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Toronto East General Hospital – Time to Treat (Lung) Request for Respirology and Thoracic Surgery Consultation Tel: (416) 469-6580 x2171 email: [email protected] Given Name Birthdate Fax: (416) 469-6154 Surname Gender dd/mm/yy Street Home Phone ( City ) Primary Contact Surname Work ( ) Primary Contact Given Name Referring Physician Name Referral to: Respirologist Postal Code Physician Number F Translator Needed OHIP Number Home ( M VC ) Relationship Signature of Referring Physician (Mandatory) (Please refer to Clinical Pathway on other side) Thoracic Surgeon Either Reason for Referral Chest X-ray Suspicious of Lung Cancer Peripheral nodule or mass in smoker Non-peripheral mass or nodule in smoker Nodule or mass in non-smoker Multiple pulmonary nodules Pleural effusion Mediastinal or contralateral hilar adenopathy Insterstitial infiltrates Slowly or non-resolving pneumonia Fibroapical disease possible TB Clinical Symptoms Suspicious of Lung Cancer Massive hemoptysis Non-Massive hemoptysis Superior Vena Cava Syndrome (SVC) Stridor Date of suspicious X-Ray ____/_____/____________ (dd/mm/yyyy) (Please fax X-ray report if available) Other Reasons (Specify) ____________________________________________________________________________ INTERNAL USE ONLY Respirologist/Thoracic Surgeon: Consult Date Consult Time Consult Date Consult Time Date Confirmed Time Confirmed Dr. D. Bain (R) Dr. I Fraser (R) Dr. R. Skrastins (R) Dr. N. Safieddine (T) Dr. C. Simone (T) Dr. R. Zeldin (T) INVESTIGATIONS BOOKED Respirology & Thoracic Surgery Flow Volume Loops Full PFT Bronchoscopy Wang Procedure Mediastinoscopy VATS Radiology/Diagnostic Imaging Chest X Ray CAT Scan FNA Other (Specify) Other Obtained History of Patient Obtained All Pre Existing Chest X Rays Obtained All Medications Taken by Patient Obtained All Blood Work Guidelines for Family Physician Please send consultant notes including HISTORY OF PATIENT, ALL BLOOD WORK and CURRENT MEDICATIONS. Patients MUST ARRIVE ON TIME and bring their HEALTH CARD and ALL X-RAYS, CT SCANS AND PERTINENT DIAGNOSTIC TESTS. Clinical Pathway Referral Respirologist Thoracic Surgeon Chest X-Ray Suspicious of Lung Cancer Peripheral nodule or mass in smoker Non-peripheral mass or nodule in smoker Nodule or mass in non-smoker OR Multiple pulmonary nodules Pleural effusion Mediastinal or contralateral hilar adenopathy Interstitial infiltrates Slowly or non-resolving pneumonia (Not resolved within 8 weeks) Fibroapical disease possible TB OR Clinical Symptoms Suspicious of Lung Cancer Massive hemoptysis (> 1 cup/24 Hours) Non-Massive hemoptysis Superior Vena Cava Syndrome Stridor Guideline for urgent Chest X-ray: Hemoptysis Unexplained or persistent (more than 3 weeks) Cough Chest/Shoulder pain Dyspnea Superior Vena Cava (SVC) Syndrome Weight Loss Chest Signs Hoarsness Finger Clubbing Persistent Cervical/Supraclavicular Lymphadenopathy Features Suggestive of Metastases From Lung Cancer (Brain, Bone, Liver, Skin)