North Bristol Referral form for Emergency Surgical Clinic
North Bristol GP Referral form for Abdominal pain/ Rectal Bleed Hot Clinic
Please fax this form to 01173406798 AND phone Surgical Admissions Unit on 01173406799 to book this patient into hot clinic
|Patient Name: |
|Date: |GP Name: |
|DOB: |GP Practice: |
|NHS / Hospital No: |GP Tel. No: |
|Patient Tel No: |GP Fax No: |
|Please tick one of the options below if an Ultrasound scan is required |Areas examined with Ultrasound |Prep |
| |All other requests should not be made | |
| |via this pathway. | |
|Lower abdominal pain - male |USS not required |[pic] |None |- |
|Obstructive Jaundice |Upper abdominal USS |[pic] |Liver, biliary tree, gallbladder, |Clear fluids only 4hours|
| | | |pancreas, spleen, abdominal aorta and |prior to scan |
| | | |kidneys | |
|RUQ/ Epigastric pain |Upper abdominal USS |[pic] | | |
|Lower abdominal pain - female |Lower abdominal USS |[pic] |Uterus, ovaries, urinary bladder and |Full bladder |
| | | |kidneys | |
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Please tick this box to confirm that the patient does not fall into any of the above categories [pic]
Please tick this box to confirm that the patient has been given the hot clinic leaflet [pic]
If the patient is of childbearing age, please tick to confirm that pregnancy been ruled out [pic]
The following conditions are NOT appropriate for hot clinic ultrasound and should be referred to radiology via the usual pathway if a scan is required:
• Wound collections / Abscesses (for review on surgical admissions unit)
• Hernia (can be seen in hot clinic but scan not possible)
• Abdominal wall conditions (can be seen in hot clinic but scan not possible)
• Testicular problems (discuss with Urologists)
• Bowel problems (ultrasound not an appropriate investigation but can be seen in clinic)
Patients that are NOT appropriate referrals to the GI Surgery Hot Clinic include
• Ischaemic / cellulitic limbs / abscesses
• Non GI / non abdominal problems
• Patients with chronic problems (should be referred to the relevant regular outpatient clinic)
• Patients too unwell to walk to radiology (should be admitted to hospital instead)
Clinical Examination:
Symptoms:
Working diagnosis:
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