شعار تجمع حفر الباطن الصحي
بوابة أطباء الرعاية الصحية الأولية
تجمع حفر الباطن الصحي — Hafr AlBatin Health Cluster

تجمع حفر الباطن الصحي

Internal Medicine

اشتراطات الإحالة لعيادة الباطنية الاستشارية وعيادات الفرز.

Hypertension — ارتفاع ضغط الدم

Routine — روتيني
  • Resistant hypertension: BP ≥140/90 mmHg despite adherence to 3 antihypertensive drugs (one ideally a diuretic).
  • Secondary hypertension suspicion — unexplained or early-onset HTN (<30 yrs), renal bruit, hypokalemia, cushingoid features, pheochromocytoma signs.
  • HTN with CKD progression — declining eGFR or rising creatinine.
  • Patients planning pregnancy requiring medication switching.
Urgent (<5 days) — عاجل (< 5 أيام)
  • Patient already pregnant requiring specialist management & medication switching.
  • Rapidly worsening BP control despite adherence and previously stable readings.
  • Newly discovered HTN with evidence of early target organ damage (proteinuria, LVH on ECG).
Immediate (ER referral) — فوري (طوارئ)
  • Hypertensive emergency — BP ≥180/120 with acute target organ damage (stroke symptoms, acute chest pain, AKI, sudden vision loss).
  • Severe HTN in pregnancy — BP ≥160/110 → risk of pre-eclampsia/eclampsia.

Dyslipidemia (High LDL or Triglycerides)

Routine — روتيني
  • Uncontrolled LDL despite maximum tolerated statin.
  • Familial hypercholesterolemia (very high LDL, xanthomas, family history of premature ASCVD).
  • Statin intolerance preventing target doses.
  • Mixed dyslipidemia requiring combination therapy.
  • Persistent hypertriglyceridemia (TG 200–999 mg/dL) despite optimization.
  • Secondary dyslipidemia not improving after addressing the cause.
  • High-risk patients needing escalation beyond PHC options (ezetimibe, combination).
Urgent (<5 days) — عاجل (< 5 أيام)
  • Severe hypertriglyceridemia (TG ≥1000 mg/dL) due to pancreatitis risk.
  • Rapidly progressive TG rise approaching this threshold.
  • Very high LDL (≥ 6.5 mmol/L / 250 mg/dL) in young adults suggestive of familial hypercholesterolemia.
Immediate (ER referral) — فوري (طوارئ)
  • —

Iron Deficiency Anemia

Routine — روتيني
  • Persistent IDA without obvious cause (esp. men or postmenopausal women) → endoscopic evaluation.
  • Failure to respond to 4–6 weeks of adherent oral iron therapy.
  • Suspected malabsorption.
Urgent (<5 days) — عاجل (< 5 أيام)
  • Severe anemia (Hb <7 g/dL) if hemodynamically stable.
  • Rapidly worsening anemia (Hb dropping ≥2 g/dL over weeks).
  • Symptomatic moderate anemia not improving for 4–6 weeks.
  • Anemia with concerning systemic signs (unintentional weight loss).
  • Multiple cytopenias or abnormal blood smear.
Immediate (ER referral) — فوري (طوارئ)
  • Severe anemia + severe symptoms or hemodynamic instability.
  • Active or massive GI bleeding (melena, hematemesis).
Note: Adequate oral dose is 100–200 mg elemental iron. Ferrous sulphate 190 mg contains only 60 mg elemental iron per tablet — 2 tablets daily, or alternate days if side effects. Continue therapy for 3 months after Hb normalizes. IV iron is indicated when oral therapy is not tolerated, ineffective, or rapid correction is needed.

Headaches

Routine — روتيني
  • Chronic or recurrent headaches unresponsive to first-line therapy.
  • Suspected medication overuse headache.
  • Headaches with stable neurological signs requiring workup.
  • New-onset trigeminal neuralgia or facial pain syndromes.
  • Cluster headaches needing specific therapy.
Urgent (<5 days) — عاجل (< 5 أيام)
  • Progressively worsening headache over weeks, especially waking from sleep.
  • New-onset headache with stable neurological deficits.
Immediate (ER referral) — فوري (طوارئ)
  • Persistent acute migraine with failed PHC management.
  • Temporal arteritis suspicion (≥50, scalp tenderness, jaw claudication, visual symptoms).
  • Thunderclap headache → SAH concern.
  • Headache with meningeal signs (neck stiffness, photophobia, fever).
  • Headache with seizure or LOC.
  • Acute headache in cancer / immunosuppressed patient.
  • Signs of raised ICP (vomiting, confusion, papilledema).

