Referral Guidelines

General Guidance

Referral Management Guidelines to Orthopedic Surgery

·         MRI PENDING is NOT acceptable for referral. Please see #2 for need to have abnormality documented on imaging prior to Ortho referral.

·         Any patients with prior ortho evals/surgeries from other commands, please call Ortho duty phone at (760)696-8610 to determine appropriate plan of care before submitting Ortho consult.

·         If a patient has seen an Ortho provider at NHCP within 1 year and wants to reestablish care for the same issue, no new referral is needed and patient can schedule a follow up appointment with that provider by calling 760-725-1619. If it is for a new issue, then a referral to Ortho should be placed if these below guidelines are met.

All consults to Ortho should have following  (#1, 2, and 3) WRITTEN IN REFERRAL: (Please note all consults not meeting the below criteria will be bounced back to provider via TCON by Referral Management with instructions as to what additional steps need to be taken)

1)      Documentation of duration of symptoms

a.       If acute (<4 weeks of symptoms), should have name of on-call Ortho provider who recommended urgent or routine referral to Ortho in the consult

b.       If chronic (>4 weeks of symptoms), see #2 and #3

2)      Documentation of which imaging has been obtained

a.       All referrals to Ortho should have XR of the affected body part

b.       All acute patients should have some sort of advanced imaging (CT, MRI or EMG/NCV depending on diagnosis) documented in referral that is less than 1 year old.

c.       For chronic patients

i.      XR with arthritis/degenerative changes, no additional imaging required

ii.      XR without arthritis/degenerative changes, referral should document imaging obtained and significant findings (i.e. meniscus tear, ACL tear, labrum tear) justifying Ortho referral. If provider feels that despite normal MRI or other advanced imaging that referral is justified, they should contact the on call Ortho duty phone

3)      Documentation of what therapy, medications, or injections have been trialed to date

a.       All chronic issues should have a minimum of 6 weeks of non-operative treatment (Physical therapy, acupuncture, chiropractic, etc) PERFORMED (not ordered) prior to placement of referral to orthopedics documented in the referral

Indications for referral for fractures

REFERRAL INDICATED:

• Acute fractures/tendon rupture seen by ED or outlying clinics, “ASAP” consult only after you call duty phone (760)696-8610 first for a provider-to-provider review.

• Ankle Fractures, foot fractures: usually a posterior short leg splint is sufficient (below the knee). Do not mistake for Tibia/Fibula fractures.

• Wrist fractures: a sugar tong splint is never wrong for any fracture of the forearm or wrist, for distal fracture a volar wrist splint may also be sufficient.

• Hand or MCP fractures: volar splint to include the fingers, wrist with slight extension, MCP flexed to 50-70 degrees, fingers straight (hold a soda can). Ulnar gutter (Boxer’s fracture, ulnar styloid fx) or radial gutter (thumb, radial, styloid, scaphoid) are appropriate for certain fracture patterns.

• Elbow Fractures (radial head, olecranon): posterior splint is sufficient for nondisplaced radial head fractures, olecranon fractures, pediatric supracondylar fractures and radiographically occult fractures.  The elbow is prone to stiffness, so only splint for a few weeks at most.

• Humeral shaft and distal humerus fractures: Long arm posterior splint and referral

• Proximal humerus fractures, reduced shoulder dislocations: a sling is typically sufficient.

Referral NOT indicated

• Toe fractures(minimally displaced): no referral needed(Light duty, buddy tape, shoe chit, usually healed and ready to RTFD after 6-8 weeks. Follow up x-ray at 6-8 weeks.

• Finger Fractures (Only if displaced or significant nail bed injury). Call if questions : aluminum finger splint is typically sufficient; a volar splint may also be used.  Buddy taping is sufficient even with avulsions or fleck fractures.  Only refer if displaced.  Finger Tuft Fractures: If the nail plate is intact, typically a short period of splinting for comfort is all that is needed.  If there is an associated nail bed laceration: repair it.  If not comfortable with this, provide wound care, PO ABX and call duty phone before placing a consult. 

FRACTURE CLINIC PROTOCOL:  

Immobilize appropriately in a splint at the BAS or ER

Send all open fractures, severely angulated fractures, or musculoskeletal injuries with neurovascular compromise to the ER immediately. 

* Please include a good patient contact number in the consult.

* Instruct the patient to set up their voicemail appropriately with their full name, for appointment messages.  The Ortho clinic staff will contact the patient with an appointment.

*All fractures and tendon ruptures/lacerations need to be reviewed provider-to-provider (Ortho duty phone (760)696-8610) before an ASAP consult to the Ortho fracture clinic can be submitted

DO NOT SEND:

* Old fracture non unions/malunion that are healed and asymptomatic

* Chronic pain with incidental radiographic abnormality or acute pain with no radiographic concerns for fracture or dislocation

* Toe fractures (minimally displaced)

* Knee soft tissue injuries: most isolated ACL or meniscus tears should be initially treated with RICE, physical therapy, Sports Medicine referral, and crutches (if needed)

*Finger sprains or reported digit dislocations (ensure there is a congruent reduction on x-ray. 

X-Ray Guidelines and Types of X-rays:

 For ALL acute musculoskeletal injuries and most chronic disorders, x-rays are a mandatory component of the work-up.  When in doubt, please order AND evaluate radiographs prior to referral.

Key aspects of interpreting bone plain films, particularly for acute trauma:

1. Patient demographics

   1. Age: important because pediatric and adult bones (particularly joints) are different

   2. Sex: may be important depending upon circumstances and findings

i. Osteoporosis and fragility fractures

ii.      Skeletal maturity: In general a 14 year old female is different than a male (typically females mature at age 14, males age 16).

2. View (position of the body part with respect to the beam)

   1. A minimum of two orthogonal views are required in all cases to adequately evaluate for deformity (Orthogonal meaning they are at a 90° angle to each other. One view is NO views)

   2.  As a rule, always image the joint above and below a fracture (e.g. Distal radius fracture needs Elbow and Forearm films, not just Wrist).

   3. Descriptors: AP, PA, lateral, oblique and a myriad of “Special Views”

i.      AP/PA: frontal or coronal views, AP means the x-ray beam hits anterior aspect first.

ii.      Lateral: side or sagittal view.

2. 4. In general: long bones need 2 views; joints, hands and feet need 3 views.

·         Foot: AP/Lat/oblique

·         Ankle: AP/Lat/mortise

·         Tib/fib (leg): AP/Lat

·         Knee: AP/Lat/sunrise

·         Femur: AP/Lat

·         Hip: AP/frog lateral or AP/cross table lateral (for fracture)

·         Hand and digits: AP/Lat/oblique

·         Wrist: AP/Lat/oblique

·         Forearm: AP/Lat

·         Elbow: AP/Lat

·         Humerus: AP/Lat

·         Shoulder and Proximal humerus: AP/axillary/Scapular-Y

1. 2. You can also comment on the quality of the view, and if it is sub-optimal.  If the image is sub-optimal, repeat the x-ray.

 Body Part

3. 1. Indicate Left versus Right

   2. Identify the body part (or bone if applicable). Use the correct anatomic terminology. Examples:

i.      When describing an x-ray of the femur, specify “femur”, not “leg”, because “leg” indicates the part of the lower extremity between the knee and ankle (that is, the tibia and fibula)

ii.      X-ray which centers on the distal radius and radial-carpal joint, but the fingers are cut off, is described as a “wrist,” not a “hand” film.

iii.      Ankle films are not the same as Foot films

 Findings

4. 1. Use the same system every time and you won’t miss things.

i.      One example: work from outside inward from soft tissue to bones to joints.

