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Dr Marie Scully Dr JP Westwood Dr Mari Thomas Ms Siobham Mcguckin SpR bleep 7050 PA: 020 3447 9884 Suspected TTP Referral Form Patient name: Name of referrer: Date of birth: Hospital/ward of referrer: NHS number: Direct contact number: Date: Time: Blood pressure: Pulse: Temperature: NEWS: GCS: Height: Weight: Current clinical condition and level of care: ........................................................................................................................................................................................... ........................................................................................................................................................................................... ........................................................................................................................................................................................... ........................................................................................................................................................................................... ........................................................................................................................................................................................... LAS: Time contacted: Anaesthetic review pre transfer Yes No Ref No: Escort required Anaesthetist Yes No Co-morbidities: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………….................. Medications/Allergies: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… Infection control: MRSA Current IV Access: CDT Status Central line FBC/Film: U&E/LDH/Ca: PT/APTT/Fibrinogen/D-dimer: ADAMTS 13 to be taken PRE PLASMA: Citrate sample: ABO Blood Group: Peripheral Cannulae NHS number: Name: DOB: Clerking proforma for patients with suspected TTP Presenting complaint ........................................................................................................................................................................................... ........................................................................................................................................................................................... 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Risk factors Current Pregnancy HIV Autoimmune Disorders Malignancy Pancreatic Disease Previous TTP
