When should I consider referring a patient with URTI symptoms for further investigation or specialist review?

Consider referring a patient with upper respiratory tract infection (URTI) symptoms for further investigation or specialist review if:

• They have symptoms or signs suggestive of a serious illness such as pneumonia or non-infective causes that cannot be adequately assessed remotely or in primary care, for example, new or increased breathlessness or confusion.
• They have comorbidities that may be exacerbated by the infection, such as frailty, chronic obstructive pulmonary disease (COPD), or immunosuppression, which lower the threshold for referral.
• An adequate assessment cannot be made remotely due to communication difficulties or other barriers.
• They are aged 40 or over with persistent or recurrent chest infection symptoms, unexplained cough, chest pain, or shortness of breath, especially if they have a history of smoking or asbestos exposure, warranting an urgent chest X-ray within 2 weeks to exclude lung cancer or mesothelioma.
• They present with persistent unexplained hoarseness aged 45 or over, which may require suspected cancer pathway referral.
• They have respiratory signs such as finger clubbing, chest signs consistent with lung cancer or pleural disease, or unexplained lymphadenopathy with systemic symptoms, indicating possible malignancy and need for urgent investigation.

In all cases, the urgency and setting of referral should be based on symptom severity and rate of deterioration, with consideration of the patient’s overall health and social circumstances. Self-care advice and safety-netting should be provided if symptoms are mild and manageable at home.

These recommendations align with NICE guidelines on suspected acute respiratory infection and suspected cancer recognition and referral pathways.

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