4. 2. Specific findings:

i.      Soft tissue: foreign bodies, gas, fat stranding, masses

ii.      Bone: fractures, masses

iii.      Joints: dislocation, effusion, foreign body, arthritic changes (decreased joint space, sclerosis, osteophytes, cysts)

5. Dislocations

   1. Definition: opposing surfaces/bones of the joint are completely incongruent (no contact).

   2. Subluxation: some portion of the joint is still in contact.

   3. Direction: This refers to the location of the distal joint surface with respect to the proximal joint surface (e.g. if the shoulder joint is dislocated, and the humeral head is anterior to the glenoid, then this is an “anterior shoulder dislocation”)

6. Displacement (medical terminology):

   1. Diastasis: fracture widening typically within a joint (describe in mm)

   2. Shortening : compression/collapse of fracture onto or next to itself

   3. Translation: amount that fracture ends are separated from each other (quantify in mm or % diameter and direction)

   4. Bayonet apposition: shortened and 100% translation

   5. Angulation: for a straight bone, indicates the amount of deformity

i.       Quantify in degrees and direction

ii.      Location and direction of the distal fracture segment related to the proximal segment (e.g. distal radius fracture with 45 degrees dorsal angulation of distal fragment)

6. 6. Rotation (often difficult to ascertain by x-ray)

7. Special Descriptions

   1. Fracture-dislocation

   2. Comminution: more than two fracture fragments

   3. Avulsion: special fractures that result from capsule or tendon or ligament pulling off a fragment/fleck of bone (indicates mechanism).

   4. Compression:  typically describes axial vertebral body fractures.

** For a splinting class, please contact 760-725-1619 and ask for HM2 Chavez or the Cast Room to schedule a training opportunity.  Splinting is also covered 1-2 times yearly during the GMO/IDC Symposiums.

Other Musculoskeletal Injuries (Excluding Fractures or Tendon Lacerations/Ruptures)

·         Ensure results of advanced imaging or diagnostic studies are reviewed by the referring provider prior to placing a consultation with Ortho to verify that a valid indication for a surgical referral exists.

·         If at any time point in workup of patient (despite these guidelines listed below) a provider has questions about what management/disposition for that patient should entail, please call Ortho duty phone at (760)696-8610 for guidance rather than just submitting a consult to Ortho.

Hand and Upper Extremity Referrals

YES: if pt meets these criteria. If not does not meet these, see below. 

• Lateral Epicondylitis(Tennis Elbow)/Medial Epicondylitis(Golfer’s Elbow): IF: Ulnar neuropathy or elbow instability at any time, Symptoms have continued for greater than 6 months despite conservative measures and pain is aggravating and disabling and patient is interested in surgical intervention. 

• DeQuervain’s Tenosynovitis: Symptoms have persisted for greater than 6 weeks, despite conservative measures; The pain is aggravating and disabling to warrant more aggressive intervention. *Obtain wrist x-ray prior to referral* 

• Carpal Tunnel Syndrome: Patient desires surgical intervention, Symptoms have persisted despite conservative treatments, *Refer to Neurology or PT for a Nerve Conduction Study prior to the Orthopedic referral*, Elbow x-rays are not needed 

• Cubital Tunnel Syndrome: Symptoms lasting greater than 3 months, Unsuccessful conservative treatment, *Refer to Neurology or PT for a Nerve Conduction Study prior to Orthopedic referral*, Elbow x-rays are not needed

• Dorsal Wrist Pain: Pt has a suspected ganglion cyst, Symptoms have occurred longer than 6 weeks despite conservative treatments, The pain is aggravating and disabling to warrant surgical intervention, The patient desires surgical intervention 

• Mallet Finger: ONLY if a very large bone fragment, with associated subluxation or malalignment of the DIP joint, is noted on x-ray. 

NO:

• Lateral Epicondylitis(Tennis Elbow)/Medial Epicondylitis(Golfer’s Elbow): Exam: Pain is focal overall the epicondyle or just distal within the muscle Origin; Pain with resisted wrist extension or flexion; Pain is common with grip. Grip strength is often decreased in full elbow extension; Conservative Measures: Stretching; Off-loader strap; Cortisone or PRP injection(Sports Medicine); Activity modification; May refer to occupational therapy, if needed.

• DeQuervain’s Tenosynovitis: Exam: Pain is focal over the 1st dorsal compartment(APB and EPB) at the radial styloid. Pain with passive ulnar deviation of the wrist. Local swelling is occasionally seen over the radial styloid. Conservative Measures: Stretching; Rest(responds well); Cortisone injection(Sports Medicine); Activity modification; Occupational therapy  *DO NOT SPLINT*

• Carpal Tunnel Syndrome: Exam: Symptoms: Paresthesias or numbness in the thumb, index, and /or middle finger, Cramping pain the palm or thenar eminence, Pain that radiates up the forearm, Weakness with grip, Dropping items such as coffee cup or pencil, pain or numbness that wakes from sleep or is most severe in the mornings, Exam Findings: Decreased sensation in a median nerve distribution, Positive Tinel’s sign over the carpal tunnel, Reproduction of symptoms with the carpal tunnel compression test, Atrophy or flattening of the thenar muscles, Conservative Measures: Stretching; Rest; Night splinting; Activity Modification; Occupational Therapy; Use conservative measures if symptoms occur during pregnancy as they resolve spontaneously after delivery usually.

• Cubital Tunnel Syndrome: Exam: Symptoms: Paresthesias or numbness in the small finger, ring finger, and/or ulnar border of the forearm, Weakness with grip or pinch, Pain or numbness that wakes from sleep, Symptoms that worsen with elbow flexion or with activities such as driving, Exam Findings: Decreased sensation in an ulnar nerve distribution, Positive Tinel’s sign over the cubital tunnel at the elbow, Reproduction of symptoms with elbow held in flexion, Atrophy or flattening of the intrinsic hand muscles, Weakness with pinch or compensatory flexion of the thumb IP joint, Weakness with finger abduction(spreading of fingers), Palpable subluxation of the ulnar nerve at the elbow, Conservative Measures: Rest; Night Splinting; Activity modification to minimize pressure on the medial elbows; Occupational Therapy 

• Dorsal Wrist Pain: Exam: Pain is focal over the dorsal wrist, usually midline or slightly radial, Pain is aggravated with loaded extension activities, such as push-ups, Local swelling is occasionally seen over the dorsal wrist, A dorsal ganglion cyst may be present, Conservative Measures: Rest; Wrist joint cortisone injection; Activity modification; Occupational therapy; a period of cast immobilization; Obtain wrist x-rays (to rule out scaphoid fracture; scapholunate ligament injury, or avascular necrosis of the carpal bone).  *In the absence of carpal injury, treatment is conservative* Ganglion cysts can be aspirated and/or injected with cortisone.  Rest or immobilization x 4-6 weeks.

• Mallet Finger: Exam: A mallet finger is an avulsion of the EXTENSOR tendon off the DORSAL aspect of a finger distal phalanx. The distal phalanx will present with a droop and inability to fully extend. Flexion should be intact. Obtain x-rays (a bony fragment is often present). Treatment: Patient is placed in DIP extension splint or Stack splint. . Instruct patient to wear this splint around the clock x 6 weeks (two stack splints can be given to the patient so one can be washed periodically). After 6 weeks, the patient transitions to a night time splint for an additional 4-6 weeks

SHOULDER GUIDELINES 

YES: if pt meets these criteria. If not does not meet these, see below. 

