North London Cancer Network Suspected Haemato-Oncology Referral Form

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North London Cancer Network Suspected Haemato-Oncology Referral Form Powered By Docstoc
					North London Cancer Network
Suspected Lung Cancer Referral Form
To make a referral, FAX this form to the relevant Hospital. You may also fax an accompanying letter / print out if you wish to do so. DATE OF REFERRAL: Please the corresponding box for the hospital the referral is being made to: Barnet Chase Farm North Middlesex Fax: 020 8216 4175 Fax: 020 8375 1977 Fax: 020 8887 2663/4 Tel: 020 8216 4322 Tel: 020 8370 9079 Tel: 020 8887 2661/2 Royal Free UCLH Whittington Fax: 020 7830 2986 Fax: 020 7380 9932 Fax: 020 7288 5621 Tel: 020 7830 2143 Tel: 020 7380 9599 Tel: 020 7288 5511/12 The PATIENT SURNAME: FIRST NAME: ADDRESS: CHEST XRAY Fax report with this form Date…………………………………………… Where………………………………………… Abnormal suspicious of cancer Abnormal other Male/Female History of COPD Current Smoker Ex-Smoker Y   Y Y Y N N N N

PAH Fax: 01279 827 171 Tel: 01279 827 550

REFERRAL INFORMATION must be completed New symptoms Urgent Chest X-ray should be done Y N

DOB TEL No: WORK NO: MOBILE NO: NHS NO (required):

Has the patient previously visited the hospital? Hospital No: Is an interpreter required? If yes, which language Is transport required? Family History: Medical History:

Y/N

SYMPTOMS: Persistent Haemoptysis in smoker or ex smoker >40 years  None  Once  >1 Unexplained or persistent symptoms (>3weeks): Cough Wheeze Weight Loss Breathlessness Chest/shoulder pain Hoarseness Chest signs Finger clubbing Lymphadenopathy cervical or supraclavicular or features of metastasis from lung cancer Information given to Patient Y Y Y Y Y Y Y Y Y N N N N N N N N N

Y/N

Medication:

The REFFERING GP: NAME: ADDRESS:

TEL NO: FAX NO: GP SIGNATURE:

Final Version 01.11.05

Lung cancer
Patient presents with

Any of the following:  haemoptysis  unexplained persistent (over 3 weeks):  chest/shoulder pain  dyspnoea  weight loss  chest signs  hoarseness  finger clubbing  cervical/supraclavicular lymphadenopathy  cough with or without any of the above  features suggestive of metastasis from lung cancer.

Patients presenting with the listed symptoms or signs AND the following risk factors:  current or ex-smoker  COPD  exposure to asbestos  history of cancer (especially head and neck). may be referred earlier for chest x-ray or to a specialist

Persistent haemoptysis in smokers or exsmokers who are 40 years or older

 Superior vena caval obstruction  Stridor

Chest X-ray (report back in 5 days)

Suggestive of lung cancer including:  Slowly resolving consolidation  pleural effusion.

Normal but referring doctor has high suspicion of cancer

Urgent referral

Consider immediate referral

Final Version 01.11.05


				
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posted:11/13/2009
language:English
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