University College Hospital Pancreaticobiliary New Patient Referral
Please email back to the sender : pancmed@uclh.nhs.uk
Dedicated PB referral line: 07939204237 (within office hours)
PATIENT DETAILS: Essential for UCH registration
Name
DOB
Address
DATE:
Phone Numbers (inc
mobile please)
GP and Practise
NHS number
essential otherwise case can’t be
done
Consultant
Hospital
Ward
Contact name and
number of referrer
(mobile preferable)
CLINICAL DETAILS and details of IMAGING (stretch the box to add details)
Many cases are done with anaesthetic support, so the following information is crucial
PAST MEDICAL HISTORY (see anaesthetic notes page 2)
Cardio
Resp
Endocrine
Neuro
Haem
GI
PAST SURGICAL HISTORY (inc previous GAs) stretch the text box if required
MEDICATIONS and ALLERGIES (especially warfarin / heparin / clopidogrel / aspirin)
Cardiology
MI/Angina
Hypertension
Pacemaker/AICD
Coronary stent
Valve disease
Endocrine/Renal
Diabetes
Thyroid disease
Kidney disease
BLOODS (all essential): Date
Coag
Platelets
Hb
WCC
Platelets
Bilirubin
ALP
Respiratory
COPD/Bronchitis
Asthma
TB
Sleep apnoea
Neurological
Epilepsy/FITS
CVA/TIA/Stroke
Muscle disease
Arthritis
GI
Acid reflux/Indigestion
Hiatus hernia
Stomach ulcer
Bowel problems
Liver disease
Haematology
Anaemia
DVT/PE/Blood clots
Blood disorders
ALT
GGT
CRP
Na
K
Urea
Creat
Important features of Past Medical History for Anaesthetic Risk – mark with a ‘Y’
Further Anaesthetic requirements:


ALL OVER 50 YEAR OLDS SHOULD ATTEND UCH WITH A RECENT ECG
THE PATIENT SHOULD ATTEND UCH WITH ORIGINAL HOSPITAL NOTES
FROM REFERRING HOSPITAL OR COPY OF NOTES
Cardiology
Pacemakers need checking by a technician before procedure.
Patients with moderate to severe heart disease need assessment by a cardiologist
and an up to date echocardiogram if possible
Respiratory
Patients with moderate to severe disease need lung function tests: spirometry & peak
flow rate.
Neurological
Patients with a significant history of recurrent TIA/CVA need a Doppler of the carotids.
Endocrine
Patients with thyroid disease need thyroid function tests.
The assessments and tests should have been done within the last 6 months (or within
a year is acceptable if the condition has been stable).
A written report of the tests and assessments should accompany the patient.
NB significant disease means disease which interfere with daily living activities