• Subacromial Impingement / Rotator Cuff:  Weakness with specific rotator cuff tests, particularly if it does not resolve after a subacromial injection (may be a sign of rotator cuff tear), Acute shoulder injury with exam concerning for acute rotator cuff tear, Failure of 2-3 months of rehabilitation 

• Shoulder Dislocation / Instability: Irreducible shoulder dislocation or a dislocation associated with a fracture (i.e. greater tuberosity) *Page the on call Ortho Provider 760-696-8610 (Communications) for directions and type of referral.*, Recurrent traumatic dislocation despite rehabilitation (Sports Medicine), place a routine referral, AMBRI patient who fails > 6 months of focused rehabilitation (Sports Medicine) 

• AC Separation / Arthritis: Grade IV-VI: Sling; Place ASAP consult to Ortho, Grade I-III injuries: persistent symptoms > 6 months of adherence to conservative treatment plan, AC Arthritis: Patient has failed 6-8 weeks of conservative treatment 

No:

• Subacromial Impingement/Rotator Cuff Injuries: Exam: History is typically one of gradual onset of anterior and lateral shoulder pain exacerbated by overhead activities and often associated with night pain Pain occurs over the greater tuberosity and inferior to the acromion as well  as pain with provocative maneuvers (impingement signs) *Obtain x-rays of the shoulder (evaluate the morphology of the acromion and bone spurs that can contribute to impingement as well as identify calcific tendonitis) Conservative Treatment: NSAIDs and activity modification for acute exacerbation of pain; Home therapy program focusing on posterior capsule stretching and rotator cuff strengthening exercises. *Sports Medicine referral for formal therapy and/or subacromial corticosteroid injection can be diagnostic and therapeutic.*

• Shoulder Dislocation / Instability: Exam: History is important to differentiate between acute traumatic dislocation(TUBS) from atraumatic multidirectional instability(AMBRI), TUBS: typically an anterior dislocation associated with significant trauma such as a fall in abducted, externally rotated position that requires manual reduction. Subsequent dislocations may be associated with less significant trauma, AMBRI: vague activity related to shoulder instability that typically self reduces.  Ask patient if they voluntarily dislocate and if they are “double jointed”, With acute dislocation, any shoulder movement will be painful and inability to externally rotate the shoulder is a sign of posterior dislocation. *With acute dislocation, conduct a good neurovascular exam including the axillary nerve pre and post reduction. X-rays (including an axillary view) are mandatory after shoulder reduction from acute dislocation*, With a history of instability, the exam should focus on provocative tests such as apprehension test and jerk test.  Evaluate for evidence of generalized ligamentous laxity. Treatments: Acute, REDUCE (if no trained personnel is available, transport the patient to the ER for reduction), and confirm reduction with radiographs.  Acute, first time dislocation can be treated with a short period of rest in a sling, RICE, and activity modification. Does not require Ortho Referral. Physical therapy program for rotator cuff strengthening. AMBRI: treat with a focused shoulder rehabilitation program and educating the patient on avoiding voluntarily dislocating.

• AC separation / arthritis: Exam: AC separation is typically caused by a fall directly onto the shoulder with pain localized to the AC joint.  Insidious onset of AC joint pain in a weight lifter is suggestive of AC arthritis or distal clavicle osteolysis. Obtain x-rays of AC or shoulder to determine the grade of injury which dictates treatment and should be compared to the contralateral shoulder. Conservative Treatments: Grade I-II: Sling for a few days; Ice; Analgesics Progress to activities as symptoms allow(full activity typically in 4 weeks), Grade III: Sling for up to 2 weeks; Ice; Analgesics. Sports Medicine for gentle motion and strengthening as symptoms allow. NO high impact or high risk activities for at least 6 weeks. AC Arthritis/distal clavicle osteolysis: activity modification; NSAIDs, AC Joint corticosteroid injection (Sports Medicine)

Knee Referral Guidelines

YES: if pt meets these criteria. If not does not meet these, see below. 

• Meniscus Tear: Younger patient with clear history of trauma and mechanical symptoms, Older patient with less clear story and exam without well-defined mechanical symptoms (i.e. popping only) that has failed 6-8 weeks of conservative measures (Sports Medicine) and symptoms continue, Locked knee: Page On-Call Ortho Provider 760-696-8610 for guidance on ASAP consult. Also see right below on guidance for “locked knee” 

• Locked Knee: Patient is non-weight bearing with knee brace and crutches, Order ASAP MRI and call Radiology Department to schedule, Refer to Ortho: Page On-Call Ortho Provider 760-696-8610 for guidance Exam: Patient typically has an acute injury, may be associated with a “pop”, when attempting to stand from a flexed knee position and is unable to straighten the leg. Knee is locked in >15-20 degrees of flexion and this must be different from pseudo-locking, where the knee pain and swelling limits terminal extension (more common), Diagnosis: Confirm by achieving good analgesia either with IV pain meds/muscle relaxants or by injecting the knee joint with a local anesthetic. If there is a mechanical block to extension, this is suspicious for a locked knee. 

• ACL TEAR: Young patient with a clear history of trauma; correlating exam; x-ray obtained; Has gone to PT to get normal ROM of knee and has normal quad strength again; MRI completed prior to referral, then refer to Ortho as routine consult. 

• Ligament Tear: IMMEDIATELY transfer any knee dislocations, multi-ligament knee injuries, or neurovascular injuries to the ER for evaluation and treatment. Page the On-Call Ortho provider 760-696-8610 for further guidance. Low grade sprains (Grade I/II) that are not improving after 8 weeks of treatment. Grade III sprains refer at time of diagnosis for further work-up, bracing, and possible surgical intervention *Place an ASAP consult for Ortho for Grade III Sprains after calling the duty phone for a provider to provider review* 

• Patellar Instability: Mechanical Symptoms or has loose body noted on x-ray, brace the knee with protected weight bearing. Page On-Call Ortho provider at 760-696-8610 for guidance.  Place consult according to the guidance from the On-Call provider. 

• Knee Arthritis: The definitive treatment for OA is knee replacement surgery and this surgery is not compatible with active duty members. If the patient has pre-existing OA and develops mechanical symptoms and fails 6-8 weeks of conservative treatment, refer for work-up. X-rays (bilateral weight bearing x-rays). No need for MRI if arthritis seen on XR.  Refer to Ortho if conservative measures have failed (i.e. NSAIDs, PT, CSIs) 

No:

• Meniscus Tear: Exam: Significant twisting injury to knee (may be minor trauma in older patient), Mechanical symptoms: locking; catching of the knee associated with medial or lateral knee pain particularly with twisting or squatting activities, Joint line tenderness and painful click with flexion-circumduction maneuver (McMurray Test), Conservative Measures: RICE; Analgesics; NSAIDs; Activity modification Cortisone injection (Sports medicine, if unavailable in the clinic)

• Locked Knee: N/A. REFER TO ORTHO. 

• ACL Tear: Exam: Significant twisting and/or hyperextension injury to knee (typically non-contact), Injury usually significant to discontinue participation in activity and often associated with an effusion, Perform Lachman test which involves drawing the tibia forward on the femur with the knee in 25 degree of flexion and is positive if there is no clear endpoint (this exam is easier to do a few weeks after injury than acutely), Obtain knee x-rays, Conservative Measures: RICE, Analgesics (Acetaminophen/Motrin); Crutches until the patient can ambulate without a limp; Sports Medicine or Physical therapy for knee ROM and strength training. Consider referral after completing conservative therapy (see above). 

