Cancer Referral form - Haematology

HAEMATOLOGY Suspected Cancer Referral(2 Week Wait Referral)Please FAX within 24 hours to the Cancer Referrals Office on:01708 435074 or 01708 435367Section 1 PATIENT INFORMATION (Please complete in BLOCK CAPITALS)SURNAMEDate of Referral / /Date of Birth / /FIRST NAMEMiss Mrs Ms Mr Other________ M [ ] F [ ] Home Tel.AddressPost CodeNHS numberUBRN - -Mobile/Daytime Tel.Transport Y N Interpreter Y NLanguageSection 2 PRACTICE INFORMATION (Please use practice stamp if available)Referring GP Locum Y NPractice AddressTelephoneFaxPost CodeSection 3 CLINICAL INFORMATION (please TICK all applicable entries)Please enclose print outs of CURRENT medications and PAST MEDICAL HISTORYBLOOD COUNT orBLOOD FILM reportsuggestive of ACUTELEUKAEMIA orCHRONIC MYELOIDLEUKAEMIADISCUSSIMMEDIATELY BYTELEPHONE WITHDUTY HAEMATOLOGYCONSULTANT OR SpRWBC [ ]Hb [ ]Platelets [ ]Neutrophils [ ]Lymphocytes [ ]Investigations:[ ] SIGNIFICANTLYMPHADENOPATHYIF persisting for > 6 weeksor > 2 cm or widespreador with splenomegaly orwith B symptoms(If < 1cm, unlikely to besignificant)Size [ ] cmSite(s) (please list)Before referring, pleaseensure glandular fevertest is negative if patient

LOCAL CONTACT DETAILSCancer Waiting Times Co-ordinator Tel. 01708 435169 Queen’s HospitalCRITERIA 1 FOR URGENT SUSPECTED CANCER REFERRALPlease FAX the referral form within 24 hoursRefer a patient who presents with symptoms suggesting haematological cancer to a team specializing inthe management of haematological cancer, depending on local arrangements.Be aware that haematological cancers can present with a variety of symptoms that may have a number ofdifferent clinical explanations.Combinations of the following symptoms and signs warrant full examination, further investigation (includinga blood count and film) and possible referral:- fatigue - breathlessness - alcohol-induced pain- drenching night sweats - bruising - abdominal pain- fever - bleeding - lymphadenopathy- weight loss - recurrent infections - splenomegaly- generalised itching - bone painThe urgency of referral depends on the symptom severity and findings of investigations.For immediate referral above please telephone duty Haematology Consultant or SpRvia switchboardInvestigationsIn patients with:• persistent unexplained fatigue carry out a FBC, blood film and ESR, plasma viscosity or C-reactiveprotein (according to local policy). Repeat at least once if the patient’s condition remains unexplainedand does not improve• unexplained lymphadenopathy carry out a FBC, blood film and ESR, plasma viscosity or C-reactiveprotein . Consider glandular fever test if age