University College Hospital Pancreaticobiliary New Patient Referral

Please email back to the sender :

Dedicated PB referral line: 07939204237 (within office hours)

PATIENT DETAILS: Essential for UCH registration

Name
DOB
Address
Phone Numbers (inc mobile please)
GP and Practise
NHS number
essential otherwise case can’t be done
Consultant
Hospital
Ward
Contact name and number of referrer (mobile preferable)

CLINICAL DETAILS and details of IMAGING (stretch the box to add details)

Many cases are done with anaesthetic support, so the following information is crucial

PAST MEDICAL HISTORY (see anaesthetic notes page 2)

Cardio / Resp / Endocrine / Neuro / Haem / GI

PAST SURGICAL HISTORY (inc previous GAs) stretch the text box if required

MEDICATIONS and ALLERGIES (especially warfarin / heparin / clopidogrel / aspirin)

BLOODS (all essential): Date

Coag / ALT
Platelets / GGT
Hb / CRP
WCC / Na
Platelets / K
Bilirubin / Urea
ALP / Creat
Cardiology
MI/Angina
Hypertension
Pacemaker/AICD
Coronary stent
Valve disease / Respiratory
COPD/Bronchitis
Asthma
TB
Sleep apnoea / Neurological
Epilepsy/FITS
CVA/TIA/Stroke
Muscle disease
Arthritis
Endocrine/Renal
Diabetes
Thyroid disease
Kidney disease / GI
Acid reflux/Indigestion
Hiatus hernia
Stomach ulcer
Bowel problems
Liver disease / Haematology
Anaemia
DVT/PE/Blood clots
Blood disorders

Important features of Past Medical History for Anaesthetic Risk – mark with a ‘Y’

Further Anaesthetic requirements:

·  ALL OVER 50 YEAR OLDS SHOULD ATTEND UCH WITH A RECENT ECG

·  THE PATIENT SHOULD ATTEND UCH WITH ORIGINAL HOSPITAL NOTES FROM REFERRING HOSPITAL OR COPY OF NOTES

Cardiology

Pacemakers need checking by a technician before procedure.

Patients with moderate to severe heart disease need assessment by a cardiologist and an up to date echocardiogram if possible

Respiratory

Patients with moderate to severe disease need lung function tests: spirometry & peak flow rate.

Neurological

Patients with a significant history of recurrent TIA/CVA need a Doppler of the carotids.

Endocrine

Patients with thyroid disease need thyroid function tests.

The assessments and tests should have been done within the last 6 months (or within a year is acceptable if the condition has been stable).

A written report of the tests and assessments should accompany the patient.

NB significant disease means disease which interfere with daily living activities