Cancer Templates – NHS Lanarkshire LanRefHelp

Urology Cancer Template

August 7, 2017August 7, 2017 Scott McLaughlin

This is a dictation template to provide a reminder of the information required to complete the referral. The fields in red are mandatory and must be completed on the referral protocol.

Presenting Complaint

Main Presenting Complaint: [Text – 98 character maximum]

Reason for Referral: [Text]

World Health Organisation Performance Scale
Using the following as a guide, please select the most appropriate answer to describe the patients general health:

Options:

Asymptomatic
Symptomatic but completely ambulatory
Symptomatic, <50% in bed during the day
Symptomatic, >50% in bed, but not bedbound
Bedbound

Priority: Urgent Suspicion of Cancer

Date of Onset: [Date]

Prefered Hospital:

Hairmyres Hospital
Monklands Hospital
Wishaw General Hospital
First Available appointment

Clinical Examinations and Findings

Examinations and Findings

Frank haematuria in an adult (unexplained):

Yes (If Yes, please provide brief details)
No

Symptomatic, non-visible haematuria in a patient over 40 years old:

Yes (If Yes, please provide brief details)
No

Palpable renal mass with/without pain, with/without haematuria:

Yes (If Yes, please provide brief details)
No

Solid renal mass found on imaging:

Yes (If Yes, please provide brief details)
No

PSA outwith age related reference range:

Yes (If Yes, please provide brief details)
No

Clinically malignant prostate on PR exam and/or bone pain suspicious of metatastic prostate cancer:

Yes (If Yes, please provide brief details)
No

Swelling in body of testis or other suspicion of testis cancer:

Yes (If Yes, please provide brief details)
No

Suspected penile cancer:

Yes (If Yes, please provide brief details)
No

Investigations

Please indicate if any of these tests have been checked.

MSSU:

U&E and FBC:

PSA – after patient has been counselled:

Urology cancer guideline

Skin Cancer Template

August 7, 2017August 7, 2017 Scott McLaughlin

This is a dictation template to provide a reminder of the information required to complete the referral. The fields in red are mandatory and must be completed on the referral protocol.

Presenting Complaint

Main Presenting Complaint: [Text – 98 character maximum]

Reason for Referral: [Text]

World Health Organisation Performance Scale
Using the following as a guide, please select the most appropriate answer to describe the patients general health:

Options:

Asymptomatic
Symptomatic but completely ambulatory
Symptomatic, <50% in bed during the day
Symptomatic, >50% in bed, but not bedbound
Bedbound

Priority: Urgent Suspicion of Cancer

Expected Outcome:

Not specified
Diagnostic advice

Date of Onset: [Date]

Will the patient accept any site for treatment:

Lesions and Risks

Lesion Characteristics

Duration of lesion (months): [Text]

Site of lesion: [Text]

Size of lesion (mm): [Text]

Are there any changes to the lesion?

Lesion Specific Details

If Yes to the above question, Are there any changes to the lesion?, please answer the following:

Change in leasion size:

Is there irregular pigmentation:

Are there irregular borders:

Is the lesion inflamed:

Does the lesion itch or have altered sensation:

Is the lesion larger than others:

Does the lesion bleed or ooze:

Risk Factors

Has the patient had previous sunbed exposure:

Is the patient immunosuppressed:

Does the patient have a history of skin cancer:

Has the patient had a previous transplant:

Provisional Diagnosis

Provisional diagnosis:

Other
Melanoma
Basal cell carcinoma
Squamous cell carcinoma
Cutaneous lymphoma

Other (please specify): [Text]

Skin cancer guidelines

Lung Cancer Template

August 7, 2017August 7, 2017 Scott McLaughlin

This is a dictation template to provide a reminder of the information required to complete the referral. The fields in red are mandatory and must be completed on the referral protocol.

Presenting Complaint

Main Presenting Complaint: [Text – 98 character maximum]

Reason for Referral: [Text]

World Health Organisation Performance Scale
Using the following as a guide, please select the most appropriate answer to describe the patients general health:

Options:

Asymptomatic
Symptomatic but completely ambulatory
Symptomatic, <50% in bed during the day
Symptomatic, >50% in bed, but not bedbound
Bedbound

What does the patient know: [Text]

Results

Chest X-ray:

Normal
Abnormal – Suspicion of cancer
Abnormal – other

Date of chest x-ray: [Date]

Blood sample for e-GFR taken within past 3 months:

Priority: Urgent Suspicion of Cancer

Date of Onset: [Date]

Will the patient accept any site for treatment:

Lung cancer referral guideline

Haematological Cancer Template

August 7, 2017August 7, 2017 Scott McLaughlin

This is a dictation template to provide a reminder of the information required to complete the referral. The fields in red are mandatory and must be completed on the referral protocol.

Presenting Complaint

Main Presenting Complaint: [Text – 98 character maximum]

Reason for Referral: [Text]

World Health Organisation Performance Scale
Using the following as a guide, please select the most appropriate answer to describe the patients general health:

Options:

Asymptomatic
Symptomatic but completely ambulatory
Symptomatic, <50% in bed during the day
Symptomatic, >50% in bed, but not bedbound
Bedbound

Priority: Urgent Suspicion of Cancer

Date of Onset: [Date]

Will the patient accept any site for treatment:

Symptoms and Investigations

Symptoms

History – Please add more details where required.

