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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.

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 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 needs to be complete & reported by end of day 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
Hospital & Ward / Contact No.
Referring Clinician / Contact No.
Relevant Past Medical History & Co-morbidities
Presenting Symptoms: (onset, duration, ongoing neurological deficit, fluctuations, persistent deficits)
EXPRESSIVE DYSPHASIA? / (Delete as appropriate)
YES / NO / ON STEROIDS? / (Delete as appropriate)
YES / NO
HEMIPARESIS? / (Delete as appropriate)
YES / NO / DATE & DOSE STEROIDS STARTED:
IMPAIRED MEMORY / CONFUSION? / (Delete as appropriate)
YES / NO / RESPONSE TO STEROIDS :
Complete / partial / none/ Please describe / (If steroids just commenced, patient may not be discussed at MDT unless you contact us with patients response, 48hrs after 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 carry on all pre-disease performance without restriction / Restricted in physically strenuous activity but ambulatory & able to carry out light work . e.g. house/office work. / Ambulatory and capable of all self care but unable to carry out any work activities. Up and about more than 50% of waking hours. / Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours. / Completely disabled. Cannot carry on any self care. Totally confined to bed or chair.

RADIOLOGICAL INVESTIGATIONS PERFORMED- CT MRI (Brain/Spine) / CT Thorax Abdomen and Pelvis

(Please FAX reports with proforma or insert reports below & ENSURE images are sent to UHW pacs for review)

Investigation / Date / Radis / Report / Summary / Hospital where investigation
was performed

HISTOLOGY IF ALREADY PERFORMED

Cancer Site / Date / Local CRN / Consultant Involved / Result / Hospital where investigation
was performed

QUESTION TO MDT? / Additional Relevant Information:

GP Details (Name, Address & Contact No.)

PLEASE CONTACT & INFORM YOUR LOCAL CANCER SERVICES DEPARTMENT OF THIS REFERRAL THROUGH YOUR LOCAL SWITCHBOARD.

If you would like to know the OUTCOME of the MDT Discussion, it will be available Monday afternoons from your local Cancer Services Department. Alternatively our team feeds back the outcomes to the referring team Monday afternoons and Tuesdays via the e-mail address provided.

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 provide an e-mail address that we can send the outcome to directly.

PLEASE EMAIL OR FAX THIS FORM FULLY COMPLETED TO THE MDT CO-ORDINATOR:

Fax: 02920 745972 Email:

Neuro-Oncology MDT Co-ordinator: Mari Jones: B4 Neurosurgery, UHW, Heath Park, Cardiff, CF14 4XW Tel: 02920 744244

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