 yrs) or signs suggestive of secondary causes (e.g., renal bruit, hypokalemia → hyperaldosteronism, cushingoid features, features of pheochromocytoma).

Hypertension with chronic kidney disease (CKD) progression → declining eGFR or rising creatinine.

Hypertensive patients planning pregnancy requiring specialist management & switching medications.

Patient already pregnant requiring specialist management & switching medications.

Rapidly worsening BP control despite adherence & previously stable readings.

Newly discovered hypertension with evidence of early target organ damage (e.g., proteinuria, LVH on ECG) → expedited workup.

Hypertensive emergency → BP ≥180/120 mmHg with acute target organ damage, e.g.:

• Neurological: stroke symptoms, hypertensive encephalopathy (confusion, seizures).
• Cardiac: acute chest pain, dyspnea, signs of heart failure.
• Renal: acute kidney injury (sudden oliguria/anuria).
• Retinal: sudden vision loss.

Severe hypertension in pregnancy → BP ≥160/110 mmHg → risk of preeclampsia/ eclampsia

Routine

Urgent (<5 days)

Uncontrolled LDL cholesterol despite maximum tolerated statin

Familial hypercholesterolemia (very high LDL, xanthomas, family history of premature ASCVD).

Statin intolerance (inability to use, or recurrent side effects preventing target doses).

Mixed dyslipidemia (high LDL + high TG ± low HDL) requiring advanced/combination therapy.

Persistent hypertriglyceridemia (TG 200–999 mg/dL / 2.3–11.2 mmol/L) despite lifestyle + pharmacological treatment.

Secondary dyslipidemia not improving after addressing the underlying cause (e.g., hypothyroidism, nephrotic syndrome, uncontrolled diabetes).

High-risk patients (established ASCVD, diabetes, CKD, multiple risk factors) needing escalation beyond primary care options (e.g., ezetimibe, combination therapy).

Severe hypertriglyceridemia (TG ≥ 1000 mg/dL / > 11.2 mmol/L) due to risk of pancreatitis.

Rapidly progressive triglyceride rise approaching or exceeding this threshold despite intervention

Very high LDL cholesterol (e.g., ≥ 6.5 mmol/L / ≥ 250 mg/dL) in young adults, strongly suggestive of familial hypercholesterolemia.

Routine

Urgent (<5 days)

Immediate (ER referral)

Persistent IDA without obvious cause (esp. men or postmenopausal women) → needs endoscopic evaluation.

Failure to respond to 4–6 weeks of adherence to oral iron therapy. *

Suspected malabsorption (e.g., persistent IDA despite treatment and dietary correction).

Severe anemia (Hb <7 g/dL) if hemodynamically stable without severe symptoms

Rapidly worsening anemia (Hb dropping ≥2 g/dL over weeks).

Symptomatic moderate anemia (e.g., lightheadedness, dyspnea) not improving with initial therapy for 4-6 weeks.

anemia with concerning systemic signs (e.g., unintentional weight loss).

Multiple cytopenias or abnormal blood smear suggestive of bone marrow pathology

Severe anemia (Hb <7 g/dL) with Severe symptoms OR Hemodynamic instability (hypotension, tachycardia, syncope).

Active or massive GI bleeding (melena, hematemesis).

* Adequate oral dose is 100-200 mg (elemental iron), ferrous sulphate 190 mg contains only 60 mg elemental iron per tablet, so 2 tablets are needed daily, or every other day if side effects are bothersome.

• Oral iron therapy should be continued for 3 months after Hemoglobin normalizes, to replenish iron stores and prevent early relapse.
• IV iron (in hospital) is indicated when oral iron is not tolerated, ineffective, or unsuitable due to malabsorption, or when rapid correction is required (e.g., late pregnancy, preoperative, severe symptomatic anemia).
• Admission & transfection indications are same as for "immediate referral"

Routine

Urgent (<5 days)

Immediate (ER referral)

Chronic or recurrent headaches unresponsive to first-line therapy, * including migraines or tension headaches not improving despite optimized acute and preventive treatment.

Suspected medication overuse headache needing specialized management to withdraw offending drugs.

Headaches associated with neurological signs that are stable but require further workup (e.g., persistent mild cranial nerve palsy).

New-onset trigeminal neuralgia or facial pain syndromes for confirmation and treatment planning.

cluster headaches → needs specific therapy (e.g., oxygen, triptans, verapamil).

