<p>Request form: MRI (only) HIGHLY CONFIDENTIAL Please complete and either: Fax 01494-472-166 or [email protected] Patient’s Registered GP details GP Name ** ‘K’ Practice code Telephone Practice name ** If Referrer different, state in ‘Referrer’s declaration’ below.</p><p>Patient details ++ DoB, minimum age: 16yrs Cressex; 18yrs Alliance NHS No. Gender Surname Date of Birth ++ First name(s) Height (m) Address Weight (kg) +* Telephone Mobile phone Post code Transport required? +* ‘Weight’ is critical, the MRI tables have different weight limits; if not known indicate whether < less than or > greater than 20 stone / 127 kgs.</p><p>MRI Examination(s) requested [ non-completion is the most common rejection / delay criteria ] enter ‘Y’ or tick: Auditory Brain Cervical Lumbosacra Thoracic Other ** l RCR Guidelines 2007 ‘Making the best use of clinical radiology services’ MBUR6 (see overleaf for In next box, try to quote RCR’s Clinical / Diagnostic code, e.g. E07 ; ** mandatory for ‘Other’. hardcopy and free online access) Clinical history / duration / indications for Examination AND Question(s) to answer Date, location and type of relevant previous investigations (surgery, radiology, laboratory results)</p><p>Medical Information : does the Patient have? Enter ‘Y’ or tick [ blank or ‘X’ or ‘N’ implies “No” ] Neuro-stimulator possibly Pregnant Aneurysm clips or Programmable shunt Cochlear Implant Cardiac Pacemaker (now / ever) Claustrophobia (if ‘Y’, clarify severity) *+* possibly Diabetic Other metallic Implants (<7wks / ever) Surgery: heart, head, chest, spine, eyes, ears any Allergies an Infection risk (e.g. MRSA) Other surgery in the last 3 months Breast feeding Metallic foreign body in Eye (ever) If Foreign body in Eye, X-ray date For all ‘Y’ items: Clarifying comment(s) incl. Date(s) *+* ‘Severe’ claustrophobia may involve referral & delay to a London-based ‘open’-scanner. Red ‘Y’ means generally not MRI appropriate.</p><p>Referrer’s declaration Radiology I have discussed the examination with the patient and have Comments considered the contraindications and detailed above GMC No. or equivalent Referring Clinician (PRINT) Radiologist (PRINT)</p><p>Admin: Referral Received date & time: ……………………………… Bucks.MRI Ref.: ………… (Tel: 01494-555-200) File: 02b283d233cf25a145525c313c2c524f.doc Suitable/Sent: Alliance / BHT / Cressex Provider Notified date & time: ……………..……………… Referring Clinician Radiologist Signature Signature Date Date</p><p>Admin: Referral Received date & time: ……………………………… Bucks.MRI Ref.: ………… (Tel: 01494-555-200) File: 02b283d233cf25a145525c313c2c524f.doc Suitable/Sent: Alliance / BHT / Cressex Provider Notified date & time: ……………..……………… Bucks. health economy : ‘MRI Imaging Summary [not definitive OR complete]</p><p>Bucks. use The Royal College of Radiologists (RCR) guidelines ‘Making the best use of clinical radiology services’ 2007; hardcopy (£16 or less) and free NHS N3 online access http://www.rcr.ac.uk/content.aspx?PageID=995 . Guidance is not to use MRI imaging for all MSK Extremities, e.g. Ankle, Elbow, Foot, Hip, Knee, Shoulder – these are generally initially sent for X-ray, and/or referred to an MSK specialist to develop a Patient-specific pathway.</p><p>Complaint & Code Examples of Patient History / Symptoms Imaging Notes  Cord damage / compression Head / neck MRI : Head  Recent or complex injury  Ligament injuries trauma T01 CT : Head  Vertebral fractures ‘Red flags’ e.g.: Behavioural /  Confusion Cognitive  CT : identifies subarachnoid change :  Memory loss haemorrhage CT : Head (normally 1st) Sudden /  Drowsiness  MRI : identifies inflammation MRI : Head ) Severe n  Consciousness – loss of  N/A for primary headache, i</p><p> a headache r  Paralysis (partial, one side of body) e.g. tension, migraine B</p><p>( N05  Vision - blurred / loss K C</p><p>E  Frequency / severity increase N</p><p> Recent start & >60years</p><p>&  Triggers waking from sleep Chronic CT : Head D headache  Previous tumour / disease</p><p>A  Worse when cough, sneeze, strain MRI : Head E N06  N/A for primary headache, H  Co-ordination loss, dizzy, tingling, e.g. tension, migraine numbness  ENT specialist must evaluate Hearing /  Sensorineural (90%) and Conductive MRI : IAM (Internal images & report; also do Loss E01/02 Auditory Meatus)  Ave.23% occurrence in >65year olds Audiometry CT : Head URGENT  TIA (Transient Ischemic Attack)  Neurovascular must evaluate Stroke / TIA plus MRI if <30years [weakness in face OR arms & legs, within 7days of event N01/02 slurred speech : lasts few minutes, [may change as result of  Consider Hospital / Clinic 24hrs no signs] new NICE guidelines]</p><p>Cervical Spine pain Surgery is appropriate; if (intractable) / Patient willing to  Shows disc herniation  Chronic (no improvement after 6 undergo surgery, then Brachialgia weeks of conservative therapy)  Also refer to Orthopaedic MRI : Cervical or surgeon ) Sciatica c</p><p> i Lumbosacral</p><p> c M02/04 a r o h</p><p>T Acute (<12 wks) & ‘red flag’, e.g.:</p><p>, l</p><p> a  Malignant infection / disease - known  Definitive for spinal infection, r</p><p> c or signs e.g. TB (can lead to paralysis) a s MRI : Lumbosacral o  Onset age <20 and >55  Evidence of cord compression b URGENT if previous – urgent referral to Oncologist m  Raised plasma viscosity u Low-Back cancer history / Orthopaedic surgeon L</p><p>, pain  Progressive & persistent l  Intractable pain, refer to Pain a</p><p> c M05/06  Previous cancer i Service / Spinal surgeon v r  HIV, drugs, steroids, etc. e C (</p><p>E Acute (<12 wks) no ‘red flag’  Post operation: advise N I features: MRI : shows disc </p><p>P Oncologist / Orthopaedic herniation S  Post failed management / treatment surgeon</p><p>Thoracic (recent onset, persistent) spine pain  Unresponsive to treatment MRI : Thoracic  Additional markers may help M06/15 T13/14  Osteoporosis (collapse) suspected Knee Soft tissue masses – M10; Pain – M23/24; Fall/Blunt trauma – T21 X-Ray (MRI: ligaments / menisci)</p><p>File: 02b283d233cf25a145525c313c2c524f.doc</p>