Cardiff Digestive Diseases Unit

V 7 Request for discussion at Neuro-Oncology MDT Meeting

PLEASE MAKE SURE THAT YOU HAVE CONTACTED THE NEUROSURGICAL ON-CALL REGISTRAR ON 02920 747747 Bleep 6464 BEFORE COMPLETING THIS PROFORMA.

PLEASE COMPLETE FORM FULLY, LEGIBLY AND IN BLOCK CAPITALS - Please be aware if the form is not completed fully then it will be returned without discussion. & EMAIL TO: [email protected] CANNOT BE FAXED IMPORTANT INFORMATION: Please only inform your patient and their families, that they are being discussed at MDT when you have confirmed the date of discussion with the MDT Co-ordinator or Clinical Nurse Specialist (contact details below) If patient has been discharged home, please provide contact numbers: Patient Contact No: Next of Kin Contact No:

The strict deadline for referrals is 13.00 on the Thursday prior to the Monday meeting you would like the patient discussed at. Referrals received after this time will be listed for the following weeks MDT. Any Imaging requested by the neurosurgical registrar (including up-to-date CT CAP if suspected brain mets) needs to be completed by 13.00 on Thursday for discussion at MDT the following Monday. If imaging is done after this deadline the patient will be rolled over to the following MDT. DATE OF REFERRAL TO NEUROSURGICAL REGISTRAR: PATIENT DETAILS Full Name Local Hosp No Address DOB: MDT DETAILS Referring Consultant & Speciality Contact Hospital & Ward No. Contact Referring Clinician No. Relevant Past Medical History & Co- morbidities Presenting Symptoms: (onset, duration, ongoing neurological deficit, fluctuations, persistent Page 1 of 2 deficits)

EXPRESSIVE (Delete as appropriate) (Delete as appropriate) ON STEROIDS? DYSPHASIA? YES / NO YES / NO DATE & DOSE (Delete as appropriate) HEMIPARESIS? YES / NO STEROIDS STARTED: RESPONSE TO (If steroids just commenced, patient may not be discussed at IMPAIRED MEMORY / (Delete as appropriate) STEROIDS : MDT unless you contact us with CONFUSION? YES / NO Complete / partial / patients response, 48hrs after none/ Please describe steroids started) Drug History (Aspirin, Clopidogrel / Warfarin, etc) Social / Occupational History e.g. home circumstances Known Primary Cancer Site and current Oncologist Previous Oncological Treatment (Dates, Surgeon, Oncologist)

CURRENT (as they are today) WHO Performance score (Please estimate and circle performance score below.) 0 1 2 3 4 Fully active, able to Restricted in Ambulatory and Capable of only Completely disabled. carry on all pre- physically strenuous capable of all self limited selfcare, Cannot carry on any disease performance activity but care but unable to confined to bed or self care. Totally without restriction ambulatory & able to carry out any work chair more than 50% confined to bed or carry out light work . activities. Up and of waking hours. chair. e.g. house/office about more than work. 50% of waking hours. RADIOLOGICAL INVESTIGATIONS PERFORMED- CT & MRI (Brain/Spine) / CT Thorax Abdomen and Pelvis (Please ATTATCH reports with proforma or insert reports below & ENSURE images are sent to UHW pacs for review)

Hospital where Investigation Date Radis Report / Summary investigation was performed

HISTOLOGY IF ALREADY PERFORMED Cancer Site Date Local Consultant Result Hospital where Page 2 of 2 investigation CRN Involved was performed

QUESTION TO MDT? / Additional Relevant Information:

GP Details (Name, Address & Contact No.)

The OUTCOME of the MDT Discussion will be sent to the referring team on Monday afternoon or Tuesday via the e-mail address you have provided below. Tertiary referrals - Unless the outcome of the meeting is ‘patient TCI for surgery’, it is your responsibility as the referring team to keep the patient updated and implement any MDT recommendations. Please also contact your Local Cancer Services Department through your local switchboard and inform them of this referral. Please provide an e-mail address that we can send the outcome to directly.

MDT CO-ORDINATOR: Neuro-Oncology MDT Co-ordinator: Mari Marshall: Cancer Services Department, UG Floor, UHW, Heath Park, Cardiff, CF14 4XW Tel: 02921 847900