LUNG – Suspected Cancer TWR referral form
Please fax this form back within 24 hours of seeing the patient for hospital appointment within 14 days
Surname
First name(s)
Address
Date of birth
Home telephone:
Mobile/Work telephone:
NHS number:
Hospital number: / GP’s DETAILS
GP’s name
Surgery name
Surgery address
Surgery telephone:
Surgery fax:
Patients with STRIDOR or SIGNS of SUPERIOR VENA CAVAL OBSTRUCTION (i.e. swollen face/neck with fixed jugulat venous pressure elevation) ADMIT IMMEDIATELY
URGENT TWR REFERRAL CRITERIA / TICK
Persistent haemoptysis in smokers or ex-smokers aged 40 or older
A chest X-ray suggestive of lung cancer including pleural effusion and slowly resolving consolidation
A normal x-ray where there is a high suspicion of lung cancer
A history or asbestos exposure with recent onset chest pain/breathlessness/unexplained systemic symptoms, where a chest x-ray indicates pleural effusion, pleural mass or any suspicious lung pathology
RENAL FUNCTION – PLEASE ENSURE THAT ONE OF THE TWO BOXES IS COMPLETED
PLEASE NOTE THAT THE REFERRAL WILL NOT BE ACCEPTED WITHOUT THIS INFORMATION
eGFR in the last 2 months ______mL/min
Date: / If no eGFR within last 2 months, please arrange bloods to be taken at the point of referral.
Date of blood test:
PATIENTS WHO NEED AN URGENT X-RAY (REPORTED WITHIN 5 DAYS) INCLUDE:
Unexplained or persistent (longer than 3 weeks)
· Haemoptysis
· Underlying chronic respiratory problems with unexplained changes in existing symptoms / · Chest and/or shoulder pain
· Dyspnoea
· Weight loss
· Chest signs
· Hoarseness
· Finger clubbing / · Neck or supraclavicular lymph nodes
· Cough
· Features suggestive metastasis from lung cancer (brain/bone/liver/skin etc)
ADDITIONAL MANDATORY CLINICAL INFORMATION REQUIRED:
Attach summary of past medical history, medication and allergies / TICK
Summary of past medical history, medication and allergies attached?
I have told this patient I am referring them under the TWR and have explained this process
Referral letter attached?
Referral date: GP signature
TO MAKE A REFERRAL TO ROYAL SURREY COUNTY HOSPITAL, fax this form and any additional correspondence to: 01483 464848