Making a Referral

As we have expanded and started to offer advice in Malawi and also take on more clinical officers in Zambia, we thought it would be helpful to do a quick post of what to include in your referral to the Virtual Doctors advisors.

The picture below highlights the most important information to include.

Observations are really important so that we can advise upon the urgency of a clinical decision and get an idea of how unwell your patient is.

Knowing their background- age, gender and whether they have known HIV is really helpful as we can then rule in or rule out certain diagnoses.

Understanding why they have come to see you and what their main complaint is, is probably the most important thing to know, but putting this in context, by knowing if they have any past medical history or take any medication is also very important. If they have no past history and take no medication, please say so!

As we reply upon what you tell us, sending us any relevant examination findings, including photos is really useful. You are our eyes in the field! Our advice can only be as good as the information we receive!

Part of the process is to help with learning and education. It is helpful for us to know what you are thinking. What do you think is going on with the patient? Most importantly, what are you worried about? what do you want help with?

Please try and be specific when possible. This will help us be able to offer you the best advice we can to benefit the patients and clinical officers using the service.

Diagram Slide1.jpg

Sore throats and antibiotics


The majority of acute sore throats (including pharyngitis and tonsillitis) are self‑limiting and often triggered by a viral infection of the upper respiratory tract. The symptoms can last for around 1 week, but most people will get better within this time without antibiotics, regardless of cause (bacteria or virus).

If you are concerned it may be strep throat (and therefore benefit from antibiotics) use the FeverPAIN scoring system. This reduces antibiotic prescribing by 30%!

FeverPAIN criteria

  • Fever (during previous 24 hours)
  • Purulence (pus on tonsils)
  • Attend rapidly (within 3 days after onset of symptoms)
  • Severely Inflamed tonsils
  • No cough or coryza (inflammation of mucus membranes in the nose)

Each of the FeverPAIN criteria score 1 point (maximum score of 5). Higher scores suggest more severe symptoms and likely bacterial (streptococcal) cause.

0 or 1 =13 to 18% likelihood of isolating streptococcus.

2 or 3 = 34 to 40% likelihood of isolating streptococcus.

4 or 5 =62 to 65% likelihood of isolating streptococcus. Treat these with penicillin (unless allergic) for a 5 to 7 day course ONLY (new evidence). Consider giving the same dosage twice a day rather than 4 times a day to improve compliance.



There is new guidance from the UK’s Faculty of Sexual and Reproductive Health with regards to taking the COCP. Please note this is accepted practice but is ‘off licence’ meaning the drug has not been formally approved for use in this way.

Most errors in taking the cocp occur in the pill free week. This pill free week is not necessary and should be shortened to 4 days.

Patients can now

  1. Run 2 or 3 packets together. This will give them regularity and regular menses. Only a 4 day break is needed.
  2. Continue running packets together until they get spotting. Then stop for 4 days.
  3. Continue running packets together whether there is spotting or not (like the POP).

Consider discussing this with your patients. It gives them more control and flexibility with their menses and reduces risk of pregnancy.


Quiz 2


A 51 year old man attends a clinic with cellulitis. He has a history of psoriasis but hasn’t had any active psoriatic lesions for over 10 years. Whilst you are examining him and assessing the cellulitis, you notice numerous dark/purple growths on his foot. Several of them appear almost verruca-like. They are not painful, and are present on both sides of the feet. The man states they have been present for about a year. There are no signs of psoriasis on examination.

  1. What is the diagnosis?
  2. What further tests are required?

Answers and discussion will be posted in a couple of weeks….



  1. The lesions are typical of Kaposi’s sarcoma.
  2. Both the Kaposi’s and the cellulitis may be suggestive of an HIV infection. He needs an HIV test.


Warty growths can be seen in many skin conditions, including viral warts, seborrheic keratosis, squamous cell carcinomas, and Kaposi’s. Raised dark/purple lesions may be seen in lichen planus, cutaneous sarcoid, mycobacterial infection and Kaposi’s. So the 2 features together make Kaposi’s the most likely diagnosis.

The most important part of treating Kaposi’s is ART, and often lesions will get smaller as the CD4 count improves. In some cases, this may be the only treatment needed for Kaposi’s.  However, if there are other symptoms such as pain or swelling, then other treatments may benefit. If there are only a few small lesions, then topical retinoids (benzyl peroxide) may help. The other option if lesions are very painful, or if lesions are problematic in the mouth or anus, is a referral for radiotherapy (depending on availability). Chemotherpay can also be considered for the most severe/numerous/symptomatic lesions, but again this would depend very much on local availability.

Kaposi’s may look different on African skin, so here are a few examples