• Collateral Ligament Injuries: Exam: MUST differentiate an isolated collateral ligament injury from a multi-ligament knee injury (knee dislocation). History is most important in making this differentiation including the mechanism of injury (low or high energy), the ability to ambulate or return to play after the injury and any distal nerve dysfunction (i.e. numbness or weakness). Isolated collateral ligament injury involves tenderness along the course of the ligament along with laxity when stressing the ligament (varus or valgus) in 25 degree of knee flexion.  Laxity in full extension is concerning for a more serious injury and is typically also associated with knee effusion. Grade the injury: I-III (subjective). I-Pain with no laxity. II-Pain and laxity with firm endpoint (incomplete tear). III-Pain and laxity with no endpoint (complete tear). Document neurovascular exam. Obtain x-rays to look for associated avulsion fractures, Conservative Measures:  MCL injuries can be treated non-operatively with RICE; NSAIDS; activity modification; May also refer to Sports Medicine for evaluation. Higher grade sprains (II/III) may require time on crutches and a hinged knee brace to provide side to side stability during the healing process.

• Patellar Instability: Exam: The patella typically dislocates laterally and may occur with minimal trauma with predisposing anatomy or with severe direct or indirect trauma with normal anatomy. Check apprehension sign and tenderness along the medial border of the patella. Obtain x-rays to include a Merchant view to obtain the best view the patellofemoral joint. Conservative Measures: Acutely, use a compressive wrap; ICE; Splint/bracing in extension with protected weight bearing to allow healing of medial structures;  Send to Sports Medicine or Physical Therapy for isometric quad exercises immediately and advance motion and strengthening as symptoms allow.  May want to brace or tape as the patient returns to sports.

• Knee Arthritis: Exam: Osteoarthritis (OA) is the most common form of knee arthritis and typically involves patients older than 55 years; obesity and family history are risk factors as well. Osteoarthritis can affect younger patients with a history of knee trauma (ACL/Meniscus tear). Ask about previous surgeries. Symptoms: pain with high impact activities that progresses to pain with ambulation and daily activities, as well as stiffness; On exam: angular deformity  of the knee (genu varum/bowlegged is most common), mild effusion; diffuse joint line tenderness, loss of motion; crepitus. Obtain weight bearing x-rays bilaterally for comparison and note the joint space narrowing. Conservative Measures: Treat the symptoms; Educate the patient; Ice and compression for acute flare ups; activity modification (swimming and biking instead of running). NSAIDS for discomfort.  Avoid narcotic medications. Knee injections (corticosteroids and visco-supplements). Send patient to Sports Medicine for evaluation and treatment initially if the comfort measures listed above are not working.

HIP GUIDELINES

YES: if pt meets these criteria. If not does not meet these, see below. 

• Femoral Acetabular Impingement: Clear diagnosis of FAI and patient desires surgery. Also must have failed 6 weeks of PT and had temporary relief of pain from CSI before referral to Ortho. 

• Hip Arthritis: Conservative measures have failed and patient desires to explore surgical options. If XR shows arthritis, no need to order MRI or MRA of hip. Refer to Ortho if conservative measures have failed (i.e. NSAIDs, PT, CSIs) 

No: 

• Femoral Acetabular Impingement: Exam: Hip pain and/or abnormal radiographs do not make the diagnosis of symptomatic FAI. History of hip pain with activities that require repetitive joint loading particularly flexion or prolonged sitting (i.e. driving a car). Pain is usually localized in the groin. Hip exam maneuvers with limited internal rotation and pain with flexion and internal rotation (impingement test) are important clues for diagnosis. Weight bearing bilateral hip with AP and lateral view x-rays should be ordered to evaluate for FAI features (i.e. pincer and/or cam deformities) as well as exclude joint space narrowing which is an indicator of arthritis. Conservative Measures:  Activity modification; NSAIDs for acute pain flares; PT/Sports Medicine for hip stiffness or muscle atrophy; intraarticular hip corticosteroid injection for mild symptoms may be beneficial( injections are done using fluoroscopy guidance in the radiology department or under ultrasound guidance in the SMART clinics)

• Hip Arthritis: Exam: Gradual onset of anterior thigh or groin pain that is progressive in a stepwise fashion and eventually is associated with decreased hip range of motion. Loss of internal rotation is an early manifestation as the disease progresses; global motion will be restricted and painful. Gait abnormalities are common. Obtain weight bearing hip x-rays: these will demonstrate joint space narrowing, osteophytes, subchondral cysts, and sclerosis. Conservative Measures: Activity modification; assistive device (cane) held in the contralateral hand; NSAIDs/acetaminophen for pain control; Do not administer narcotic medications for arthritis; Order an intraarticular hip corticosteroid injection which is done in the radiology department.

Foot / Podiatry Referral Guidelines:

YES: if pt meets these criteria. If not does not meet these, see below. 

• Ankle Sprain / Instability: 

  • Refer to Podiatry - Condition worsens or becomes chronic in nature, Patient desires custom rigid orthotics, NO osteochondral defects on MRI

  • Refer to Orthopaedic Surgery - Recurrent ankle instability, refractory to non-op measures, Associated Osteochondral lesions (talus, tibia) 

• Plantar Fasciitis: If condition worsens or chronic in nature, For consideration of steroid injections, custom rigid orthotics, or surgery

• Bunions: If condition worsens or chronic in nature, For consideration of custom rigid orthotics or surgery, Weight bearing foot x-ray required for podiatry referral

No:

• Ankle Sprain / Instability: Exam: Symptoms: Normally inversion style injury with pain and instability noted lateral ankle. Pain, weakness, and edema to lateral ankle.  Sometimes noted in medial ankle. Can be aggravated after high impact athletic activity. Conservative Measures: Immobilize with crutches, Cam Boot x 4 weeks for severe pain; ASO ankle brace for mild to moderate pain x 4 weeks and after Cam Boot immobilization, or for recurrent instability (for use prn), NSAIDS x 2-3 weeks, Activity Modification (avoid high impact activity, but continue with low impact activities. Consider PT for strength training. If x-rays are ordered, weight bearing x-rays are indicated (send to NHCL main radiology for x-rays if they cannot be done at the local BAS). Consider MRI for chronic ankle sprain/chronic pain prior to referral.

• Plantar Fasciitis - Exam: Symptoms:  Pain to plantar aspect of heel or arch. Most symptomatic with 1st steps in AM or after standing from long periods of rest. Can also be aggravated after high impact athletic activity. Exam Findings:  Pain to plantar aspect of heel or arch. Tight calf muscles. Usually no edema noted. Conservative Treatment: Calf stretching is the #1 treatment. Ensure toes are point straight/ perpendicular to wall with runners stretch.  10 seconds/ leg x 8-10 times / day x 2 weeks. Have patient purchase Superfeet inserts $29 or Sole inserts $25 from Uniform section of MEX. NSAIDS x 2-3 weeks. Activity Modification (avoid high impact activity, but continue w/ low impact activity). Immobilize with crutches, cam boot x 4 weeks for severe pain. Purchase traditional style running shoes (New Balance, Asics, Brooks, and Saucony).  Avoid flexible shoe brands like Nike, Rebook, UnderArmor, and five finger shoe gear/ minimalists. **If you perform x-rays, ensure they are weight bearing x-rays. (send to main radiology at hospital for WB x-rays if can’t be done at local BAS). **

• Bunions: Exam: Symptoms:  Pain to medial forefoot at big toe joint, Pain to big toe joint associated with high impact athletic activity or restrictive shoe gear. Exam Findings:  Prominent osseous bump to medial 1st metatarsal head and big toe drifting lateral. Sometimes soreness associated w/big toe range of motion. Conservative Treatment: Have patient purchase Superfeet inserts $29 or Sole inserts $25 from Uniform section of MEX. NSAIDS x 2-3 weeks for pain reduction, Wider shoes, Activity Modification (avoid high impact activity, but continue w/ low impact activity). Immobilize with crutches, cam boot x 4 weeks for severe pain. **If you perform x-rays, ensure they are weight bearing x-rays. (send to main radiology at hospital for WB x-rays if can’t be done at local BAS). **

Radiology Imaging Prioritization & Indication Ordering Guidelines

Imaging Prioritization:

The below suggested prioritization wait times and guidelines are the recommended maximum wait times for patients, based upon an appropriate balance between limited access and patient need.  STAT patients will be imaged as quickly as possible and wait times may vary depending on demand and availability of resources.  The ultimate responsibility for prioritization rests with the referring physician in consultation with the attending radiologist.  

