• Emergent: Same day (within 24 hours)
• Urgent: Within 2–4 weeks
• Semi-urgent: Within 4–8 weeks
• Routine: Standard scheduling (about 8–12 weeks)
• May not need referral: Often managed in primary care

Adults

Emergent

Same day (within 24 hours)

Condition	Look for in the referral	First action
Giant cell arteritis (GCA)	Age 50 or older with a new headache, scalp tenderness or jaw claudication Visual symptoms: transient monocular loss (amaurosis fugax), diplopia or sudden vision loss Shoulder and hip girdle aching (PMR symptoms), fever, weight loss or fatigue Arm claudication, unequal arm blood pressures or bruits suggest large-vessel involvement	Start glucocorticoids on the day of clinical suspicion; don't wait for biopsy or imaging. A typical starting dose is prednisone 40–60 mg daily.
ANCA-associated vasculitis with organ threat	Rapidly progressive glomerulonephritis: rising creatinine, blood and protein on urinalysis, RBC casts Diffuse alveolar hemorrhage: hemoptysis, a falling hemoglobin, new infiltrates or hypoxia Mononeuritis multiplex (foot or wrist drop), scleritis, or stridor from subglottic stenosis GPA: chronic sinusitis, crusting, epistaxis, hearing loss, lung nodules or cavities	Pulmonary hemorrhage or a rapidly rising creatinine needs the emergency department or admission. Contact rheumatology and nephrology directly.
Connective tissue disease with organ-threatening features	Diffuse alveolar hemorrhage in SLE Rapidly progressive ILD, especially anti-MDA5 dermatomyositis (often with skin ulcers and little weakness) Scleroderma renal crisis: new severe hypertension and acute kidney injury, sometimes with microangiopathic hemolysis. Risk is highest in early diffuse SSc, with anti-RNA polymerase III, and with high-dose glucocorticoids. Severe lupus nephritis (nephrotic-range proteinuria, active sediment, rising creatinine) or neuropsychiatric lupus (seizures, psychosis, myelitis)	Emergency or inpatient evaluation is often needed. Contact rheumatology directly.
Macrophage activation syndrome / HLH (adult)	Unremitting fever with new or worsening cytopenias Very high or rapidly rising ferritin (often above 5,000–10,000 ng/mL), raised AST/ALT, LDH and triglycerides Falling fibrinogen and ESR despite a rising CRP. This mismatch is a classic warning sign. Hepatosplenomegaly, coagulopathy, confusion or multiorgan dysfunction	Send to the emergency department. Involve rheumatology and hematology the same day.

