Birmingham Hospitals Urgent Referral for Suspected

BIRMINGHAM HOSPITALS URGENT REFERRAL FOR SUSPECTED

PROSTATE, PENILE & TESTICULAR CANCER IN ADULTS (16 AND OVER).

Patient details:
Surname:
Forename:
DoB: Gender:
Address
Hospital/NHS number:
Interpreter required? Y/N First Language: / GP Details:
Fax no:
Date of Decision to refer:
Date of referral:
GP Signature:
GPDeclaration

Ihaveinformedthepatient theyhavesymptoms whichmaybecausedbycancer,thattheyarebeingreferred totherapidaccesssuspectedcancer clinic and the nature of the tests likely to take place.

Ihaveprovidedthepatientwitha 2weekwait informationleaflet.

Mypatienthasconfirmedtheyareavailabletoattendwithin2weeks.

GP Investigations/examinations: Prostate
Test / Tick if done / Hospital/Result
DRE
MSU
FBC
U+E
PSA
Prostate – likely to have TRUS & Biopsy
Tick if chosen /

Feature

/ Tick if present
Prostate feels malignant on digital rectal examination
PSA levels are above the age-specific range with no evidence of UTI

Significant symptoms suggestive of metastases and raised PSA

Patients aged >60 withrecurrent or persistent unexplained UTIbut without a risk factor or clinical features listed below should be referred as normal to the local, urology clinic
Penile –likely to be seen in Clinic
Tick if chosen /

Feature

/ Tick if present
Penile mass or ulcerated lesion, where sexually transmitted infection has been excluded.
Persistent penile lesion after treatment for sexually transmitted infection has been completed.
Unexplained or persistent symptoms affecting the foreskin or glans.
Testicular – likely to have a Scrotal USS
Tick if chosen /

Feature

/ Tick if present
A non-painful enlargement or change in shape or texture of the testis.
PMH, Medication or Any other Comments:
Performance Status: 0 1 2 3 4 highlight as appropriate
Anticoagulant/aspirin/clopidogrel – yes/no
PROSTATE, PENILE & TESTICULAR RAPID ACCESS FACILITIES
Hospital / Tel / Email
QEHB / 0121 371 7060 /
HGS / 0121 424 5000 /

Please be aware that forms that contain missing data or are incorrectly completed will be returned to the Practice for correction and resubmission.