Progressively worsening headache over weeks, especially if waking patient from sleep or worse lying down → raised intracranial pressure concern.


New-onset headache with neurological deficits (e.g., weakness, sensory loss, ataxia) not acutely evolving.

Persistent Acute Migraine with failed management in PHC

Temporal arteritis suspicion in patients ≥50 years → new headache with scalp tenderness, jaw claudication, or visual symptoms → early ESR/CRP and urgent referral.

Thunderclap headache → sudden onset, “worst headache of life” → concern for subarachnoid hemorrhage.

Headache with meningeal signs → neck stiffness, photophobia, fever → possible meningitis.

Headache with seizure or loss of consciousness.

Acute headache in a patient with known cancer or immunosuppression → possible intracranial lesion or infection.

Signs of increased intracranial pressure → vomiting, confusion, papilledema.

* Criteria (any of the following): 1) Tried 2–3 first-line acute treatments (NSAIDs, acetaminophen, triptans) correctly in ≥2–3 headache episodes, but still have moderate-severe pain not resolving within 2 hours. 2) Headaches persistently interfere with daily life despite proper treatment. 3) ≥4 migraine days/month with significant disability despite therapy. 4) Tried a first-line preventive medication (if indicated) at therapeutic dose for 2–3 months without ≥50% improvement in headache frequency or severity.

Routine

Urgent (< 5 days)

Immediate (ER referral)

Persistent elevated TSH despite adequate levothyroxine titration and adherence

Suspected secondary (central) hypothyroidism (e.g., low/normal TSH with low free T4)

Goiter or thyroid nodules in patients with hypothyroidism → refer for imaging ± specialist evaluation.

Pregnancy with hypothyroidism → early referral for specialist management to optimize maternal and fetal outcomes.

New or worsening hypothyroid symptoms despite treatment → signs like significant bradycardia, altered mental status, or worsening depression.

Suspicious features on exam or history (e.g. Rapidly enlarging goiter.

Hard, fixed thyroid mass.

compressive symptoms, Cervical lymphadenopathy,

Personal or family history of thyroid cancer, History of head and neck radiation).

Myxedema coma → rare but life-threatening emergency with profound hypothyroidism, altered mental status, hypothermia, hypotension, or respiratory depression

Routine

Urgent (< 5 days)

Immediate (ER referral)

Newly diagnosed hyperthyroidism in stable patients → for confirmation of etiology (e.g., Graves’, toxic nodules) and definitive management planning (antithyroid meds, radioiodine, surgery).

Persistent or relapsing hyperthyroidism despite adequate therapy → needs specialist input for second-line treatments.

Patients planning pregnancy with hyperthyroidism → requires early endocrine referral to minimize maternal-fetal risks.

Suspected drug-induced hyperthyroidism (e.g., amiodarone) needing specialist guidance.

pregnant with hyperthyroidism → requires early endocrine referral to minimize maternal-fetal risks.

Hyperthyroid patients with new or worsening moderate symptoms, such as:

• Marked weight loss, persistent vomiting, or diarrhea.
• Unexplained tachycardia (>120 bpm at rest).
• Significant tremors impacting daily activities.

Suspicious features suggestive of malignancy or aggressive disease:

• Rapidly enlarging thyroid mass.
• Compressive symptoms: (dysphagia, dyspnea, hoarseness).
• Cervical lymphadenopathy.

Subclinical hyperthyroidism in older adults (TSH <0.1) with arrhythmias (e.g., new atrial fibrillation) or heart failure symptoms.

Thyroid storm → life-threatening hyperthyroidism with:

• High fever.
• tachyarrhythmia.
• Delirium, seizures, or coma.
• Hypertension or heart failure signs.
  

Routine

Urgent (< 5 days)

Immediate (ER referral)

Uncontrolled asthma despite step 4–5 therapy (high-dose ICS ± LABA, LAMA, or add-ons) → consider biologics or further evaluation.

Frequent exacerbations (≥2 oral steroid bursts/year or ≥1 hospitalization) despite adherence.

Uncertain diagnosis or atypical symptoms → e.g., persistent cough without wheeze,

Need for allergy testing or immunotherapy 

Rapidly worsening asthma control with increasing reliever use or falling peak flows despite treatment.

Severe side effects from controller medications (e.g., adrenal suppression with ICS).