Urgent

Within 2–4 weeks

Condition	Look for in the referral	First action
New inflammatory arthritis (suspected RA)	Soft, boggy joint swelling (synovitis) of one or more joints, especially the small joints of the hands and feet Morning stiffness lasting 30–60 minutes or more, and pain that improves with use A positive squeeze test across the MCP or MTP joints RF or anti-CCP positive, or raised ESR/CRP. Normal blood tests do not exclude inflammatory arthritis.	Refer as soon as synovitis is suspected; don't wait for test results. EULAR recommends that people with arthritis are seen by a rheumatologist within 6 weeks of symptom onset, and NICE advises urgent referral even when blood tests are normal.
Psoriatic arthritis (suspected)	Psoriasis now or in the past. Check the scalp, ears, umbilicus, gluteal cleft and nails (pitting, onycholysis). Patterns: asymmetric oligoarthritis, symmetric polyarthritis, DIP-predominant disease, axial disease, or arthritis mutilans Dactylitis ("sausage digit") and enthesitis (Achilles, plantar fascia) Uveitis or inflammatory bowel disease may coexist	Refer within 2–4 weeks. Early treatment prevents irreversible joint damage.
Suspected systemic lupus erythematosus (SLE)	Positive ANA (usually 1:80 or higher by HEp-2 IFA; the entry criterion in the 2019 EULAR/ACR classification) Photosensitive or malar rash, discoid lesions, oral or nasal ulcers, non-scarring alopecia Inflammatory arthritis, serositis (pleurisy, pericarditis), fevers Cytopenias (leukopenia, lymphopenia, thrombocytopenia, hemolysis)	Send ANA titer and pattern, anti-dsDNA, ENA panel (Sm, RNP, SSA/Ro, SSB/La), C3/C4, CBC with differential, metabolic panel, urinalysis with microscopy and urine protein-to-creatinine ratio.
Suspected inflammatory myopathy (myositis)	Symmetric proximal weakness: trouble rising from a chair, climbing stairs or lifting the arms Raised CK. AST, ALT and LDH are also often high, which can be mistaken for liver disease. Dermatomyositis skin signs: heliotrope rash, Gottron papules, shawl or V-sign, mechanic's hands, periungual changes Dysphagia, dyspnea or cough (ILD), Raynaud's, arthritis	Send CK, aldolase, AST/ALT, LDH, TSH, CBC, metabolic panel, ESR/CRP, ANA, and a myositis-specific and myositis-associated antibody panel.
Suspected systemic sclerosis (scleroderma)	Raynaud's with puffy or swollen fingers, sclerodactyly, digital pitting scars or ulcers Skin thickening proximal to the MCPs, telangiectasias, calcinosis Reflux, dysphagia, dyspnea, or a reduced DLCO ANA with an SSc-specific antibody: anti-centromere, anti-Scl-70 (topoisomerase I) or anti-RNA polymerase III	Send ANA with pattern, anti-centromere, anti-Scl-70, anti-RNA polymerase III, CBC, metabolic panel and urinalysis, and check blood pressure.
Sjögren's disease with systemic features	Persistent dry eyes and mouth, plus systemic features Salivary or parotid gland swelling, lymphadenopathy Purpura, peripheral neuropathy, interstitial nephritis or renal tubular acidosis, ILD, inflammatory arthritis Anti-SSA/Ro, RF, hypergammaglobulinemia, low C4, cryoglobulins	Send ANA, SSA/Ro, SSB/La, RF, CBC, metabolic panel, urinalysis, serum protein electrophoresis or IgG, and C3/C4. Add cryoglobulins if there is purpura or neuropathy.
Mixed connective tissue disease (MCTD)	Raynaud's (nearly universal) and puffy hands Arthritis, myositis, esophageal dysmotility ILD and pulmonary hypertension, the main long-term risks High-titer speckled ANA with anti-U1 RNP	Send ANA, anti-U1 RNP, CK, CBC, metabolic panel and urinalysis.