Hypothyroidism

Routine — روتيني
  • Persistent elevated TSH despite adequate levothyroxine and adherence.
  • Suspected secondary (central) hypothyroidism (low/normal TSH with low free T4).
  • Goiter or thyroid nodules → imaging ± specialist evaluation.
Urgent (<5 days) — عاجل (< 5 أيام)
  • Pregnancy with hypothyroidism.
  • New or worsening hypothyroid symptoms despite treatment.
  • Suspicious features: rapidly enlarging goiter, hard/fixed mass, compressive symptoms, cervical lymphadenopathy, history of thyroid cancer or H&N radiation.
Immediate (ER referral) — فوري (طوارئ)
  • Myxedema coma (altered mental status, hypothermia, hypotension, respiratory depression).

Hyperthyroidism

Routine — روتيني
  • Newly diagnosed hyperthyroidism in stable patients (Graves’, toxic nodules) for definitive planning.
  • Persistent or relapsing disease despite adequate therapy.
  • Patients planning pregnancy with hyperthyroidism.
  • Suspected drug-induced hyperthyroidism (amiodarone).
Urgent (<5 days) — عاجل (< 5 أيام)
  • Pregnant with hyperthyroidism.
  • New or worsening moderate symptoms (marked weight loss, persistent vomiting/diarrhea, resting HR >120, severe tremors).
  • Suspicious features: rapidly enlarging mass, compressive symptoms, cervical lymphadenopathy.
  • Subclinical hyperthyroidism in older adults (TSH <0.1) with new AF or HF.
Immediate (ER referral) — فوري (طوارئ)
  • Thyroid storm (high fever, tachyarrhythmia, delirium/seizures/coma, HTN or HF).

Bronchial Asthma

Routine — روتيني
  • Uncontrolled asthma despite step 4–5 therapy → consider biologics.
  • Frequent exacerbations (≥2 OCS bursts/year or ≥1 hospitalization) despite adherence.
  • Uncertain diagnosis or atypical symptoms.
  • Need for allergy testing or immunotherapy.
Urgent (<5 days) — عاجل (< 5 أيام)
  • Rapidly worsening asthma control despite treatment.
  • Severe side effects from controllers (e.g., adrenal suppression).
  • New-onset asthma in adults with red flags suggesting alternative diagnoses.
Immediate (ER referral) — فوري (طوارئ)
  • Severe attack unresponsive to initial bronchodilators (unable to speak full sentences, RR >30, HR >120, silent chest, cyanosis).

COPD

Routine — روتيني
  • Frequent exacerbations (≥2/year) despite optimized therapy.
  • Rapid decline in FEV1 (>100 mL/year).
  • Early-onset COPD (<40 years) → alpha-1 antitrypsin deficiency workup.
  • Persistent symptoms suggesting alternative diagnosis (bronchiectasis, ILD).
Urgent (<5 days) — عاجل (< 5 أيام)
  • New or worsening hypoxemia (SpO₂ <88% at rest) or signs of cor pulmonale.
  • Marked weight loss / cachexia features.
  • New arrhythmias or right heart failure signs.
Immediate (ER referral) — فوري (طوارئ)
  • Acute severe exacerbation: severe dyspnea at rest, RR >30, confusion or drowsiness, hypercapnia/acidemia.

Elevated Liver Enzymes

Routine — روتيني
  • Persistent ALT/AST >2× ULN for >3–6 months after ruling out common causes.
  • Suspected chronic liver disease.
  • Evidence of autoimmune or genetic liver disease.
  • New or worsening signs of chronic liver disease (spider angiomata, palmar erythema).
  • Elevated ALP or GGT with unclear source.
Urgent (<5 days) — عاجل (< 5 أيام)
  • Rapidly rising enzymes over days–weeks without clear cause.
  • Elevated bilirubin or INR prolongation suggesting progressive dysfunction.
  • New-onset jaundice without benign cause.
Immediate (ER referral) — فوري (طوارئ)
  • Systemic signs of acute liver involvement (fever, rash, joint pain).
  • Acute liver failure: coagulopathy (INR ≥1.5), encephalopathy, severe hypoglycemia, suspected hepatic failure from drug-induced injury.

