(Only in an emergency should the Neurosurgical Registrar on call be contacted via LGI switchboard )
Please save this form to your desktop, add details and email to address below
Section A Patient Details
First name: / NHS No:
Last name: / Male ( ) Female ( )
Patient’s current location:
Home ( ) or Hospital ( )
If Home please provide their contact phone number if known Phone Number:
Address:
GP name:
Date of Birth: / GP address:
Name of Neurosurgical Registrar
patient discussed with if applicable
Referring Hospital: / Ward: Tel:
Referring doctor: / Bleep:
Consultant: / Tel:
Specialty:
For clinicians within the Yorkshire Cancer Network the MDT outcome will be available on PPM within 24 hours of the meeting
**PLEASE COMPLETE SECTION B FOR FULL DISCUSSION AT MDT**
Section B
Date of admission if an inpatient: / Date and mode of symptom onset: / (i.e. sudden/gradual)
History of illness: (include details of symptoms of raised ICP, specific neurological deficits and seizures)
Past history: (include details of comorbid conditions, bleeding tendencies and any other previous or existing malignancy and prior treatment) / Please tick if medications include:
Aspirin ( )
Clopidogrel ( )
Warfarin ( )
Dexamethasone ( )
Anticonvulsants( )
If known to have an extracranial primary tumour please state outcome from local oncology MDT discussion:
(include details of prior oncology treatment, prognosis and plans for further treatment of extracranial disease).
Examination: (in particular mental status/conscious level, focal neurological deficits and signs of raised intracranial pressure)
Karnofsky Score* ( ) Or WHO Performance Status*( )
See Notes for definitions of these scores:
Imaging (include type of scan –CT/MR, PET, date of investigation, and if imaging not on LTHT PACS then location of scans.)
Summary of findings: / Questions for MDT:
Please complete this form and send it via e-mail to:
Please make sure that you enter Brain MDT Referral in the subject line of the e-mail.
Imaging should be sent by image link from the referring hospital to Leeds Teaching Hospitals NHS Trust.
Brain/CNS MDT Admin office telephone number: 0113 3928461 / 3928547
Cases will NOT usually be discussed at the Wednesday MDT meeting unless this form and the relevant imaging are received by 3.30pm on the immediately preceding Monday.
Notes
Karnofsky Score:
100 Normal No complaints
90 Able to carry on normal activities: minor signs or symptoms of disease
80 Normal activity with effort
70 Cares for one self. Unable to work
60 Ambulatory. Requires some assistance in activities of daily living and self care.
50 Requires considerable assistance and frequent medical care.
40 Disabled; requires special care and assistance.
30 Severely disabled;
20 Very sick; hospitalisation and active supportive treatment
10 Moribund
WHO Performance Scale.
0 Fully active, able to carry out all normal activity (Karnofsky 100)
1 Restricted in physically strenuous activity but ambulatory and able to carry out light work (Karnofsky 80-90)
2 Ambulatory and capable of all self care but unable to carry out any work. Up and about more than 50% of waking hours (Karnofsky 60-70).
3 Capable of only limited self care, confined to bed or chair more than 50% of waking hours. (Karnofsky 40-50)
4 Completely disabled. Cannot carry on any self care. Totally confined to bed or chair (Karnofsky 20-30)
Revised 18/08/2017