YORK TEACHING HOSPITALS NHS TRUST

SCARBOROUGHHOSPITAL

Gynaecology Urgent Two Week Wait Referral

Please fax this form to the Women’s Unit within 24 hours of the referral date. Please also attach a letter to the clinical team.

Is patient aware the referral is urgent?
/
Y / N

Guidelines are on the reverse side.

Women’s Unit contact numbers

Fax 01723385065 Tel 01723385358

Section 1 – PATIENT INFORMATION. Please complete in BLOCK CAPITALS.

SURNAME
/
Has patient visited this hospital before?
/
Y / N
FIRST NAME
/
NHS
Number
/
Hospital
Number
D.O.B.
Address
Post Code
/
First language
Interpreter required?
/
Y / N
Transport required?
/

Y / N

Daytime Telephone

/

Is patient available for appointment Y / N

within 2 weeks

Home Telephone (if different)

/ Mobile No.

Section 2 – PRACTICE INFORMATION. Please use practice stamp if available.

Referring GP

/

Locum?

/

Y / N

Practice Address

Post Code
/

Telephone

Fax

Section 3 – CLINICAL INFORMATION. Please tick the relevant boxes.

Cancer type suspected

 Ovary /  Cervix /  Endometrium /  Vagina / Vulva

Menopausal status

 Premenopausal /  Postmenopausal /  Hysterectomy /  On HRT

Bleeding PV

 Intermenstrual

Number of episodes

/  Postcoital /  Postmenopausal
Duration (days / weeks)

Abdominal symptoms

/  Yes /  No

Examination findings

 Negative /  Abdominal mass /  Pelvic mass /  Visible cervical lesion
 Vulval /vaginal lesion /  Bleeding / ulcerated vulval /vaginal lesion

Additional information - Attach patient computer record summary if available. Continue on separate sheet if required.

Refer urgently patients:

  • With clinical features suggestive of cervical cancer on examination. A smear test is not required before referral, and a previous negative result should not delay referral
  • With an unexplained vulval lump
  • Not on HRT with postmenopausal bleeding
  • On HRT with persistent or unexplained postmenopausal bleeding after cessation of HRT for 6 weeks
  • Taking tamoxifen with post menopausal bleeding
  • With vulval bleeding due to ulceration.
  • With a palpable abdominal or pelvic mass on examination that is not obviously uterine fibroids or not of gastrointestinal or urological origin. Obtain Ca125, Ca199 and CEA markers.
Consider an urgent referral for patients with persistent inter-menstrual bleeding and negative pelvic examination.
Use this proforma to refer urgently (2 Week Wait)

Investigations in Primary Care:

A full pelvic examination, including speculum examination of the cervix, is recommended for patients presenting with any of the following:
  • postmenopausal bleeding
  • vaginal discharge.
Carry out an abdominal palpation, and consider a pelvic examination, in patients with vague, non-specific, unexplained abdominal symptoms such as
  • bloating
  • unexplained weight loss
  • loss of appetite
  • constipation
  • abdominal pain
  • back pain
  • urinary symptoms.
In patients with vulval pruritus or pain, a period of ‘treat, watch and wait’ is reasonable. Active follow-up is recommended until symptoms resolve or a diagnosis is confirmed. If symptoms persist, the referral may be urgent or non-urgent, depending on the symptoms and the degree of concern about cancer.
Non-urgent referrals should be made using Choose & Book or a letter.

Patient information and support:

Consider the information and support needs of patients and the people who care for them while they are waiting for the referral appointment.

.

June 2014