·   STAT: 24 hours.  Most ER & ICU studies.  Conditions within the ER, ICU & MSW realm, which are more urgent than others should always be communicated directly to the imaging technician and the radiologist as needed.  All Outpatients studies that are thought to be STAT implies immediate/emergent patient care and require a provider-to-radiologist consultation.  All outpatient STAT orders should have a referring provider contact phone number on it.

·   ASAP: 72 hours - 1 week.  Conditions which do not require an immediate treatment, but do necessitate a prompt medical evaluation.  All outpatient ASAP requests require a provider-to-radiologist consultation. 

·   Administrative ASAP: 2 - 4 weeks.  Expedited administrative evaluation (i.e. immediate deployment).  All admin ASAP requests require a provider-to-radiologist consultation.

·   Routine:  Next available.  Most imaging studies.  An ordering provider may consult referral management for network imaging requests that have a wait time exceed 28 days. 

Imaging Indication:

Medical imaging should only be used for clinical analysis and medical intervention.  Plain films/x-rays are the best initial screening imaging exam for most conditions and should proceed all initial musculoskeletal/extremity and spine MRI requests. 

·   Recommended Reference Guide:

o   American College of Radiology (ACR) Appropriateness Criteria.

Ø  https://acsearch.acr.org/list

·   Acute Conditions (General):  X-ray & CT.

·   Chronic Conditions (General):  MRI.

·   Ultrasound:  Gallbladder, Gonadal/Reproductive, Vasculature & Superficial lesion evals.

·   Intravenous Contrast:  Vasculature, Inflammation/Infection & Neoplastic evaluations.

·   Arthrograms:  Only accepted from Ortho, Sports Medicine & Physical Therapy clinics.

Radiologist Consultation is available as needed: 760-719-3448

Radiologist Daily Schedule is available:

Ø  http://www.amion.com – Login: nhcprads

CP MRI, ABDOMEN ANGIOGRAPHY W/CONTRAST

70545

CP MRI, ABDOMEN ANGIOGRAPHY W/O CONTRAST

70545

CP MRI, ABDOMEN VENOGRAPHY W/CONTRAST

74181

CP MRI, ABDOMEN VENOGRAPHY W/O CONTRAST

70545

CP MRI, ABDOMEN W/CONTRAST

74181

CP MRI, ABDOMEN W/O CONTRAST

74181

CP MRI, ADRENALS W/CONTRAST

72196

CP MRI, BRACHIAL PLEXIS W/O CONTRAST

73221

CP MRI, BRACHIAL PLEXUS W/CONTRAST

73222

CP MRI, BRAIN AND ORBITS W/CONTRAST

70551

CP MRI, BRAIN AND ORBITS W/O CONTRAST

70551

CP MRI, BRAIN ANGIOGRAPHY W/0 CONTRAST

70551

CP MRI, BRAIN ANGIOGRAPHY W/CONTRAST

70545

CP MRI, BRAIN VENOGRAPHY W/CONTRAST

70545

CP MRI, BRAIN VENOGRAPHY W/O CONTRAST

70551

CP MRI, BRAIN W/CONTRAST

70552

CP MRI, BRAIN W/O CONTRAST

70551

CP MRI, BREAST (SILICONE RUPTURE)

77047

CP MRI, BREAST BILATERAL W/WO CONTRAST

77059

CP MRI, BREAST BIOPSY

19085

CP MRI, BREAST W/CONTRAST

77059

CP MRI, BREAST W/O CONTRAST

77058

CP MRI, CHEST ANGIOGRAPHY W/CONTRAST

70545

CP MRI, CHEST ANGIOGRAPHY W/O CONTRAST

71555

CP MRI, CHEST VENOGRAPHY W/ CONTRAST

70545

CP MRI, CHEST VENOGRAPHY W/O CONTRAST

70545

CP MRI, CHEST W/CONTRAST

71551

CP MRI, CHEST W/O CONTRAST

71550

CP MRI, C-SPINE W/CONTRAST

72141

CP MRI, C-SPINE W/O CONTRAST

72141

CP MRI, ENTEROGRAPHY

72195

CP MRI, EXTREMITY ANGIOGRAPHY W/CONTRAST

73222

CP MRI, EXTREMITY ANGIOGRAPHY W/O CONTRAST

73223

CP MRI, EXTREMITY VENOGRAPHY W/CONTRAST

73223

CP MRI, EXTREMITY VENOGRAPHY W/O CONTRAST

70545

CP MRI, EXTREMITY W/CONTRAST

70545

CP MRI, EXTREMITY W/O CONTRAST

70545

CP MRI, IAC'S W/ CONTRAST

70542

CP MRI, IAC'S W/O CONTRAST

70540

CP MRI, LEFT ANKLE ARTHROGRAM (ORTHO,SM & PT ONLY)

73722

CP MRI, LEFT ANKLE W/CONTRAST

73721

CP MRI, LEFT ANKLE W/O CONTRAST

73721

CP MRI, LEFT ELBOW W/CONTRAST

73225

CP MRI, LEFT ELBOW W/O CONTRAST

73221

CP MRI, LEFT FEMUR W/CONTRAST

73720

CP MRI, LEFT FEMUR W/O CONTRAST

73718

CP MRI, LEFT FINGER(S) W/CONTRAST

73222

CP MRI, LEFT FINGER(S) W/O CONTRAST

73221

CP MRI, LEFT FOOT W/CONTRAST

73721

CP MRI, LEFT FOOT W/O CONTRAST

73718

CP MRI, LEFT FOREARM W/CONTRAST

73225

CP MRI, LEFT FOREARM W/O CONTRAST

73218

CP MRI, LEFT HAND W/CONTRAST

73222

CP MRI, LEFT HAND W/O CONTRAST

73218

CP MRI, LEFT HIP ARTHROGRAM (ORTHO SM, & PT ONLY)

73722

CP MRI, LEFT HIP W/CONTRAST

73722

CP MRI, LEFT HIP W/O CONTRAST

73721

CP MRI, LEFT HUMERUS W/CONTRAST

73225

CP MRI, LEFT HUMERUS W/O CONTRAST

73218

CP MRI, LEFT KNEE ARTHROGRAM (ORTHO, SM & PT ONLY)

73722

CP MRI, LEFT KNEE W/CONTRAST

73222

CP MRI, LEFT KNEE W/O CONTRAST

73721

CP MRI, LEFT PECTORALIS MUSCLE TEAR W/O CONTRAST

73221

CP MRI, LEFT SHOULDER ARTHROGRAM (ORTHO, SM & PT ONLY)

