Brain and CNS referral form - Barts Health NHS Trust

BRAIN / CNS Suspected Cancer Referral
(2 Week Wait Referral)
Please FAX within 24 hours to Cancer Pathways department: 020 7363 8818
Section 1 PATIENT INFORMATION (Please complete in BLOCK CAPITALS)
SURNAME
Date of Referral / /
Date of Birth / /
FIRST NAME
NHS number
UBRN - -
Miss Mrs Ms Mr Other:_________ M [ ] F [ ] Home Tel.
Address
To support NICE guidance 2005
Mobile/Daytime Tel.
Post Code
Language
Ethnicity
Section 2 PRACTICE INFORMATION (Please use practice stamp if available)
Transport Y N Interpreter Y N
Referring GP Locum Y N
Practice Address
Telephone
Fax
Post Code
Section 3 CLINICAL INFORMATION (please TICK all applicable entries)
Please enclose print outs of CURRENT medications and PAST MEDICAL HISTORY
Signs and symptoms for urgent referral
[ ] Focal Seizures and other neurological features
[ ] Papilloedema
[ ] New onset early morning headache and drowsiness with early morning vomiting and ataxia
[ ] Progressive focal neurological signs on examination suggestive of an intracranial tumour
If your patient does not meet any of these criteria, or symptoms/signs of brain tumour is
suspected or unsure if tumour or other brain pathology, or if the patient has severe symptoms
please contact the neurological SPR or consultant to discuss the referral
(see local contacts at the top of the guideline)
INVESTIGATIONS
Medical History, Known Allergies and Medication
Discussed urgent suspected cancer referral with patient: Y
N
Comments/other reasons for suspecting a brain tumour
Hospital use only: (Tick where appropriate)
Date Appointment Booked: / / Date of Referral receipt: / /
Target Dates 2ww / / Database: Patient confirmed:
62/7 / /
A separate letter only need accompany if you feel it necessary
Approved by the North East London Cancer Network April 2006

LOCAL CONTACT DETAILS
If you wish to discuss any clinical issues concerning this referral please contact:
Dr Julian Fearnley Consultant Neurologist 020 7363 8002
If you wish to discuss any other aspect of this referral please contact the Cancer Pathways Office
on 020 7363 8817 / 9275 / 3399
CRITERIA FOR URGENT SUSPECTED CANCER REFERRAL 1
Please FAX the referral form within 24 hours
Refer a patient who presents with symptoms suggestive of brain or CNS cancer to an appropriate
specialist, depending on local arrangements.
Discuss any concerns about a patient’s symptoms and/or signs with a local specialist. If
rapid access to scanning is available, consider as an alternative to referral.
Re-assessment and re-examination is required if the patient does not progress according to
expectations.
Urgently refer patients with:
Symptoms related to the CNS in whom a brain tumour is suspected including:
o Progressive neurological deficit (e.g. Hemiparesis)
o New onset seizures
o Headaches with vomiting and papillodema
o Mental changes
o Cranial nerve palsy / unilateral sensorineural deafness
Early morning headaches of recent onset accompanied by features suggestive of
raised intracranial pressure, e.g. vomiting, drowsiness, posture related headache
(worse when lying down), or by other focal or nonfocal neurological symptoms (e.g.
blackout, change in personality or memory)
A new, qualitatively different, unexplained headache that becomes progressively
severe and of up to two weeks duration
Refer urgently patients previously diagnosed with any cancer who develop any of the
following symptoms, e.g. recent-onset seizure, progressive neurological deficit,
persistent headaches, new mental or cognitive changes or new neurological signs.
Consider urgent referral to an appropriate specialist in patients with rapid progression of:
o Subacute focal neurological deficit
o Unexplained cognitive impairment, behavioural disturbance or slowness, or a
combination of these
o Personality changes confirmed by a witness and for which there is no reasonable
explanation even in the absence of the other symptoms and signs of a brain tumour
Please do not use the proforma for non urgent referrals
Refer the patient by means of a routine referral letter
Investigations
• In a patient with new, unexplained headaches or neurological symptoms, undertake a
neurological examination guided by the symptoms, but including examination for
papilloedema. Note that the absence of papilloedema does not exclude the possibility
of a brain tumour.
• When a patient presents with seizure, take a detailed history from the patient and an
eyewitness to the event. Carry out a physical examination, including cardiac,
neurological and mental state, and developmental assessment, where appropriate.
1 Based on Referral Guidelines for Suspected Cancer (NICE, 2005)
Notes in grey refer to the evidence grading used in the NICE guidelines, for more information see
www.nice.org.uk/cg027NICEguideline