Antiphospholipid syndrome (APS)	Venous or arterial thrombosis, especially when young, unprovoked or at unusual sites Pregnancy morbidity: recurrent early loss, fetal death, or preterm delivery from preeclampsia or placental insufficiency Livedo, thrombocytopenia, heart valve thickening, microvascular kidney disease Lupus anticoagulant, anticardiolipin or anti-β2-glycoprotein I positive on two occasions at least 12 weeks apart	Test lupus anticoagulant, anticardiolipin IgG/IgM and anti-β2-glycoprotein I IgG/IgM. Anticoagulants interfere with lupus anticoagulant testing, so note what the patient is taking.
Adult-onset Still's disease (AOSD)	Quotidian (daily, spiking) fevers, often 39 °C or higher Evanescent salmon-pink rash that comes with the fever Sore throat, arthralgia or arthritis, serositis, lymphadenopathy, splenomegaly Neutrophilic leukocytosis, raised liver tests, very high ferritin (glycosylated fraction under 20% if measured)	Send CBC, metabolic panel with liver tests, ferritin, CRP/ESR and LDH.
Behçet's syndrome	Recurrent oral ulcers (3 or more episodes a year) plus genital ulcers Uveitis or retinal vasculitis. Eye involvement can threaten sight. Skin lesions: erythema nodosum, pseudofolliculitis, a positive pathergy test Venous thrombosis, arterial aneurysms, or neurologic involvement	Same-day ophthalmology for visual loss, floaters or a painful red eye. Coughing blood (possible pulmonary artery aneurysm), sudden neurologic symptoms or sudden vision loss need emergency care.
Takayasu arteritis / large-vessel vasculitis	Usually onset before age 40, though 2022 ACR/EULAR classification allows up to 60 Arm or leg claudication, a reduced pulse, or a systolic BP difference between arms (20 mm Hg or more scores in the 2022 classification criteria) Carotid, subclavian or abdominal bruits, carotidynia, hypertension Constitutional symptoms and raised inflammatory markers	Get CTA or MRA of the aorta and its branches. PET may be used by specialists.
Polyarteritis nodosa (PAN)	Tender skin nodules, livedo racemosa, ulcers Mononeuritis multiplex, testicular pain, hypertension, renal infarcts Post-prandial abdominal pain from mesenteric involvement Associated with hepatitis B in some patients. ANCA is typically negative.	Send ESR, CRP, CBC, metabolic panel, urinalysis, hepatitis B and C serology and ANCA (to exclude ANCA vasculitis).
Palpable purpura / small-vessel vasculitis (adult)	Palpable, non-blanching purpura, usually on the legs Arthralgia, abdominal pain, hematuria or proteinuria, neuropathy Causes include IgA vasculitis, cryoglobulinemic vasculitis (often hepatitis C), drug-induced vasculitis, ANCA vasculitis and urticarial vasculitis	Fever or a patient who looks unwell: treat as possible sepsis or endocarditis first, with same-day emergency assessment and blood cultures.
Checkpoint inhibitor rheumatic adverse events (irAEs)	Inflammatory arthritis (RA-like, oligoarticular, or reactive-like). RF and anti-CCP are usually negative. PMR-like illness, sicca, or vasculitis Myositis, which can overlap with myocarditis and myasthenia (weakness, ptosis, dysphagia, dyspnea, troponin rise) These often persist after the checkpoint inhibitor stops, unlike many other irAEs	Refer promptly and coordinate with oncology. Don't assume musculoskeletal symptoms come from the cancer.
Interstitial lung disease in autoimmune disease	Exertional dyspnea, dry cough or inspiratory crackles in a patient with a systemic autoimmune rheumatic disease Highest risk: systemic sclerosis, myositis (especially antisynthetase and anti-MDA5), MCTD; also RA and Sjögren's with risk factors A falling FVC (about 10% or more, or 5–10% with worsening symptoms or imaging) or DLCO (about 15% or more)	Get PFTs with spirometry, lung volumes and DLCO, plus HRCT chest. ACR/CHEST 2023 conditionally advises against chest X-ray or 6-minute walk alone for screening.