73222

CP MRI, LEFT SHOULDER W/CONTRAST

73222

CP MRI, LEFT SHOULDER W/O CONTRAST

73221

CP MRI, LEFT TIB-FIB W/CONTRAST

73719

CP MRI, LEFT TIB-FIB W/O CONTRAST

73718

CP MRI, LEFT TOE(S) W/CONTRAST

73722

CP MRI, LEFT TOE(S) W/O CONTRAST

73721

CP MRI, LEFT WRIST ARTHROGRAM (ORTHO, SM & PT ONLY)

73222

CP MRI, LEFT WRIST W/CONTRAST

73222

CP MRI, LEFT WRIST W/O CONTRAST

73221

CP MRI, L-SPINE W/CONTRAST

72149

CP MRI, L-SPINE W/O CONTRAST

72148

CP MRI, MRCP

74181

CP MRI, NECK ANGIOGRAPHY W/CONTRAST

70546

CP MRI, NECK ANGIOGRAPHY W/O CONTRAST

70548

CP MRI, NECK SOFT TISSUE W/CONTRAST

70542

CP MRI, NECK SOFT TISSUE W/O CONTRAST

70540

CP MRI, NECK VENOGRAPHY W/CONTRAST

70545

CP MRI, NECK VENOGRAPHY W/O CONTRAST

70545

CP MRI, ORBIT W/CONTRAST

70543

CP MRI, ORBIT W/O CONTRAST

70540

CP MRI, ORBIT W/WO CONTRAST

70540

CP MRI, PANCREAS W/CONTRAST

74183

CP MRI, PANCREAS W/O CONTRAST

74181

CP MRI, PELVIS W/CONTRAST

72196

CP MRI, PELVIS W/O CONTRAST

72195

CP MRI, PROSTATE W/ CONTRAST

72196

CP MRI, PROSTATE W/O CONTRAST

72197

CP MRI, RENAL ANGIOGRAPHY W/CONTRAST

74182

CP MRI, RENAL ANGIOGRAPHY W/O CONTRAST

73718

CP MRI, RENAL W/ CONTRAST

72197

CP MRI, RENAL W/O CONTRAST

74181

CP MRI, RIGHT ANKLE ARTHROGRAM (ORTHO, SM & PT ONLY)

73722

CP MRI, RIGHT ANKLE W/CONTRAST

73721

CP MRI, RIGHT ANKLE W/O CONTRAST

73718

CP MRI, RIGHT ELBOW W/CONTRAST

73222

CP MRI, RIGHT ELBOW W/O CONTRAST

73221

CP MRI, RIGHT FEMUR W/CONTRAST

73719

CP MRI, RIGHT FEMUR W/O CONTRAST

73718

CP MRI, RIGHT FINGER(S) W/CONTRAST

73222

CP MRI, RIGHT FINGER(S) W/O CONTRAST

73221

CP MRI, RIGHT FINGERS W/O CONTRAST

73221

CP MRI, RIGHT FOOT W/CONTRAST

73719

CP MRI, RIGHT FOOT W/O CONTRAST

73718

CP MRI, RIGHT FOREARM W/CONTRAST

73225

CP MRI, RIGHT FOREARM W/O CONTRAST

73221

CP MRI, RIGHT HAND W/CONTRAST

73222

CP MRI, RIGHT HAND W/O CONTRAST

73221

CP MRI, RIGHT HIP ARTHROGRAM (ORTHO, SM & PT ONLY)

73722

CP MRI, RIGHT HIP W/CONTRAST

73722

CP MRI, RIGHT HIP W/O CONTRAST

73721

CP MRI, RIGHT HUMERUS W/CONTRAST

73225

CP MRI, RIGHT HUMERUS W/O CONTRAST

73221

CP MRI, RIGHT KNEE ARTHROGRAM (ORTHO, SM & PT ONLY)

73722

CP MRI, RIGHT KNEE W/CONTRAST

73722

CP MRI, RIGHT KNEE W/O CONTRAST

73721

CP MRI, RIGHT PECTORALIS MUSCLE TEAR W/O CONTRAST

73221

CP MRI, RIGHT SHOULDER ARTHROGRAM (ORTHO, SM & PT ONLY)

73222

CP MRI, RIGHT SHOULDER W/CONTRAST

73222

CP MRI, RIGHT SHOULDER W/O CONTRAST

73221

CP MRI, RIGHT TIB-FIB W/CONTRAST

73719

CP MRI, RIGHT TIB-FIB W/O CONTRAST

73718

CP MRI, RIGHT TOE(S) W/CONTRAST

73222

CP MRI, RIGHT TOE(S) W/O CONTRAST

73721

CP MRI, RIGHT WRIST ARTHROGRAM (ORTHO, SM & PT ONLY)

73222

CP MRI, RIGHT WRIST W/CONTRAST

73222

CP MRI, RIGHT WRIST W/O CONTRAST

73221

CP MRI, SACRUM  W/O CONTRAST

72195

CP MRI, SACRUM W/CONTRAST

72196

CP MRI, SCAPHOID FX LEFT W/O CONTRAST

73221

CP MRI, SCAPHOID FX RIGHT W/O CONTRAST

73221

CP MRI, SELLA W W/O CONTRAST

70553

CP MRI, SELLA W/O CONTRAST

70551

CP MRI, SINUS W W/O CONTRAST

70543

CP MRI, SINUS W/CONTRAST

70542

CP MRI, SINUS W/O CONTRAST

70540

CP MRI, SOFT TISSUE MASS

23065

CP MRI, SPORTS HERNIA (ATHLETIC PUBALGIA)

72195

CP MRI, TESTICLE W/ CONTRAST

72196

CP MRI, TESTICLE W/O CONTRAST

72195

CP MRI, THORACIC OUTLET SYNDROME

73222

CP MRI, TMJ  W/O CONTRAST

70336

CP MRI, TMJ W/CONTRAST

70336

CP MRI, T-SPINE W/CONTRAST

72147

CP MRI, T-SPINE W/O CONTRAST

72146

CP MRI, URETHRA W/CONTRAST

72195

CP MRI, URETHRA W/O CONTRAST

72195

CP MRI, UTERUS W/CONTRAST

72197

CP MRI, UTERUS W/O CONTRAST

Naval Hospital Camp Pendleton Referral Guidelines Allergy/Immunology

CONTACT DERMATITIS

Updated: 6/30/2022

Refer to Allergy/Immunology ONLY if:

o Patient has already been seen by Dermatology and they recommend or referral is from Dermatology.

PATCH TESTING

Refer to Allergy/Immunology ONLY if:

o Patient has already been seen by Dermatology and they recommend or referral is from Dermatology. 

Naval Hospital Camp Pendleton Referral Guidelines

Pulmonary

Updated: 6/30/2022

INSOMNIA

 Do not refer to Pulmonary, refer to Behavioral Health for CBT-i.

PULMONARY FUNCTION TEST (PFT)

 Include reason for PFT in referral request.

SLEEP STUDY – Enter referral for Sleep Medicine Clinic

 State in referral the reason for requesting a sleep study: what are the patient’s symptoms 

and what are you trying to rule-out? Also, include whether or not patient has already had a 

sleep study of any kind.

 IF patient has had a TBI/concussion, be sure to state that in the referral.

Services NOT available at NHCP:

• Advanced bronchoscopy

Naval Hospital Camp Pendleton Referral Guidelines

Neurology

Updated: 6/30/2022

BACK PAIN (MUSCULOSKELETAL)

 Do not refer to Neurology. Should be managed by PCM, Sports Medicine, or Pain Clinic.

CONCUSSION/TBI (active duty)

 Do not refer to neurology. Refer to Intrepid Center/Concussion Clinic.

CONCUSSION/TBI (non-active duty)

 Uncomplicated, acute concussion (less than 3 months) should be managed by PCM.