Fatigue:

Yes (If Yes, please provide brief details)
No

Night Sweats:

Yes (If Yes, please provide brief details)
No

Weight Loss:

Yes (If Yes, please provide brief details)
No

Itching:

Yes (If Yes, please provide brief details)
No

Breathlessness:

Yes (If Yes, please provide brief details)
No

Bruising:

Yes (If Yes, please provide brief details)
No

Recurrent Infections:

Yes (If Yes, please provide brief details)
No

Bone Pain:

Yes (If Yes, please provide brief details)
No

Polyuria and polydipsia (with normal glucose)

Yes (If Yes, please provide brief details)
No

Clinical Examinations

Hepatomegaly:

Yes (If Yes, please provide brief details)
No

Splenomegaly:

Yes (If Yes, please provide brief details)
No

Lymphadenopathy greater than 2cm over 6 weeks:

Yes (If Yes, please provide brief details)
No

Haematology cancer guideline

Gynaecology, Suspicion of Cancer Template

August 7, 2017August 7, 2017 Scott McLaughlin

This is a dictation template to provide a reminder of the information required to complete the referral. The fields in red are mandatory and must be completed on the referral protocol.

Presenting Complaint

Main Presenting Complaint: [Text – 98 character maximum]

Reason for Referral: [Text]

World Health Organisation Performance Scale
Using the following as a guide, please select the most appropriate answer to describe the patients general health:

Options:

Asymptomatic
Symptomatic but completely ambulatory
Symptomatic, <50% in bed during the day
Symptomatic, >50% in bed, but not bedbound
Bedbound

Priority: Urgent Suspicion of Cancer

Date of Onset: [Date]

Will the patient accept any site for treatment:

Symptoms and Investigations

Symptoms

Persistant intermenstrual bleeding:

Persistent postcoital bleeding:

Postmenopausal bleeding (not on HRT):

Postmenopausal bleeding on combined continuous HRT or unscheduled bleeding on sequential HRT:

Persistent abdominal pain:

Abdominal distension:

Clinical Examination

Abdominal / Pelvic mass palpable by abdominal examination:

Yes (If Yes, please provide brief details)
No

Ascites

Cervical or vaginal lesion, suspicion of cancer:

Vulval lesion suspicion of cancer:

Investigation

Please indicate if any of the following have been checked

FBC and ESR sent:

CEA sent (if ovarian cancer suspected):

CA125 sent (if ovarian cancer suspected):

Ultrasound scan arranged:

Yes (If Yes, please provide brief details)
No

Gynaecology, Suspicion of Cancer Guideline

Gastrointestinal (Upper) Cancer, Surgeon Template

August 7, 2017August 7, 2017 Scott McLaughlin

This is a dictation template to provide a reminder of the information required to complete the referral. The fields in red are mandatory and must be completed on the referral protocol.

Presenting Complaint

Main Presenting Complaint: [Text – 98 character maximum]

Reason for Referral: [Text]

World Health Organisation Performance Scale
Using the following as a guide, please select the most appropriate answer to describe the patients general health:

Options:

Asymptomatic
Symptomatic but completely ambulatory
Symptomatic, <50% in bed during the day
Symptomatic, >50% in bed, but not bedbound
Bedbound

Priority: Urgent Suspicion of Cancer

Date of Onset: [Date]

Will the patient accept any site for treatment:

Symptoms and Investigations

Symptoms

Unexplained weight loss:

Yes (If Yes, please provide brief details)
No

Unexplained iron deficiency anemia:

Yes (If Yes, please provide brief details)
No

Family history of oesophago-gastric cancer in more than two first degree relatives:

Yes (If Yes, please provide brief details)
No

Family history of familial adenomatous polyposis in any first degree relative:

Yes (If Yes, please provide brief details)
No

Barrett’s oesophagus:

Yes (If Yes, please provide brief details)
No

Pernicious anaemia:

Yes (If Yes, please provide brief details)
No

Gastric surgery over 20 years ago:

Yes (If Yes, please provide brief details)
No

Known dysplasia, atrophic gastritis, intestinal metaplasia:

Yes (If Yes, please provide brief details)
No

Upper abdominal epigastric mass:

Yes (If Yes, please provide brief details)
No

Iron deficiency anaemias:

Yes (If Yes, please provide brief details)
No

Clincal Examination

Jaundice:

Yes (If Yes, please provide brief details)
No

Upper abdominal mass:

Yes (If Yes, please provide brief details)
No

Investigations

FBC and ESR sent:

LFT, U&E sent:

Previous endoscopy done:

Upper GI cancer surgeon guideline

Gastrointestinal (Upper) Cancer, Endoscopy Template

August 7, 2017August 7, 2017 Scott McLaughlin

This is a dictation template to provide a reminder of the information required to complete the referral. The fields in red are mandatory and must be completed on the referral protocol.