Semi-urgent

Within 4–8 weeks

Condition	Look for in the referral	First action
Suspected axial spondyloarthritis (axSpA)	Back pain for 3 months or more that began before age 45 Inflammatory features: insidious onset, morning stiffness over 30 minutes, improves with exercise but not rest, night pain, alternating buttock pain Plus: HLA-B27, uveitis, psoriasis, IBD, dactylitis or enthesitis, family history, a good NSAID response, or a raised CRP	Send CRP, ESR and HLA-B27.
Polymyalgia rheumatica (PMR)	Age 50 or older with bilateral shoulder and/or hip girdle pain, morning stiffness over 45 minutes Raised ESR or CRP, normal CK Usually a rapid, marked response to moderate-dose glucocorticoids, though response alone does not confirm the diagnosis Atypical: age under 60, peripheral arthritis, normal markers, poor steroid response, or prominent systemic symptoms	Check for GCA features (headache, scalp tenderness, jaw claudication, visual symptoms, limb claudication). If present, treat as emergent.
Gout: complex or refractory	Tophaceous gout or radiographic damage Two or more flares a year despite adequately dosed urate-lowering therapy (ULT) Serum urate not below 6 mg/dL despite titration, or allopurinol hypersensitivity or intolerance CKD stage 4–5, transplant, or other comorbidity that makes ULT difficult	Send serum urate, creatinine/eGFR, CBC and liver tests, and include joint aspiration results if available.
Calcium pyrophosphate deposition (CPPD)	Acute monoarthritis (knee, wrist) in older adults, often after illness or surgery Chronic inflammatory arthritis resembling RA, or OA in unusual joints (MCP, wrist, shoulder) Chondrocalcinosis on X-ray or ultrasound. CPP crystals (weakly positive birefringent) in synovial fluid confirm it.	Aspirate and examine fluid for crystals and culture when possible.
Raynaud's phenomenon with secondary features	Onset after about 30–40, asymmetric attacks, or thumb involvement Digital pitting scars, ulcers, or puffy fingers Abnormal nailfold capillaries (dilated loops, dropout, hemorrhages) Positive ANA, especially with anti-centromere, Scl-70 or RNA polymerase III	Send ANA with pattern, an ENA panel including centromere and Scl-70, CBC, metabolic panel, ESR/CRP and urinalysis.
Reactive arthritis (persistent or recurrent)	Asymmetric oligoarthritis of the legs, enthesitis, dactylitis Follows enteric infection (Salmonella, Shigella, Campylobacter, Yersinia) or Chlamydia Conjunctivitis, urethritis, oral ulcers or keratoderma	NSAIDs are first-line. Most cases settle within weeks to months.
IgG4-related disease	Salivary or lacrimal gland enlargement, autoimmune pancreatitis or cholangitis Retroperitoneal fibrosis, aortitis, orbital disease, pachymeningitis Raised serum IgG4 in many patients. A normal level does not exclude it.	Send serum IgG4 and IgG subclasses, CBC with eosinophils, metabolic panel, lipase if relevant, and C3/C4.
Sarcoidosis with rheumatologic features	Löfgren syndrome: bilateral hilar lymphadenopathy, erythema nodosum and ankle periarthritis Chronic arthritis, lupus pernio, uveitis, hypercalcemia Cardiac or neurologic involvement	Get a chest X-ray or CT. Send calcium, CBC, metabolic panel with liver tests, and urinalysis.
Drug-induced rheumatic disease	Drug-induced lupus: hydralazine, procainamide, minocycline, isoniazid, TNF inhibitors (anti-histone antibodies common) Statin myopathy, including anti-HMGCR necrotizing myopathy ANCA vasculitis linked to hydralazine, propylthiouracil, levamisole-adulterated cocaine Arthralgia or arthritis from aromatase inhibitors, retinoids, or fluoroquinolones (tendinopathy)	Stop or switch the likely drug when possible. Most cases improve over weeks to months.
VEXAS syndrome	Usually men over 50 (about 1 in 4,000 men over 50). Women, especially with X-chromosome loss, are occasionally affected. Recurrent fevers, ear or nose chondritis, neutrophilic dermatosis (Sweet-like), vasculitis, lung infiltrates Macrocytic anemia, thrombocytopenia, or myelodysplasia Venous thromboembolism	Send CBC with smear (macrocytosis), CRP/ESR and a metabolic panel.
Relapsing polychondritis	Auricular chondritis that spares the earlobe, and nasal chondritis (saddle nose) Tracheobronchial involvement: hoarseness, cough, stridor Inflammatory arthritis, eye inflammation, hearing loss or vertigo In men over 50 with cytopenias, consider VEXAS	Send ESR, CRP, CBC and a metabolic panel.

Routine referral

Standard scheduling (about 8–12 weeks)

Condition	Look for in the referral	First action
Established RA: treatment change or review	Persistent disease activity despite DMARDs, or side effects Questions about biologics or targeted therapy, or tapering in sustained remission Pregnancy planning (this one is often urgent; see co-management)	Continue the current DMARDs and monitoring.
Gout: new, uncomplicated	Podagra or another typical flare, or crystal-proven gout Strong ULT indications: tophi, radiographic damage, or 2 or more flares a year Conditional indications: first flare with CKD stage 3 or worse, serum urate above 9 mg/dL, or urolithiasis	Treat flares with colchicine, an NSAID or a glucocorticoid.
Osteoporosis: complex or refractory	Fragility fracture while on therapy, or multiple vertebral fractures T-score of −3.0 or lower, or very high FRAX risk Glucocorticoid-induced osteoporosis needing advanced therapy Atypical femoral fracture, osteonecrosis of the jaw, or bisphosphonate intolerance	Most osteoporosis is treated in primary care. Send DXA results, fracture history, prior and current treatment, and calcium, 25-OH vitamin D, creatinine and PTH if checked.
Undifferentiated connective tissue disease (UCTD)	Positive ANA plus at least one clinical feature No organ involvement and stable over time A minority evolve into a defined CTD, usually within the first few years	Send ANA titer and pattern, ENA panel, anti-dsDNA, C3/C4, CBC, metabolic panel, urinalysis and ESR/CRP.
Sjögren's disease: sicca-predominant	Persistent dry eyes and/or mouth, often with dental caries Anti-SSA/Ro positive, without purpura, neuropathy, cytopenias, gland swelling or organ involvement	Treat dryness: artificial tears, saliva substitutes, sugar-free lozenges, dental care, and review of drying medications.
Positive anti-CCP or high-titer RF with joint pain, no swelling	Joint pain, often in the hands, without objective swelling Anti-CCP positive (especially high titer) or high-titer RF Morning stiffness, difficulty making a fist, or a positive squeeze test raise the risk	Examine carefully for synovitis. Any objective swelling makes this an urgent new inflammatory arthritis referral.

