Upper GI Cancer - Plymouth Hospitals NHS Trust

Plymouth Hospitals NHS Trust
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URGENT TWO WEEK REFERRAL FOR SUSPECTED UPPER GI CANCER
If patient does not fulfil the criteria- please consider urgent/routine referral or treat/watch and wait approach.
PATIENT DETAILS
Surname:
Forename(s):
DOB:
Age:
Male/Female:
NHS Number:
Address:
Postcode:
Telephone 1:
Telephone 2:
GP DETAILS
Referring GP:
Registered GP:
Practice name/address:
Postcode:
Telephone:
Fax:
Date of Referral:
Translator required Yes No If yes please contact GP Practice
Is patient aware of a possible Cancer diagnosis Yes No
____________________________________________________________________________
Please tick all that apply:
DYSPHAGIA
UNEXPLAINED UPPER ABDO PAIN and WEIGHT LOSS +/- back pain
UPPER ABDOMINAL MASS (without dyspepsia)
OBSTRUCTIVE JAUNDICE **
DYSPEPSIA with any of the following (urgent referral for endoscopy/referral to specialist)
progressive unintentional wt loss suspicious Ba meal result GI bleeding
persistent vomiting dysphagia epigastric mass iron deficiency anaemia*
Unexplained worsening in character of dyspepsia PLUS one of the following:
peptic ulcer surgery >20 yrs ago
Barrett’s oesophagus
known dysplasia, atrophic gastritis or intestinal metaplasia
Indicate if: family h/o of gastric Ca pernicious anaemia previous gastric surgery
URGENT ENDOSCOPY for patients >55 with unexplained and persistent recent
onset dyspepsia alone

Plymouth Hospitals NHS Trust
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PATIENT DETAILS
Surname:
Forename(s):
DOB:
NHS Number:
____________________________________________________________________________
Consider urgent Referral for patients without DYSPEPSIA but with any of the
following:
Persistent vomiting and weight loss
Iron Deficiency Anaemia*
* please use IRON DEFICIENCY ANAEMIA form where available
** please use FAST TRACK JAUNDICE form where available
Indicate pt on - Warfarin
Insulin
Additional clinical information:
Additional clinical information including drug history: (please see information below or attach
separately)
Consultation Notes (last 5 days):
CLINICAL INFORMATION SUMMARY
BMI:
BP:
Smoker:
Current Medication:
Repeat Medication:
Known Drug Allergies or Adverse Effects:
CHOOSE AND BOOK:
SPECIALTY = 2WW
CLINIC TYPE = 2WW Upper GI
IF FAXING, FAX TO CANCER CENTREAL OFFICE : 01752 763989
DO NOT SEND PAPER COPY AS WELL AS CHOOSE AND BOOK OR FAX.
In Case of problems phone: Plymouth Hospitals 01752 437506 or Sentinel Healthcare Southwest 0845 155 8283
Version: 03/CAB/Microtest Owner/Name: M Ahearne / Sentinel
Date for Review: 31 May 2013