Chronic Kidney Disease (including DM nephropathy)

Routine — روتيني
  • eGFR <60 mL/min/1.73 m² → nephrology co-management.
  • Progressive decline in eGFR (≥5 mL/min/year or >10 mL/min/5 years).
  • Persistent significant proteinuria (urine ACR >300 mg/g).
  • Hematuria with proteinuria.
  • Resistant hypertension on ≥3 antihypertensives.
  • Suspected hereditary kidney disease (PKD).
Urgent (<5 days) — عاجل (< 5 أيام)
  • New/worsening electrolyte abnormalities not responsive (e.g., persistent K⁺ >6).
  • Rapidly rising creatinine.
  • Signs of uremia developing gradually.
Immediate (ER referral) — فوري (طوارئ)
  • AKI with complications (severe K⁺ + ECG changes, pulmonary edema, uremic encephalopathy, severe acidosis).
  • Rapidly progressive glomerulonephritis signs.

Polycythemia

Routine — روتيني
  • Sustained elevated Hb/Hct on multiple measurements.
  • Symptoms suggestive of hyperviscosity (headache, dizziness, visual disturbance, pruritus).
  • Suspected secondary causes (COPD, OSA, renal tumors).
Urgent (<5 days) — عاجل (< 5 أيام)
  • Rapidly increasing hematocrit over weeks.
  • Polycythemia with new thrombotic events.
  • Splenomegaly with elevated red cell mass.
Immediate (ER referral) — فوري (طوارئ)
  • Hyperviscosity syndrome (acute neurological symptoms, chest pain, retinal hemorrhages).
  • Severe sudden thrombotic events (stroke, massive PE).

Cytopenia (neutropenia, thrombocytopenia)

Routine — روتيني
  • Unexplained persistent cytopenias >4 weeks.
  • Bicytopenia or pancytopenia → marrow concern.
  • Mild isolated cytopenia not resolving after correcting reversible causes.
Urgent (<5 days) — عاجل (< 5 أيام)
  • Moderate thrombocytopenia (20–50K) with symptoms.
  • Worsening trends over days–weeks.
  • Cytopenias with systemic signs (fever, weight loss, lymphadenopathy).
  • Suspected secondary causes (HIV, hepatitis, autoimmune).
Immediate (ER referral) — فوري (طوارئ)
  • Profound neutropenia (ANC <500) with fever.
  • Platelets <20K with bleeding.
  • Severe anemia with instability.
  • Signs of TTP/HUS (neuro symptoms, renal dysfunction, fever).

Dyspepsia

Routine — روتيني
  • Persistent dyspepsia despite 6–8 weeks PPI ± H. pylori test-and-treat.
  • Recurrent symptoms after initial response → endoscopy.
  • PUD history with new symptoms.
  • Functional dyspepsia impacting QoL despite optimal treatment.
Urgent (<5 days) — عاجل (< 5 أيام)
  • Age ≥60 with new-onset dyspepsia (uninvestigated).
  • Alarm features: weight loss, dysphagia/odynophagia, ongoing vomiting, GI bleed, IDA, palpable mass, family history of upper GI malignancy.
  • Persistent vomiting unresponsive to empirical treatment.
Immediate (ER referral) — فوري (طوارئ)
  • Overt upper GI bleeding with hypovolemia.
  • Severe vomiting with dehydration / electrolyte imbalance.
  • Suspected perforation or acute abdomen.
  • Hemodynamic instability with suspected GI source.

Irritable Bowel Syndrome

Routine — روتيني
  • Persistent/severe IBS despite low-FODMAP, antispasmodics, fiber adjustment.
  • Diagnostic uncertainty — exclude IBD, celiac.
  • Consideration for 2nd-line agents (rifaximin, TCAs, eluxadoline, linaclotide).
  • Significant mental health impact needing multidisciplinary care.
Urgent (<5 days) — عاجل (< 5 أيام)
  • Red flags: weight loss, rectal bleeding, IDA, family history of CRC/IBD/celiac, onset ≥50.
  • Worsening or new change after stability.
Immediate (ER referral) — فوري (طوارئ)
  • Severe abdominal pain with peritonitis signs.
  • Suspected obstruction.
  • Hemodynamic instability / massive bleeding.

Examples of other conditions requiring referral:

  • Hematology: unexplained anemia not responding to iron/B12/folate; persistent cytopenias; sustained leukocytosis/thrombocytosis; iron overload / ferritin concern.
  • Rheumatology / Autoimmune: inflammatory arthritis >6 weeks; suspected RA, SLE, spondyloarthritis, PMR; recurrent gout/tophi; vasculitic rash/arthralgia.
  • Gastro / Hepatic: chronic diarrhea >4 weeks or malabsorption; recurrent dyspepsia with alarm features; suspected IBD.
  • Fibromyalgia and chronic widespread pain syndromes.