May not require referral

Often managed in primary care

Condition	Look for in the referral	First action
Positive ANA without symptoms	In healthy people, about 32% are positive at 1:40, 13% at 1:80 and 5% at 1:160 (Tan 1997) Low titers and a dense fine speckled (DFS70) pattern are common in healthy people No rash, arthritis, serositis, Raynaud's, cytopenias or abnormal urinalysis	Document why the ANA was ordered, and the titer and pattern.
Osteoarthritis	Pain with use, morning stiffness under 30 minutes Bony enlargement (Heberden and Bouchard nodes), crepitus, reduced range of motion Normal ESR/CRP. Imaging is not needed for a typical presentation.	Exercise and weight loss for knee and hip OA carry strong recommendations. The 2026 ACR update adds a conditional recommendation for a GLP-1 receptor agonist, with diet and exercise, in knee OA with obesity.
Fibromyalgia	Widespread pain for 3 months or more, fatigue, unrefreshing sleep, cognitive difficulty Normal joint exam apart from tenderness, and normal inflammatory markers Often coexists with other conditions, including inflammatory disease	A focused workup is enough: CBC, metabolic panel, ESR/CRP, TSH, plus CK if on a statin or weak.
Mechanical (non-inflammatory) back pain	Pain worse with activity or posture, better with rest Short morning stiffness and no night waking from pain No uveitis, psoriasis, IBD or other extra-articular features. Onset is often after 45.	Manage with activity, exercise and physical therapy, and NSAIDs if appropriate.
Regional soft-tissue problems	Localized pain from a tendon, bursa or entrapment, without features of inflammatory arthritis	Manage through MSK pathways: physical or occupational therapy, splints or orthotics, and injections where appropriate.
Asymptomatic hyperuricemia	Raised urate with no flares, tophi or urate stones	The ACR conditionally recommends against starting ULT for asymptomatic hyperuricemia.
Primary Raynaud's phenomenon	Onset usually between 15 and 30, symmetric episodes (white, then blue, then red) No pitting, ulcers or puffy fingers Negative or low-titer ANA and normal nailfold capillaries	Keep the whole body warm, use gloves, stop smoking, and avoid vasoconstrictors.
Joint hypermobility without complications	Hypermobility with or without pain. No recurrent dislocations, skin fragility or vascular history.	Reassure and refer to physical therapy for strengthening and proprioception.

Redirect: usually another service first

Referral describes	Redirect to	Why
Suspected septic arthritis	Emergency department / orthopedics	An acute hot, swollen joint with fever or immunosuppression needs urgent aspiration (cell count, Gram stain, culture, crystals) before antibiotics when the patient is stable. Crystals and infection can coexist.
Suspected bone or joint malignancy, or metastases	Oncology / orthopedic surgery	Night pain, weight loss, a known cancer, or a destructive lesion on imaging. Use the local cancer pathway.
Cauda equina syndrome or spinal cord compression	Emergency department / spine surgery	Saddle anesthesia, new bladder or bowel dysfunction, or progressive leg weakness is a surgical emergency.
Isolated mechanical or soft-tissue problems	MSK pathway (PT, orthopedics, sports medicine)	Tendinopathy, bursitis, entrapment and mechanical joint pain without inflammatory features.