MIGRAINE HEADACHE

 Refer to Neurology ONLY if:

o Patient has failed at least one oral prophylactic medication for at least 3 months at maximum tolerated dose.

RADICULAR NECK OR BACK PAIN

 MRI of appropriate spinal segment completed and images/report available PRIOR to referral to Neurology.

TENSION TYPE HEADACHE

 Refer to Neurology ONLY if:

o Patient has failed at least one oral prophylactic medication for at least 3 months at maximum tolerated dose.

Services NOT available at NHCP:

• Electromyography (EMG)

• Nerve conduction studies (NCS)

• Vagal nerve stimulator

• Occipital nerve stimulator

• Deep brain stimulator

• Baclofen pump (implant or manage)

• Radiofrequency nerve ablation

• Intracranial shunt management

• Somatosensory evoked potentials

• Visual evoked potentials

• Epilepsy monitoring unit

• Ambulatory/video EEG

• Movement disorder

• Epilepsy, dementia

Naval Hospital Camp Pendleton Referral Guidelines

Dermatology

Updated: 6/30/2022

ACNE

 Refer to Dermatology ONLY if:

o Patient has failed 3 or more months of standard therapy with PCM OR severe nodulocystic acne.

ATHLETE’S FOOT

 Refer to Dermatology ONLY if:

o Patient has failed 3 or more months of first-line treatment.

DERMATOPHYTE INFECTION

 Refer to Dermatology ONLY if:

o Patient has failed 3 or more months of first-line treatment.

ECZEMA

 Refer to Dermatology ONLY if:

o Patient has failed 3 or more months of first-line treatment OR BSA >30%.

JOCK ITCH

 Refer to Dermatology ONLY if:

o Patient has failed 3 or more months of first-line treatment.

MALE PATTERN HAIR LOSS

 Do not refer to Dermatology. No treatment is covered by Tricare. Treatment options are OTC or RX at cost to patient.

MOLLUSCUM

 Refer to Dermatology ONLY if:

o Lesion is on face or near nail.

PSEUDOFOLLICULITIS BARBAE (PFB)

 Waiver/input from Dermatologist is no longer required. PCM (IDC, PA, NP, MD, DO) can write the patient’s no shave chit.

 Refer to Dermatology ONLY if:

o Patient wants laser hair reduction.

PSORIASIS

 Refer to Dermatology ONLY if:

o Patient has failed 3 or more months of first-line treatment OR BSA >30%.

SKIN SCREEN

 Refer to Dermatology ONLY if:

o High risk features are present (any of the following): personal history of skin cancer, multiple atypical nevi, history of tanning bed use or multiple blistering sunburns, family history of melanoma skin cancer.

SKIN TAG or SEBORRHEIC KERATOSIS

 Refer to Dermatology ONLY if:

o There is associated inflammation or interference with wearing operational gear/clothing.

TINEA BARBAE

 Refer to Dermatology ONLY if:

o Patient has failed 3 or more months of first-line treatment.

TINEA CORPORIS

 Refer to Dermatology ONLY if:

o Patient has failed 3 or more months of first-line treatment.

TINEA CRURIS

 Refer to Dermatology ONLY if:

o Patient has failed 3 or more months of first-line treatment.

WART

 Refer to Dermatology ONLY if:

o Lesion is on face or near nail

Naval Hospital Camp Pendleton Referral Guidelines

Cardiology

Updated: 6/30/2022

ABNORMAL EKG/ECG – ASYMPTOMATIC

 Discuss and review with cardiologist. Send via MHG communication.

HYPERLIPIDEMIA

 Do not refer to Cardiology. Should be managed by PCM. If assistance is needed, refer to Internal Medicine.

HYPERTENSION

 Do not refer to Cardiology. Should be managed by PCM. If assistance is needed, refer to Internal Medicine.

NUCLEAR STRESS TEST

 This is booked through Radiology.

PALPITATIONS

 Referring provider to place one of the following monitor orders in MHG (not referral) with 

COMPLETE description of symptoms in comment field. Clinic will call patient to schedule.

o CV Holter Monitor

o CV Extended Holter Monitor

o CV Mobile Cardiac Output Telemetry

Services NOT available at NHCP:

• Tilt table test

• Ambulatory blood pressure monitor

• Cardiac catheterization

• Electrophysiology stud

Testicular Pain: Currently, testicular pain is a significant issue here aboard MCB Camp Pendleton. Only a small part of this population has a Urologic etiology, and an even smaller percentage can be managed surgically. The majority of “testicular pain” is actually a referred/perceived pain from the lower abdomen, groin/inguinal region, back/spine, and pelvis. In order to differentiate true testicular pain from referred/neurogenic pain requires an extensive history and physical exam. Radiologic imaging can be useful as well – testicular US, pelvic MRI, and spine imaging if neurogenic pain is suspected. We are currently enlisting the assistance of Pelvic Floor Physical Therapy (PFPT), Sports Medicine, Pain Management, and occasionally General Surgery to address this issue using a multidisciplinary approach. Please see the attached Examination Guide and Referral Algorithm to make the management/referral process more efficient and appropriate. Given the limited number of specialists and the vast number of patients, PCM’s and GMO’s are going to need to be the primary manager of these patients and the referral algorithm should serve as their guide.

 If there is concern for (1) TESTICULAR TORSION or in setting of (2) ACUTE TRAUMA, we recommend immediate US evaluation, preferably through the ED.

 If a patient has a history of testicular/scrotal surgery, please comment on this in the referral. These patients will be booked with the next available Urologist.

Testicular Mass:

 All INTRAtesticular masses are considered malignant until proven otherwise. A timely (STAT) Urologic evaluation including HCG (tumor marker), AFP (tumor marker), CHEM18, and a CT chest/abdomen/pelvis is paramount. We DO NOT require that the labs and CT be ordered/completed prior to consult placement.

 If a mass is PARAtesticular, it is much less likely to be malignant (<5%). These consults can be placed routine.

Kidney Stone:

 First of all, KIDNEY stones are “usually” asymptomatic. Pain from a stone is caused by an obstruction of urine flow which typically does NOT occur when stones are isolated to the kidneys, especially the lower pole.

 Most symptomatic stones are within the URETER. Pain typically worsens as the stone crosses the ureteropelvic junction (UPJ), iliac vessels, and ureterovesicular junction (UVJ) and patients can be counseled accordingly based on the location of their stone.

 With all this being said, a CT scan is necessary to risk stratify patients with stone disease (only imaging modality that provides (1) size information and (2) exact location). An US and/or KUB is not sufficient as a large number of stones are not visible. Consults WITHOUT a recent CT scan will be returned to the ordering provider.

 FLOMAX is only beneficial for (1) ureteral stones and (2) stones <10 mm. There is no need to start Flomax for “kidney stones” and there is no proven benefit in the spontaneous passage rates of stones >10 mm.

 A majority of URETERAL stones <5 mm will pass spontaneously without the need for surgical intervention (~56% in less than 23 days). Large stones are less likely to pass spontaneously (6 mm or greater <41%).

 Consults for kidney stones can be placed routine. Please provide patients with adequate pain control while they await their Urologic evaluation. This is the primary reason for repetitive ED visits during acute stone episodes. The hallmark of pain management for renal colic includes all of the following: (1) scheduled NSAIDs, (2) Tylenol, and (3) Opioids (Tramadol, Hydrocodone, Oxycodone).

Hematuria:

 Definition: >3 RBCs per HPF on microscopic evaluation of a SINGLE, properly collected urine specimen.

