Lung Two-Week Wait Referral Proforma - Royal Shrewsbury ...

Royal Shrewsbury Hospital and Princess Royal HospitalTwo Week Suspected Cancer Referral ProformaLUNGTwo Week Wait Referrals Must be made using this proforma. A referral letter can accompany form.Please Fax completed Proforma to the central referral point – Fax number – 01743 261333Clinical Team Enquiries: 01743 261058 / 01952 641222 EX 4493 (Not for patient use)Enquiry Number for patient use: 01743 261663 – Two Week Wait Co-ordinator Contact NumberPatient DetailsG.P. DetailsName:Name of Referring G.P.:Address:NHS No:Date of Birth:IMPORTANTTo be able to contact the patient within 48 hours ofreferral (day and evening) please provide patientspreferred contact telephone number:Home:Work:Mobile:Address:Telephone No:Fax No:G.P. Signature:Date of decision to refer:Please Confirm :• You have discussed the possibility of a cancer diagnosis with this patient.• The patient can attend an appointment within the next 14 days.• The patient is aware the appointment may be at either RSH or PRHCriteria for requesting URGENT CHEST XRAY HaemoptysisXXUnexplained or persistent (longer than 3 weeks): Cough Hoarseness Chest signs(e.g. unilateral wheeze) Dyspnoea Cervical or supraclavicular Chest and / or Shoulder painLymphadenopathy Unexplained Weight loss Finger clubbingFeatures suggestive of metastasis from a lung cancer (e.g. secondaries in the brain, bone, liver, skin)Underlying chronic respiratory problems with unexplained changes in existing symptoms.Criteria for URGENT Two Week Wait Referral to Chest Physician:• Persistent haemoptysis (in smokers or ex smokers aged 40 years and older).• A chest xray suggestive of lung cancer (including pleural effusion and slowly resolvingconsolidation).• A normal chest xray where there is a high suspicion of lung cancer.X• A history of asbestos exposure and recent onset of chest pain, shortness of breath or unexplainedsystemic symptoms where a chest xray indicates pleural effusion, pleural mass or any suspicious lung pathology.If patient has had chest xray / CT scan at different hospital please provide details of the hospital and date oftest. Please arrange for images to put onto a disc and sent to the chest physician urgently.If on Warfarin, consider stopping, if non essential, pending diagnostic procedureSigns of superior vena caval obstruction (swelling of the face / neck with fixed elevation of jugular venouspressure) or Stridor are suggestive of cancer and Emergency Referral / Telephone Consultation isindicated.Trust web site: www.sath.nhs.uk 1 of 2 LUNG / V – 1.0 / 2012

Royal Shrewsbury Hospital and Princess Royal HospitalTwo Week Suspected Cancer Referral ProformaLUNGNAME: D.O.B. NHS No:Additional Comments relating to this referral (Free text):Please attach sheet/s as appropriate:Current investigations: (e.g. scans)Current Medication:Past / Present Medical History:ADDITIONAL INFORMATIONTrust web site: www.sath.nhs.uk 2 of 2 LUNG / V – 1.0 / 2012