New-onset asthma in adults with risk factors suggesting alternative diagnoses (e.g., lung cancer, heart failure).

Severe asthma attack unresponsive to initial bronchodilators → signs include inability to speak in full sentences, RR >30, HR >120, silent chest, cyanosis.

Routine

Urgent (< 5 days)

Immediate (ER referral)

Frequent exacerbations (≥2/year) despite optimized inhaled therapy.

Rapid decline in FEV1 (>100 mL/year)

Early-onset COPD (<40 years) → consider alpha-1 antitrypsin deficiency.

Needs evaluation for lung procedures or transplant 

Persistent or unexplained symptoms suggesting alternative diagnosis (e.g., bronchiectasis, ILD).

New or worsening hypoxemia → persistent SpO₂ <88% at rest or signs of cor pulmonale.

Marked weight loss, muscle wasting, or features of cachexia.

Development of new arrhythmias or right heart failure signs.

Acute severe exacerbation with:

• Severe dyspnea at rest, unable to speak.
• RR >30, signs of exhaustion.
• Confusion or drowsiness.
• Worsening hypercapnia or acidemia on ABG.

Routine

Urgent (< 5 days)

Immediate (ER referral)

Persistent unexplained elevation of ALT or AST >2× upper limit of normal (ULN) for >3–6 months, after ruling out common causes (alcohol, meds, fatty liver, viral hepatitis).

Suspected chronic liver disease (e.g., positive viral hepatitis markers, abnormal imaging).

Evidence of autoimmune or genetic liver disease (e.g., elevated autoimmune markers, iron studies suggestive of hemochromatosis).

New or worsening signs of chronic liver disease → e.g., spider angiomata, palmar erythema.

Elevated alkaline phosphatase or GGT with unclear source (after excluding bone disease).

Rapidly rising liver enzymes over days to weeks (e.g., ALT/AST increasing several-fold without clear explanation).

Elevated bilirubin or INR prolongation suggesting progressive liver dysfunction.

New-onset jaundice without obvious benign cause (e.g., Gilbert’s syndrome excluded).

Systemic signs suggestive of liver involvement (e.g., fever, rash, joint pain → autoimmune hepatitis or viral hepatitis).

Acute liver failure → elevated liver enzymes with:

• Coagulopathy (INR ≥1.5).
• Encephalopathy (confusion, altered mental status).
• Severe hypoglycemia, lactic acidosis.
• Suspected drug-induced liver injury (e.g., acetaminophen overdose) with signs of hepatic failure.

Routine

Urgent (< 5 days)

Immediate (ER referral)

eGFR <60 mL/min/1.73 m² → needs nephrologist co-management.

Progressive decline in eGFR → drop of ≥5 mL/min/year or >10 mL/min over 5 years.

Persistent significant proteinuria → urine ACR >300 mg/g (or >30 mg/mmol) or proteinuria confirmed on 24-hour urine.

Hematuria with proteinuria → suggestive of glomerular disease.

Resistant hypertension → BP uncontrolled despite ≥3 antihypertensives.

Suspected hereditary kidney disease → e.g., polycystic kidney disease (family history, enlarged cystic kidneys on imaging).

New or worsening electrolyte abnormalities not responding to outpatient management (e.g., persistent hyperkalemia >6.0 mmol/L).

Rapidly rising creatinine without clear cause (e.g., doubling in days–weeks → acute on chronic kidney injury).

Signs of uremia developing gradually (e.g., nausea, pruritus, fatigue) but not yet requiring immediate hospitalization.

Acute kidney injury with complications, such as:

• Severe hyperkalemia with ECG changes.
• Pulmonary edema unresponsive to diuretics.
• Uremic encephalopathy (confusion, seizures).
• Severe metabolic acidosis (pH <7.2).
• Rapidly progressive glomerulonephritis signs → hematuria, nephritic syndrome, systemic symptoms (e.g., vasculitis features) → needs urgent hospitalization.

Routine

Urgent (< 5 days)

Immediate (ER referral)

Sustained elevated hemoglobin or hematocrit (Hgb >16.5 g/dL in men, >16 g/dL in women; or Hct >49% men, >48% women) on multiple measurements → needs evaluation for polycythemia vera or secondary causes.

Symptoms suggestive of hyperviscosity, e.g., headaches, dizziness, visual disturbances, pruritus → especially after bathing (aquagenic pruritus).