 If “blood” is noted on a dipstick UA only, a urine microscopy MUST be completed to verify as other substances can cause a false positive dipstick reading (i.e. myoglobin).

 A urologic workup is indicated only in the absence of another identifiable cause (i.e. menstruation, infection, renal disease).

 All positive infectious etiologies should be treated appropriately and urine studies should be repeated prior to a Urology consult being placed. If the hematuria resolves, no Urology consult is indicated. If hematuria persists, a full workup is indicated.

 We recommend that the following infectious etiologies be investigated: typical genitourinary pathogens (routine urine culture), atypical genitourinary pathogens (Ureaplasma, Mycoplasma), and sexually transmitted infections (Gonorrhea, Chlamydia).

 An order set has been made in CHCS including all labs to investigate – NMRTC UROLOGY (ORE  new  set  NMRTC UROLOGY). All labs are urine based tests.

 Either use culture based sensitivities or recent literature (UpToDate) to determine appropriate treatment recommendations, particularly for the atypical pathogens as these recommendations are regularly changing due to increasing resistance.

 Recent changes to urologic guidelines have done away with a CT hematuria for ALL patients. Our policy at NMRTC NHCP will be that ALL hematuria patients complete a non-contrasted CT PRIOR to referral.

BPH:

 This is a very common urologic condition and a majority of this can be managed non-surgically by the PCM. The hallmark of initial management is alpha-blocker therapy (Tamsulosin, Alfuzosin, etc.). Some patient’s symptoms may progress and additional medication may be required in the form of 5-alpha reductase therapy (Finasteride). BPH truly becomes an issue for the Urologist once a patient progresses to the point where (1) he needs surgical management (urinary retention, failed medical therapy, recurrent infections, bladder stones, persistent hematuria, renal failure secondary to bladder outlet obstruction) or (2) if a patient is interested in surgical management instead of medication (i.e. Urolift, Rezum). If after a patient is initially counselled/managed by Urology and it is determined that (1) the patient is not interested in surgery or (2) surgery is not indicated, he will be returned to his PCM for continued medical management. The patient can return to Urology if his symptoms change/worsen or if they desire surgical management.

 Prior to a consult for BPH being seen in the NMRTC Urology Department, a trial of alpha-blocker therapy must be completed. The patient should be followed up 3-4 weeks after initiation of therapy. If no response is noted by the patient, either subjective or objective (PVR), a consult can be placed to Urology for further evaluation and management.

Chronic UTI’s:

 Definition: >2 CULTURE CONFIRMED urinary tract infections in 6 months or >3 CULTURE CONFIRMED urinary tract infections in 12 months.

 Patients are routinely told by acute care clinics and ED’s that they have UTI’s when in fact they do not as there is rarely follow up on the actual culture data.

 If there is no objective data suggestive of chronic UTI’s, consider a referral to Pelvic Floor Physical Therapy (PFPT) prior to Urology to address their urinary complaints as this is the recommended first line therapy for voiding complaints in the absence of any evidence of infection.

 In women who are peri- or post-menopausal, vaginal estrogen therapy should be considered (Premarin cream intravaginally, Vagifem tabs intravaginally) to address irritative voiding symptoms as well as chronic infections.

 Although interstitial cystitis (IC) is in the differential diagnosis of bladder irritation/pain, it is a diagnosis of exclusion that can only be made by a Urologist after a thorough work up has been completed. Please refrain from suggesting to people that they have IC. This creates a significant amount of anxiety in patients and distracts from our initial encounter as a majority of time is spent explaining IC vs addressing their actual issues.

Renal Mass: Please place consult documenting which imaging study has been completed. A urinalysis with microscopy helps determine between RCC and UTUC which may affect surgical planning. A CBC and Chem18 assess for paraneoplastic processes and evidence of metastatic disease.

Infertility: Male infertility is a rather simple workup. If a semen analysis is normal and there is no evidence of varicocele (purpose for the testicular US), it is done. Criteria for assessing a semen analysis is based on the WHO criteria. Normal semen parameters are as follows:

 Ejaculate Volume: > 1.5 mL

 Sperm density: > 15 million/mL

 Motility: > 40% total motility ** TOTAL MOTILITY: subtract 100 – immotile value, do not just look at progressive motility **

If a semen analysis is abnormal, repeat the test in 4 weeks and submit a referral.

Erectile Dysfunction:

 Unfortunately this diagnosis is completely subjective. There is really no role for nocturnal tumescence studies or penile duplex US studies as were done in the past to assess for venous leak or arterial insufficiency UNLESS the patient has a history of pelvic trauma/pelvic fracture. Currently, the only recommended work up, besides a detailed history, is obtaining a total testosterone level shortly after waking (ideally before 0900). Prior to a referral to Urology, a trial of PDE-5 inhibitor is required. Viagra is our current formulary drug and can be dosed up to 100 mg daily. Daily Cialis is only used to treat BPH refractory to alpha-blockers. Levitra is no longer covered by Tricare/DHA.

 We will accept referrals for patients with low testosterone (hypogonadism) or failed response to appropriately dosed Viagra.

 Consider a mental health consult for young males with ED, particularly if they report engaging in the use of excessive pornography.

Vasectomy: A referral for this can be placed for any male patient requesting PERMANENT sterilization. A vasectomy WILL NOT be completed if a patient’s spouse is currently pregnant. This appointment will be booked directly by the Urology clinic ONLY.

Incontinence/Voiding Complaints: All voiding complaints should have an initial infectious evaluation. Only after an infectious etiology is ruled out should a referral to the Urology clinic be placed.

 All positive infectious etiologies should be treated appropriately and urine studies should be repeated prior to a Urology consult being placed. If the patient’s symptoms resolve with treatment, no Urology consult is indicated. If their symptoms persists, a Urologic workup is indicated.

 We recommend that the following infectious etiologies be investigated: typical genitourinary pathogens (routine urine culture), atypical genitourinary pathogens (Ureaplasma, Mycoplasma), and sexually transmitted infections (Gonorrhea, Chlamydia).

 An order set has been made in CHCS including all labs to investigate – NMRTC UROLOGY (ORE  new  set  NMRTC UROLOGY). All labs are urine based tests.

 Either use culture based sensitivities or recent literature (UpToDate) to determine appropriate treatment recommendations, particularly for the atypical pathogens as these recommendations are regularly changing due to increasing resistance.

 Although interstitial cystitis (IC) is in the differential diagnosis of bladder irritation/pain, it is a diagnosis of exclusion that can only be made by a Urologist after a thorough work up has been completed. Please refrain from suggesting to people that they have IC. This creates a significant amount of anxiety in patients and distracts from our initial encounter as a majority of time is spent explaining IC vs addressing their actual issues.

Circumcision: A referral can be placed for (1) anyone requesting circumcision or (2) has foreskin complaints (i.e. pain, irritation, inability to retract, infection). Please comment on symptoms, if present, in the actual consult request. This appointment will be booked directly by the Urology clinic ONLY.

Bladder Mass: Please contact the duty Urologist and place an ASAP consult. If a CT hematuria has not been completed, please have the patient complete prior to their Urologic evaluation.

Hypogonadism/Testosterone: There are many etiologies to explain decreased energy, fatigue, malaise, weight gain, longer recovery following exercise, decreased libido, erectile dysfunction, etc. in men. An initial workup of these complaints should include a total testosterone completed shortly after waking (ideally prior to 0900). For patients with a total testosterone <300, please place a referral to Urology. For men with a total testosterone >300, regardless what they claim “their” normal is, do NOT place a consult. We will NOT offer testosterone replacement therapy (TRT) in men with normal testosterone values.