TWO WEEK REFERRAL SERVICES

HEAD AND NECK

Indications for an urgent referral for a suspected new malignancy are:

  • Hoarseness persisting for > 3 weeks
  • Dysphagia persisting for 3 weeks
  • Unilateral nasal obstruction particularly when associated with purulent bloodstained discharge
  • Unresolving neck masses for > 3 weeks
  • Cranial neuropathies
  • Ulceration of oral mucosa persisting for > 3 weeks
  • Oral swellings persisting for > 3 weeks
  • All red or red and white patches of the oral mucosa
  • Unexplained tooth mobility not associated with periodontal disease

Pre-investigations required of G.P: Nil.

NOTE:

  1. The level of suspicion is further increased if the patient is a heavy smoker or heavy alcohol drinker is and aged over 45 years and male. Other forms of tobacco use (chewing Betel, Gutkha, Pan) should also arouse suspicion.
  2. A diagnostic service is provided by all the ENT Consultants but the treatment is undertaken only by Messrs. Cable, Patel and Phillips.

GEORGE ELIOT HOSPITAL, NUNEATONFAX REFERRAL TO: 02476 865279

Clinical advice may be obtained from:

Consultants:Mr P.Patel02476 538967

ST CROSS HOSPITAL, RUGBYFAX REFERRAL: 02476 844185

Clinical advice may be obtained from:

Consultants:Mr P.L.Kander01788 545196

Mr D. Jones01788 545196

WALSGRAVE HOSPITAL, COVENTRYFAX REFERRAL: 02476 844185

(Including COVENTRY & WARWICKSHIRE HOSPITAL)

Clinical advice may be obtained from:

Consultants:Mr P.J.Patel02476 538967

Mr D. Jones02476 535021

WARWICK HOSPITAL, WARWICKFAX REFERRAL: 01926 482665

Clinical advice may be obtained from:

Consultant:Mr D.Phillips01926 495321 ext 4620

Cover:Mr H.Cable01926 495321 ext 4290

To: / Please indicate other Acute Provider:

This referral is made on the basis that the referring doctor consider that the patient has clinical indications of a new malignancy

Is patient aware of reason for referral (please indicate) Yes No

HEAD AND NECK

For Hospital use only
Time and date received: / Signed: / Printed:
Date of appointment
For Hospital use only
Criteria for referral met / Y / N / Comments:
Signed: / Date:

Please indicate reason for referral

REASON FOR REFERRAL / TICK / REASON FOR REFERRAL / TICK
ENT / ORAL
  • Hoarseness > 3 weeks
/
  • Ulceration of oral mucosa > 3 weeks

  • Dysphagia > 3 weeks
/
  • Oral swelling > 3 weeks

  • Unresolving neck masses > 3 weeks
/
  • Patches on oral mucosa

  • Cranial neuropathies
/ Red / Red and white
  • Unilateral nasal obstruction with purulent blood stained discharge
/
  • Tooth mobility without peridontal disease

Risk factors: / Smoker / Ex-smoker / Chewing tobacco / Alcohol
Additional history/comments (including medications and / or any recent investigations)
Medical history
Patient Details / GP Details
Surname: / Registered GP: (Dentist)
Forename: / Dentist Address:
Address: / Postcode:
Post Code: / Phone number:
Hospital Number: / Fax Number:
NHS No: / GP Signature:
Date of Birth: / Date of decision to refer:
How can we communicate time and date of this urgent appointment to the patient? / Practice Code
Phone (day time contact number): / GP Code
Evening contact number: / Interpreter Needed ? / Yes No

Ref. TW005Issue: 110 Jan 2005