Suspected secondary causes, e.g., chronic hypoxia (COPD, OSA), renal tumors producing excess erythropoietin

Rapidly increasing hematocrit over weeks → concern for aggressive polycythemia vera or secondary erythrocytosis.

Polycythemia with new or worsening thrombotic events, such as DVT, PE, or strokes → early hematology involvement.

Splenomegaly with elevated red cell mass → suggests myeloproliferative neoplasm.

Hyperviscosity syndrome → acute neurological symptoms (confusion, ataxia, seizures), chest pain, or retinal hemorrhages with very high hematocrit.

Severe, sudden thrombotic events in polycythemic patient → stroke, massive PE → needs emergent management.

Routine

Urgent (< 5 days)

Immediate (ER referral)

Unexplained persistent cytopenias → e.g., anemia, neutropenia, or thrombocytopenia lasting >4 weeks without reversible cause.

Bicytopenia or pancytopenia → ≥2 cell lines reduced → suggests bone marrow failure or infiltration.

Mild asymptomatic isolated cytopenia that doesn’t resolve with correction of reversible causes (e.g., nutritional deficiencies, medications).

Moderate thrombocytopenia (20,000–50,000) with symptoms (e.g. easy bruising, mucosal bleeding.

Moderate cytopenias with worsening trends → falling counts over days to weeks.

Cytopenias with systemic signs → fever, weight loss, lymphadenopathy, hepatosplenomegaly → concern for malignancy or marrow pathology.

Suspected secondary causes, such as HIV, hepatitis, or autoimmune diseases, needing specialist workup.

Severe cytopenias with life-threatening complications, including:

• Profound neutropenia (ANC <500) with fever → risk of sepsis.
• Platelets <20,000 with bleeding → risk of intracranial or major hemorrhage.
• Severe anemia causing hemodynamic instability.

Signs of thrombotic microangiopathies (TTP/HUS), such as:

• Neurological symptoms (confusion, seizures).
• Renal dysfunction.
• Fever.

Routine

Urgent (< 5 days)

Immediate (ER referral)

Persistent dyspepsia despite 6–8 weeks of appropriate therapy, including:

• Empirical PPI trial (e.g., omeprazole 20–40 mg daily).
• H. pylori test-and-treat strategy (if not done or failed).
  

Recurrent symptoms after initial response, requiring endoscopy.

History of peptic ulcer disease with new or worsening symptoms.

Patients with functional dyspepsia impacting quality of life despite optimal treatment.

Any patient ≥60 years with new-onset dyspepsia, especially if uninvestigated.

Alarm features, regardless of age:

• Unintended weight loss.
• Dysphagia or odynophagia.
• Ongoing vomiting.
• GI bleeding (melena or hematemesis).
• Iron-deficiency anemia.
• Palpable mass or lymphadenopathy.
• Family history of upper GI malignancy.

Persistent vomiting not responsive to empirical treatment.

Overt upper GI bleeding (e.g., hematemesis, melena with signs of hypovolemia).

Severe vomiting with dehydration or electrolyte imbalance.

Suspected gastric perforation or acute abdomen (rigid abdomen, rebound tenderness).

Hemodynamic instability with suspected GI source.

Routine

Urgent (< 5 days)

Immediate (ER referral)

Persistent or severe IBS symptoms that interfere with daily life despite optimized first-line management:

• Diet modification (low-FODMAP trial).
• Antispasmodics (e.g., mebeverine, hyoscine).
• Fiber adjustment (soluble fiber preferred).

Diagnostic uncertainty despite clinical workup — to exclude IBD, celiac disease, or other pathology.

Consideration for second-line treatments (e.g., rifaximin, tricyclics, or newer agents like eluxadoline or linaclotide) not available or initiated in PHC.

Significant impact on mental health or quality of life, needing multidisciplinary care.

Red flag symptoms (any of the following, even with IBS features):

• Unexplained weight loss.
• Rectal bleeding (not from hemorrhoids).
• Iron-deficiency anemia.
• Family history of colorectal cancer, IBD, or celiac disease.
• Onset after age ≥50 years (NICE uses ≥50, AAFP uses ≥60 for caution).

Worsening or new change in symptoms after a period of stability.

Severe abdominal pain with signs of peritonitis (guarding, rebound).

Suspected obstruction (no flatus/stool, distension, vomiting).

Hemodynamic instability or massive GI bleeding not explained by IBS.