Presenting Complaint

Main Presenting Complaint: [Text – 98 character maximum]

Reason for Referral: [Text]

World Health Organisation Performance Scale
Using the following as a guide, please select the most appropriate answer to describe the patients general health:

Options:

Asymptomatic
Symptomatic but completely ambulatory
Symptomatic, <50% in bed during the day
Symptomatic, >50% in bed, but not bedbound
Bedbound

Priority: Urgent Suspicion of Cancer

Date of Onset: [Date]

Will the patient accept any site for treatment:

Symptoms and Investigations

Symptoms

Unexplained weight loss:

Yes (If Yes, please provide brief details)
No

Unexplained iron deficiency anemia:

Yes (If Yes, please provide brief details)
No

Family history of oesophago-gastric cancer in more than two first degree relatives:

Yes (If Yes, please provide brief details)
No

Family history of familial adenomatous polyposis in any first degree relative:

Yes (If Yes, please provide brief details)
No

Barrett’s oesophagus:

Yes (If Yes, please provide brief details)
No

Pernicious anaemia:

Yes (If Yes, please provide brief details)
No

Gastric surgery over 20 years ago:

Yes (If Yes, please provide brief details)
No

Known dysplasia, atrophic gastritis, intestinal metaplasia:

Yes (If Yes, please provide brief details)
No

Upper abdominal epigastric mass:

Yes (If Yes, please provide brief details)
No

Iron deficiency anaemias:

Yes (If Yes, please provide brief details)
No

Clincal Examination

Jaundice:

Yes (If Yes, please provide brief details)
No

Upper abdominal mass:

Yes (If Yes, please provide brief details)
No

Investigations

FBC and ESR sent:

LFT, U&E sent:

Previous endoscopy done:

Upper GI cancer endoscopy guideline

Colorectal, Suspicion of Cancer Template

August 7, 2017August 7, 2017 Scott McLaughlin

This is a dictation template to provide a reminder of the information required to complete the referral. The fields in red are mandatory and must be completed on the referral protocol.

Presenting Complaint

Main Presenting Complaint: [Text – 98 character maximum]

Reason for Referral: [Text]

World Health Organisation Performance Scale
Using the following as a guide, please select the most appropriate answer to describe the patients general health:

Options:

Asymptomatic
Symptomatic but completely ambulatory
Symptomatic, <50% in bed during the day
Symptomatic, >50% in bed, but not bedbound
Bedbound

Priority: Urgent Suspicion of Cancer

Date of Onset: [Date]

Will the patient accept any site for treatment:

Symptoms and Investigations

Symptoms

Rectal bleeding:

Passage of mucus:

Tenesmus:

Anal Symptoms:

Change in bowel habit greater than 4 weeks:

Abdominal mass palpable:

Rectal lesion palpable:

Yes
No
Not Applicable

If not applicable, please state reason: [Text]

Iron deficiency anaemia:

Family history:

Please provide details of onset and duration of symptoms: [Text]

For ‘Low Risk’ patients, please provide their next review date: [Date]

Investigations

Please indicate if the following have been checked:

FBC and U&E sent:

TFT, CRP, and Faeces Culture sent (diarrhoea only):

Recent E-GFR:

Suspicion of Colorectal Cancer Guidelines

Breast, Suspicion of Cancer Template

August 7, 2017August 7, 2017 Scott McLaughlin

This is a dictation template to provide a reminder of the information required to complete the referral. The fields in red are mandatory and must be completed on the referral protocol.

Presenting Complaint

Main Presenting Complaint: [Text – 98 character maximum]

Reason for Referral: [Text]

World Health Organisation Performance Scale
Using the following as a guide, please select the most appropriate answer to describe the patients general health:

Options:

Asymptomatic
Symptomatic but completely ambulatory
Symptomatic, <50% in bed during the day
Symptomatic, >50% in bed, but not bedbound
Bedbound

Date of Onset: Date

Priority: Urgent Suspicion of Cancer

Is this a fast track referral of a previous breast cancer:

Is there a suspicion of bilateral disease:

Will the patient accept any site for treatment:

Protocol Specific Questions

HRT History:

Never
Previously
Current

Number of years on HRT: [Text]

Menopause Status:

Pre-Menopausal
Menopausal
Post-Menopausal
Male patient or not applicable

Last Menstrual Period: [Date]

Is there a family history of breast cancer:

If yes to previous question, please give relationship and age at diagnosis: [Text]

Previous Mammograms: [Text (please provide date and location or N/A)]

Previous Ultrasounds: [Text (please provide date and location or N/A)]

Previous Breast Clinic appointments: [Text (please provide date and location)]

Breast Examination

Left Breast

Is there any left breast abnormality present:

Left breast abnormality: [Text (Please accurately describe the location and type of abnormality)]

Left breast degree of suspicion:

Uncertain
Probably Benign
Probably Malignant

Right Breast

Is there any right breast abnormality present:

Right breast abnormality: [Text (Please accurately describe the location and type of abnormality)]

Right breast degree of suspicion:

Uncertain
Probably Benign
Probably Malignant

Suspicion of Breast Cancer Guidelines