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Suspected Haematological Malignancies 2ww Referral Form For Choose and Book referrals, attach this template to a referral in Choose and Book within 24 hours of creating the request - an appointment must be made for the patient before they leave the practice. Please X the corresponding box for the hospital the referral is being made to and fax/send within 24 hours. Barnet Chase Farm BHRUT Barts & London Fax: 020 8375 1977 Fax: 020 8375 1977 Fax: 01708 435 074/ Fax: 020 3594 3278 Tel: 020 8370 9079 Tel: 020 8370 9079 01708 435 367 Tel: 020 7767 3333 Tel: 01708 435 065 Homerton Newham North Middlesex PAH Fax: 020 8510 7832 Fax: 020 7363 8818 Fax: 020 8887 2663/4 Fax: 01279 827 171 Tel: 020 8510 5099 Tel: 020 7363 8817 Tel: 020 8887 2662 Tel: 01279 827 550 Royal Free UCLH Whipps Cross Whittington Fax: 020 7433 2950 Fax: 020 3447 9932 Fax: 020 8928 8836 Fax: 020 7288 5621/3793 Tel: 020 7433 2969 Tel: 020 3447 9599 Tel: 020 8535 6856 Tel: 020 7288 3070 PATIENT DETAILS (Please complete in block capitals) GP DETAILS (Please complete in block capitals) Forename: Surname: Address: Date referral sent: Name of referrer: Address: Post code: Date of Birth: / / Sex: M F NHS Number: Has the patient previously visited the hospital? Y N Hospital Number: Post code: Interpreter required: Y N Phone number: Language: Fax number: IMPORTANT: To be able to contact the patient within 48 hours of referral (day and evening) please provide patients preferred contact phone details Home: Mobile: Work: REFERRAL INFORMATION (Mandatory) Malignancy Leukaemia Hodgkins or Non Hodgkins suspected: Lymphoma If acute leukaemia suspected on blood test telephone haematology immediately Myeloma If spinal cord compression suspected refer immediately for investigation Symptoms: Examination Findings: Night Sweats Itching Bruising/ Bleeding Recurrent infections Back pain with ‘Red Flags’ Persistent bone pain Unexplained LN >1cm for 6 weeks Or Unexplained LN >2cm Weight loss Breathlessness Other Unexplained splenomegaly Renal failure suspected Other Results of Investigations Hb WBC Plat ESR WHICH HOSPITAL LABORATORY: Creatinine Calcium Albumin Bilirubin If myeloma suspected: Serum protein electrophoresis MSU for Bence Jones Protein Radiology as appropriate Family History of cancer including age of their diagnosis: Other relevant information (free text): e.g. location of LNs I confirm that I have discussed the possibility with the patient that the diagnosis may be cancer PLEASE INCLUDE WITH THIS PROFORMA PAST MEDICAL HISTORY, MEDICATIONS AND RESULTS AND YOUR REFERRAL LETTER IF APPROPRIATE London Cancer 2ww Haematology referral form Page 1 of 3 Haematological cancers Patient presents with Combinations of the following: drenching night sweats persistent unexplained fever weight loss generalised itching breathlessness bruising bleeding recurrent infections bone pain alcohol-induced LN pain abdominal pain lymphadenopathy splenomegaly. Full clinical examination, investigate with FBC and blood film, ESR/CRP Unexplained lymphadenopathy– >1cm for 6 weeks Or unexplained LN>2cm Persistent unexplained fatigue or symptoms of anaemia (iron deficiency anaemia excluded) Unexplained bleeding, bruising, purpura Persistent unexplained splenomegaly Following features of lymphadenopathy: persistence for 6 weeks or more lymph nodes increasing size lymph nodes > 2 cm widespread nature associated splenomegaly, night sweats or weight loss. Persistent unexplained skeletal pain RED FLAG FEATURES? Age >50 or <20 years Constitutional symptoms (malaise, weight loss) Thoracic pain Pain worsening at night or when supine Severe or progressive sensory alteration or leg weakness Bladder or bowel dysfunction Full clinical examination; investigate with FBC and blood film, ESR/CRP +/_ Clotting screen Full clinical examination, investigate with FBC and blood film, ESR/CRP Full clinical examination; investigate FBC, U&E, liver and bone profile, serum protein electrophoresis and MSU for BJP, ESR/CRP. Consider X-ray FBC/Blood film suggestive of acute leukaemia N Y N 2 WW Y IMMEDIATE REFERRAL Possible spinal cord compression or renal failure suspected of being caused by myeloma IMMEDIATE REFERRAL Do: Remain vigilant for red flag symptoms indicating a malignant cause for bone pain. Consider myeloma in these cases. Safety net patients with lymphadenopathy. Explain that they should return if the LNs grow, persist for over 6 weeks or are associated with other symptoms (fever, night sweats, weight loss, pain in LNs after drinking alcohol). Include all relevant clinical information on the 2ww form. If blood tests are not available at time of referral, indicate the laboratory where tests were done. If in doubt about whether to refer, consider phoning for advice; use the contact list opposite. Don’t × If suspecting myeloma, don’t be reassured by a normal serum protein electrophoresis; 1 in 3 patients with myeloma have normal serum electrophoresis but positive urine BJP. Be Specific: When referring via two week wait, be specific about when the patient should have heard from the hospital and what to do if they have not. Try to inform the patient that the purpose of the 2ww referral is to exclude serious conditions such as cancer. London Cancer 2ww Haematology referral form Page 2 of 3 If you wish to discuss clinical issues relating to the two week wait referral please contact: Barnet Hospital Chase Farm Hospital Barking, Havering and Redbridge University Hospitals NHS Trust Barts and the London Hospital Tel: 020 8216 4383 Louise Edwards (CNS) via Chase Farm Hospital Day Clinic – 020 8375 2066 Tel: 020 8375 1457 Cancer Referrals Office Tel: 01708 435065 Bodley Scott Day Unit; Tel: 020 3465 6780/6789 Out-of hours: bleep the On Call Haematology Oncology Specialist Registrar or Consultant Homerton University Hospital NHS Foundation Trust Tel: 07909 002 671 (24 hours) Secretaries’ Office: 020 8510 7325 Dr Roger Amos; Consultant Haematologist Tel: 020 8510 7900 Josie Robinson, Secretary to above Tel: 020 8510 7309/ Fax: 020 8510 7555 Newham University Hospital North Middlesex University Hospital NHS Trust Princess Alexandra Hospital NHS Trust Royal Free London NHS Foundation Trust University College London NHS Foundation Trust Whipps Cross University Hospital Dr Pavel Kotoucek – Consultant Haematologist via Jackie (Secretary to Dr Kotouchek) Tel: 020 7363 3413 Dr Thuraisamy Kumaran and Dr Neil Rabin; Consultant Haematologists Tel: 020 8887 2471 Fast Track Office Tel: 01279 827 550 Dr Kate Cwynarski; Consultant Haematologist Tel: 020 7317 7514 Fran Penny, CNS Tel: 0207 7940500 ext 33477 or bleep 1102 Dr Kirit Ardeshna; Consultant Haematologist, via secretary Melissa Crozier Tel: 020 3447 9443 Dr Naim Akhtar; Consultant Haematologist Lorraine Limburn Secretary: Tel: 020 8539 5522 x 4547 London Cancer 2ww Haematology referral form Page 3 of 3