Children and adolescents

Emergent

Same day (within 24 hours)

Condition	Look for in the referral	First action
Systemic JIA / macrophage activation syndrome	Quotidian fever for 2 weeks or more, evanescent rash, arthritis, serositis, hepatosplenomegaly MAS signs: persistent fever with a falling platelet count, very high or rising ferritin, raised AST, triglycerides and LDH, low fibrinogen, coagulopathy 2016 classification in sJIA: ferritin above 684 ng/mL plus 2 of platelets ≤181,000, AST above 48 U/L, triglycerides above 156 mg/dL, fibrinogen ≤360 mg/dL	Suspected MAS needs the emergency department and same-day pediatric rheumatology. ICU care is often needed.
Kawasaki disease	Fever for 5 days or more plus 4 or more of: bilateral non-exudative conjunctival injection, red cracked lips or strawberry tongue, polymorphous rash, hand and foot erythema or edema (later peeling), cervical node over 1.5 cm Incomplete Kawasaki disease (fewer features) is common in infants. Use the AHA algorithm with CRP, ESR and supplemental labs.	Send to the emergency department or admit.
Multisystem inflammatory syndrome in children (MIS-C)	CDC definition (2023): age under 21, fever of 38.0 °C or higher, CRP of 3.0 mg/dL or higher, and illness needing hospitalization (or resulting in death) New involvement in at least 2 categories: cardiac (reduced EF, coronary dilation or aneurysm, raised troponin), mucocutaneous, shock, gastrointestinal, or hematologic (platelets under 150,000 or lymphocytes under 1,000) Lab or epidemiologic evidence of SARS-CoV-2 within the prior 60 days, and no more likely alternative diagnosis (including Kawasaki disease)	Admit for multidisciplinary care with rheumatology, cardiology, infectious disease and critical care as needed.
Pediatric vasculitis with organ threat	ANCA vasculitis: pulmonary hemorrhage, rapidly progressive glomerulonephritis PAN: painful nodules, livedo, testicular or abdominal pain, hypertension Takayasu: claudication, absent pulses, hypertension, bruits in an adolescent	Contact pediatric rheumatology directly. Organ threat needs the ED or admission.

Urgent

Within 2–4 weeks

Condition	Look for in the referral	First action
Juvenile idiopathic arthritis (JIA)	Persistent joint swelling or effusion, morning stiffness, limp, or reluctance to use a limb Symptoms for 6 weeks or more, starting before age 16 Enthesitis or back pain suggests enthesitis-related arthritis or juvenile spondyloarthritis ANA-positive young girls with oligoarthritis have the highest uveitis risk	Refer within 2–4 weeks. Send CBC with differential, ESR, CRP, metabolic panel and ANA (for uveitis risk). Add HLA-B27 if enthesitis or back pain is present.
JIA-associated uveitis	Often no symptoms. Can cause synechiae, cataract, glaucoma and vision loss. Highest risk: oligoarticular or polyarticular RF-negative JIA, ANA-positive, onset before age 7, within 4 years of onset	High-risk children need a slit-lamp exam every 3 months (ACR 2019; reaffirmed 2026).
Pediatric (childhood-onset) SLE	Rash, arthritis, fever, oral ulcers, alopecia Cytopenias, proteinuria or hematuria, hypertension ANA positive in nearly all, with anti-dsDNA or anti-Sm and low complements	Send ANA, anti-dsDNA, ENA, C3/C4, CBC, metabolic panel, urinalysis with microscopy, urine protein-to-creatinine ratio and BP.
Juvenile dermatomyositis (JDM)	Heliotrope rash, Gottron papules, nailfold capillary changes Proximal weakness (Gowers sign), fatigue, dysphagia or voice change Raised CK, aldolase, AST or LDH. Muscle enzymes can be normal.	Send CK, aldolase, AST/ALT, LDH, CBC, metabolic panel, ANA and a myositis antibody panel.
IgA vasculitis (Henoch-Schönlein purpura)	Purpura or petechiae with lower-limb predominance (mandatory for EULAR/PRINTO/PReS classification), often palpable, on the legs and buttocks Arthralgia or arthritis, colicky abdominal pain (GI bleeding, intussusception risk) Hematuria or proteinuria. Nephritis can appear weeks to months later. Peak age is 3–10.	First exclude infection: fever, an ill-appearing child or a rapidly spreading non-blanching rash needs emergency assessment for sepsis.
Pediatric systemic sclerosis	Raynaud's, sclerodactyly, digital pitting or ulcers Dysphagia or reflux, dyspnea ANA with Scl-70 or anti-centromere	Send ANA, ENA including Scl-70 and centromere, CBC, metabolic panel and urinalysis, and check BP.
Acute rheumatic fever	Major Jones criteria: carditis (clinical or on echo), arthritis, chorea, erythema marginatum, subcutaneous nodules Low-risk vs moderate/high-risk populations use different joint criteria (AHA 2015) Evidence of recent group A strep: ASO, anti-DNase B, or culture or rapid antigen	Send ASO, anti-DNase B, ESR, CRP, CBC and an ECG. Get an echocardiogram.
Neonatal lupus	Congenital heart block (about 2% of first pregnancies with anti-Ro; higher if a previous child was affected) Annular, photosensitive rash, cytopenias, or raised liver tests in the first months The mother may have no known autoimmune disease	Fetal bradycardia or heart block needs urgent fetal cardiology or MFM.

