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Prince Charles Hospital TIA Referral Form

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Prince Charles Hospital TIA Referral Form Powered By Docstoc
					                           TIA CLINIC REFERRAL FORM

NAME:
                                                             AFFIX HOSPITAL STICKER OR
                                                               FILL IN PATIENT DETAILS
ADDRESS:
                                                                PLEASE WRITE CLEARLY
DOB:




Referring Doctor:                                            Date of TIA:

General Practitioner:                                        Date of referral:

Consultant: (A&E / MAU)                                      Referral source:        A&E / GP / Other

Patient Contact No:                                                      FAX: 01685 728592



History of incident:




Medications:                                                 Past history & risk factors:




                                                                   2
Blood pressure:                                              ABCD Score                (please circle)

Cholesterol (total):                                         Low risk                 0 / 1 / 2 / 3

Other results / imaging:                                     High risk                      4 / 5

                                                             Highest risk                   6 / 7

       Patients with a score of 4 or more should ideally be assessed within 24 hrs where possible
       Start all patients on aspirin 300mg once daily, immediately, unless clear contraindications
       Check patient can physically get to outpatients and remind them no driving for a month

Version 1.0 (2010)                                                                           Dr J White
                     TIA CLINIC REFERRAL GUIDELINES
Refer patients to clinic with symptoms such as:

           Focal hemimotor deficit and / or dysphasia
           Focal hemisensory deficit including amaurosis fugax
           Vertigo, dysarthria, ataxia or diplopia of sudden onset if no other cause is more likely and the
            episode was discrete
           With full resolution within 24 hours (and usually within 15-30 mins)

               Patients with persistent or fluctuating signs should normally be admitted


        The following patients have a HIGHER RISK OF STROKE in the next 48 hours and should
                                     ideally be seen within 24 hours

                                   
                                               2
                                       ABCD score of 4 or more
                                      Recurrent TIAs (2 in one week)

         FAX: 01685 728592 (Internal: Fax or forward to MAU secretaries)
                     CALL 07917 267539 (9am to 5pm) if further advice / help needed



        The following patients have a LOWER RISK OF STROKE in the next 48 hours and should
                                      ideally be seen within a week

                     
                               2
                          ABCD score of 3 or less
                     
                              2
                          ABCD score of 4 or more but event over 1 week ago

         FAX: 01685 728592 (Internal: Fax or forward to MAU secretaries)
                     CALL 07917 267539 (9am to 5pm) if further help / advice needed




                                   ABCD² Score                                    Score     Patient’s Score

  A = Age                              > 60 years                                   1

  B = Blood Pressure                   > 140 systolic and/or > 90 diastolic         1

  C = Clinical Features                Unilateral weakness                          2

                                       Speech disturbance (no weakness)             1

                                       Other                                        0

  D = Duration of Symptoms             > 60 minutes                                 2

                                       10 - 59 minutes                              1

                                       < 10 minutes                                 0

  D = Diabetes                         Diabetes present                             1

                                                                    Total ABCD² Score:




Version 1.0 (2010)                                                                                  Dr J White

				
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