TO BE FAXED IMMEDIATELY

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					 Doncaster and Bassetlaw Hospitals
                                  NHS Foundation Trust           NHS                                                  TIA
                                                                                                                    Referral form
               TO BE FAXED IMMEDIATELY: 01302 381457
 Referring Clinician:                                           Patient Details:
 Name:                                                          Name:
 Address:                                                       Address:




 Tel No:                                                        Home tel:
 Fax No:                                                        Mobile tel:
                                                                DOB:
                                                                Male / Female
Date of Referral:                             Time:
                                                                Language:                               Interpreter required ( )
                                                                NHS No:

Clinical symptoms/signs during attack
 Important clinical findings                                   “Checklist”
                     Enter Y if                     Still                                                               Date:
    Feature           present
                                   Duration       present?
                                                                   Date of onset of the most recent event
    Unilateral                          hrs                      Dizziness, vertigo or loss of consciousness
   weakness /                                                                 present alone?                             Yes    No
   numbness                             days                                 (this is unlikely to be a TIA)
                                        hrs
                                                                        Begin on antiplatelet therapy?
   Dysphasia
                                                                       (see “primary care guidelines for stroke”)
                                                                                                                         Yes    No
                                        days

                                        hrs
 Sudden onset                                                  Have you told the patient that they should
  visual loss                                                                  not drive?
                                                                                                                         Yes    No
                                        days

                                                               Is it necessary for DBH to arrange transport to
   Current BP
                                                                             get patient to clinic?
                                                                                                                         Yes    No

                                                                    Fax completed referral to DRI

                                                                    01302 - 381457
 ABCD2
                                                SCORE
 FACTOR
                                               Please Circle   COMMENTS
 Age over 60                                        1
 Blood pressure (SBP>140 or DBP>90)                 1
 Clinical features
       unilateral weakness                          2
       speech disturbance alone                     1
 Duration of symptoms
       >60 minutes                                  2
       10-60 minutes                                1
       <10 minutes                                  0
 Diabetes                                           1
 TOTAL SCORE*

* Patients with a crescendo TIA (defined as two or more TIAs in 7 days) should be admitted in
 an emergency
 Management of ACUTE STROKE
    and TIA in Primary Care
                       Patient presents
                       with suspected
                       TIA or STROKE




                              ?
                         Neurological
                YES   symptoms resolved   NO

                              ?




      ?
  Crescendo                                    IMMEDIATE
     TIA
                            YES                ADMISSION
      ?                                          999

      NO




  Rx: Aspirin
  300mg stat                                                  DEFINITIONS
    THEN
                                                           STROKE
75mg daily if not                                            A history of sudden onset of
contraindicated                                              focal neurological deficit
                                                             (hemiparesis, hemianopsia,
                                                             numbness, dysphasia,
                                                             dysphagia) that is likely to be
                                                             of vascular origin, lasting 24
                                                             hours or more.
                                                           TIA
                                                             The same as a STROKE but
Complete                                                     the deficit is reversible and
referral form                                                lasts less than 24 hours

and fax                                                    Crescendo TIA
                                                             Two or more TIAs in 7 days
immediately
to TIA clinic
                                                            Blood Pressure
                                                           Acute stage
                                                             In the acute stage of CVA
                                                             the BP is often elevated
                                                           After a few days
                                                             Consider initiating treatment
                                                             if the BP is elevated
                                                           Hypertensive patients
                                                             Patients who are ALREADY
                                                             ON ANTI-HYPERTENSIVE
                                                             MEDICATION may continue
                                                             on their existing therapy

				
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