Semi-urgent

Within 4–8 weeks

Condition	Look for in the referral	First action
Pediatric sarcoidosis / Blau syndrome	Under 5: granulomatous rash, boggy synovitis or tenosynovitis, uveitis. Lungs are usually spared. Associated with NOD2 variants. Older children: hilar nodes, lung disease, erythema nodosum, uveitis	Arrange an ophthalmology exam. Send calcium, CBC, metabolic panel and urinalysis, and get a chest X-ray.
Chronic nonbacterial osteomyelitis (CNO/CRMO)	Bone pain, sometimes with swelling, often in the metaphyses, clavicle, pelvis or spine Normal or mildly raised inflammatory markers May come with psoriasis, palmoplantar pustulosis or IBD	Whole-body MRI is the preferred imaging.
Periodic fever / autoinflammatory syndromes	PFAPA: fevers every 3–8 weeks, starting before 5, with aphthous ulcers, pharyngitis and cervical adenitis. The child is well between episodes. FMF: 1–3 day fevers with serositis. More common in Mediterranean, Middle Eastern and Armenian ancestry. CAPS (urticarial rash, cold-triggered), TRAPS (longer episodes, myalgia, periorbital edema), MKD (younger onset, after vaccines)	Keep a fever diary and photograph rashes.
Localized scleroderma (morphea)	Circumscribed plaques or linear bands of induration and color change Linear limb lesions can cause limb-length discrepancy or contracture Facial lesions (en coup de sabre, Parry-Romberg) can involve the eye or CNS	Refer early for linear, facial, deep, generalized or rapidly progressive disease. These are urgent.
Reactive arthritis (pediatric)	Lower-limb oligoarthritis, enthesitis, dactylitis Follows Salmonella, Shigella, Campylobacter or Yersinia infection, or Chlamydia in adolescents	NSAIDs. Check ESR, CRP and HLA-B27.
Pediatric Sjögren's disease	Recurrent parotitis, dry eyes or mouth, fatigue, arthralgia ANA, SSA/Ro, SSB/La or RF positive. Can overlap with SLE.	Send ANA, SSA/SSB, RF, CBC, metabolic panel, IgG and urinalysis.

Redirect: usually another service first

Referral describes	Redirect to	Why
Septic arthritis or osteomyelitis in a child	Emergency department / pediatric orthopedics	Fever with an acutely painful joint or bone, or refusal to bear weight. Treat as infection until proven otherwise.
Possible leukemia or other malignancy	Pediatric hematology-oncology (urgently)	Bone pain (especially at night), pain out of proportion, cytopenias or blasts, high LDH, or an ill-appearing child. Malignancy can mimic JIA.
Slipped capital femoral epiphysis, Perthes disease, fractures	Pediatric orthopedics	Hip or knee pain with a limp in a child or adolescent, especially with obesity (SCFE) or ages 4–8 (Perthes). Get hip X-rays.
Possible non-accidental injury	Child protection team / pediatrics	Injuries that don't fit the history or the child's developmental stage, or multiple fractures at different ages.

The same conditions, with full detail for referring clinicians, are on When to Refer. Timeframes are typical targets; local capacity and clinical judgment decide.