Download Medical Director - Clinical Measurement Referral

<<Patient Demographics:Full Name>> DOB <<Patient Demographics:DOB>>
URN:
Family Name: <<Patient Demographics:Surname>>
Given Names: <<Patient Demographics:First Name>>
Address: <<Patient Demographics:Full Address>>
DOB: <<Patient Demographics:DOB>>
Sex: <<Patient Demographics:Sex>>
Referral to Clinical Measurements
Facility: ________________
Clinical Measurements Department - Phone: 4616 6339
Referral To
<<Referral to>>
Date of request: <<Miscellaneous:Date (short)>>
Ward/Clinic: <<Practice:Name>>
Fax: 4616 6410
Provider No: <<Doctor:Provider Number>>
 Inpatient
Routine Outpatient Outpatient appointment in
appointment in ? weeks>>
Name: <<Doctor:Name>>

Designation:

Signature:___________________
weeks<<Outpatient
Cardiac Investigations

Exercise Stress Test (EST) Protocol - Bruce Modified Bruce
Sub-maximal
Please complete EST questionnaire and eligibility criteria on page 2 of this form
ECG
72hrs 96hrs
Holter monitor (specify)  24hrs 48hrs
Ambulatory BP monitoring (24hrs)
Loop/event monitor
Tilt Table Test (TTT) please complete TTT questionnaire and eligibility criteria on page 2 of this form
Respiratory Investigations
Spirometry
Pre and Post
Clinical Details
Current medications:
<<Clinical Details:Medication List>>
Reason for test: <<Reason for test>>
Recent Investigations
Bloods
ECG
Chest x-ray
Risk Factors
Smoker
Diabetes mellitus
Family History
Hyperlipidaemia
GP
Name: <<Doctor:Name>>
Address: <<Doctor:Full Address>>
Family Name: <<Patient
Appointment date
/
/
/
/
/
/
Given Name: <<Patient
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CMD STAFF ONLY
Appointment Time
:
:
:
URN:
<<Patient Demographics:Full Name>> DOB <<Patient Demographics:DOB>>
Demographics:Surname>>
Demographics:First Name>>
Exercise Stress Test Questionnaire
Please Indicate
Beta Blockers/ Verapamil / diltiazem - cease 48 hours prior to test (if clinically advisable)
Nitrates - cease six (6) hours prior
OR
Continue medication as prescribed
Exercise Stress Test Eligibility
All criteria listed below must be met in order for a client to be deemed suitable to undergo an exercise stress
test. Is this test age appropriate?
No new significant ECG findings at rest e.g. AF
No uncontrolled hypertension (>180/100mmHg)
No untreated life-threatening cardiac arrhythmia
No myocardial infarct (,5 days)
No decompensated congestive cardiac failure
No acute myocarditis / pericarditis
No hypertrophic obstructive cardiomyopathy
Not taking digoxin

No aortic stenosis

 No left bundle branch block

 No acute infections / anaemia
No recent EST
No second or third degree A-V block
No known or suspected left main stem CAD
Patient's weight is not over 180 kg
Patient can walk briskly
If all the above criteria are not able to be met, or if they are unfit for cardiac stress test, consider:
1.
MPS with pharmacological stress/stress echo once the blood pressure and electrolyte abnormalities are
corrected.
2.
Referral to Cardiology Outpatients if EST or MPS is positive
Tilt Table Test Questionnaire
Indications for tilt testing:
Syncope is a transient loss of consciousness due to transient global cerebral hypoperfusion characterised by a
fairly rapid onset, short duration and spontaneous complete recovery. The most important tool in the evaluation of
syncope is careful history taking, with an eye-witness account where possible. Tilt testing enables the reproduction
of a neurally-mediated cardio-inhibitory reflex in laboratory conditions. It is not indicated if the history is typical of
reflex syncope. A positive tilt test is only relevant if the response on the tilt table correlates with the clinical picture.
Tilt testing may be indicated (after history, examination, ECG, Holter/event recording and appropriate investigations
for structural heart disease):

to evaluate recurrent syncope and pre-syncope in absence of structural heart disease.

after a single episode of syncope only if there are special circumstances, e.g. vocational driver, airline pilot

to differentiate syncope with myoclonic jerks from seizures.

to evaluate recurrent falls, if all other causes are excluded.

when the specific responses during syncope (hypotension vs bradycardia) may help dictate treatment.
Contraindications to tilt testing:

a history/suggesting epilepsy as the cause of loss of consciousness

inability to stand for long periods due to pain

morbid obesity

pregnancy

recent MI or stroke (< 3 months)

a tight stenosis of cardiac valve, the LV outflow tract or a carotid, vertebral or coronary artery.
TO BE COMPLETED BY REFERRER
Eligibility criteria
The history suggests neurocardiogenic syncope or orthostatic hypotension
Physical examination does not suggest the presence of structural heart disease.
If the patient has a murmur, an echo has excluded significant valve disease.
If the patient has a carotid bruit, carotid dopplers have excluded significant carotid stenosis
NB Neurological investigations (CT/MR scanning, EEG) are not indicated in the investigation of typical
neurocardiogenic syncope.
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