Haematology Suspected Cancer Referral
SOUTH EAST LONDON CANCER NETWORK
Haematology Urgent Suspected Cancer Referral
Please tick the box of the hospital clinic you are referring to and fax this form to the relevant Urgent Referral Team within 24 hours. Guidelines are on the reverse side.
| |Princess Royal | |Queen Elizabeth | |Guy’s & St Thomas’ |
| |Fax: 01689 863187 | |Fax: 020 8836 4035 | |Fax: 020 7188 0923 |
| |Tel: 01689 865676 | |Tel: 020 8836 5964/5 | |Tel: 020 7188 0902 |
| |King’s College | |Lewisham | | |
| |Fax: 020 3299 1515 | |Fax: 020 8333 3451 | | |
| |Tel: 020 3299 1516 | |Tel: 020 8333 3450 | | |
Section 1 – PATIENT INFORMATION. Please complete in BLOCK CAPITALS.
|SURNAME |Patient visited this hospital before? |Y / N |
|FIRST NAME |NHS |Hospital |
| |Number |Number |
|Gender |M / F |D.O.B. |Patient aware the referral is urgent? |Y / N |
|Address |First language |
| | |
| | |
|Post Code | |
| |Interpreter required? |Y / N |
| |Transport required? |Y / N |
|Daytime Telephone |Home Telephone (if different) |
| |/ Mobile No. |
Section 2 – PRACTICE INFORMATION. Use practice stamp if available.
|Referring GP |Date of referral |
|Practice Address |Telephone |
| | |
| | |
|Post Code | |
| |Fax |
Section 3 – CLINICAL INFORMATION. Please tick the relevant boxes and provide results.
| Acute Leukaemia | Myeloma | Lymphoma (HD or NHL) |
|Symptoms |Symptoms |Symptoms |
|Recurrent infections |Bone pain |Drenching night sweats |
| | |Weight loss |
| |Haematology results | |
|Clinical Examination |Hb |Clinical Examination |
|Bruising / petechia |WBC |Lymph Nodes |
|Splenomegaly |Platelets |Neck Groin Axilla |
|Hepatomegaly |ESR |Neck only |
| |Biochemistry results |Duration: |
| |Creatinine | |
|Haematology results |Calcium | |
|Hb |Paraprotein |Stomatis / mouth ulcers |
|WBC |Urea & Electrolytes |Bruising / petechia |
|Platelets |Urine Bence |Splenomegaly |
|ESR |Jones Protein |Hepatomegaly |
| | | |
| | |Radiology (if relevant) |
| | | |
|Additional information - Attach patient computer record summary if available. Continue on separate sheet if required. |
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SOUTH EAST LONDON CANCER NETWORK
Information to support Haematology referrals
Refer urgently patients:
| |
|With persistent unexplained splenomegaly. |
| |
|Combinations of the following symptoms and signs warrant full examination, further investigation and urgent referral (depending on the symptom severity|
|and investigation results): |
|Fatigue |
|Drenching night sweats |
|Fever |
|Weight loss |
|Generalised itching |
|Breathlessness |
|Bruising |
|Bleeding |
|Recurrent infections |
|Bone pain |
|Alcohol induced pain |
|Abdominal pain |
|Lymphadenopathy |
|Splenomegaly. |
|( Use this proforma to refer urgently (2 Week Wait) |
Refer immediately (acute admission) patients:
| |
|With a blood count / film reported as acute leukaemia. |
| |
|With spinal cord compression or renal failure suspected of being caused by myeloma. |
| |
|( Phone your haematology team to arrange admission |
Investigations in Primary Care:
| |
|In patients with persistent unexplained fatigue carry out a full blood count, blood film and erythrocyte sedimentation rate or C-reactive protein. |
|Repeat at least once if the patient’s condition remains unexplained and does not improve. |
| |
|In patients with unexplained lymphadenopathy carry out a full blood count, blood film and erythrocyte sedimentation rate or C-reactive protein. |
| |
|In patients with any of the following additional features of lymphadenopathy, investigate further and / or refer: |
|persistence for 6 weeks or more |
|lymph nodes increasing in size |
|lymph nodes greater than 2 cm in size |
|widespread nature |
|associated splenomegaly, night sweats or weight loss. |
| |
|In patients with unexplained bruising, bleeding and purpura or symptoms suggesting anaemia, carry out a full blood count, blood film, clotting screen |
|and erythrocyte sedimentation rate or C-reactive protein. |
| |
|In patients with persistent and unexplained bone pain, carry out a full blood count and X-ray, urea and electrolytes, liver and bone profile, PSA test |
|(in males) and erythrocyte sedimentation rate or C-reactive protein. |
Approved by the South East London Cancer Network in July 2012.
For comments, additional copies, or patient information resources for GPs to use contact the Network on Tel 020 7188 7090 / Fax 020 7188 7120, or visit our website: selcn.nhs.uk.
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