HYPERTENSION COMMUNITY CLINIC REFERRAL FORM
Email your referral to gst-tr.KHPCommunityAF@nhs.net Referral date:
Patient Details
Title
Surname
First Name
Address
Referrer Details (Stamp)
NHS Number:
Is an interpreter required? Y/N
If so, which language?
Date of Birth
Age
Gender
Ethnicity
Telephone (Home/mobile/work)
MANDATORY INFORMATION
Patient needs transport please? Y/N
(Incomplete form will be returned)

Blood tests:
 Urinalysis (dipstick):
Protein:
Blood:
Glucose:
(incl. dates or provide a record extract)
Creatinine:
eGFR:
 Urine ACR:
Glucose:
HbA1c:
 CVD risk (JBS2):
% Date:
TSH:
(T4:)
Urate:
 ECG (Recent within last 12 months, please attach) ☐
ALT/SGPT:
(GGT:)
TC:
HDL-C:
TG:
Past Medical History, ALL Current medication(s) & BP reading history:
please provide a medical record extract
PAST antihypertensive medications (this information is most important, please be as accurate as possible)
Name
Dose
Reason stopped
WHY ARE YOU REFFERING THIS PATIENT?
(See referral guidance for inappropriate referrals)
Y/N
Please give any relevant details



Resistant hypertension (>3 antihypertensives)
Multiple adverse reactions to antihypertensive therapies
Persistent non-adherence to drug therapies despite primary
care team best efforts
 Patients in whom prescribing decisions are complex due to
co-morbidities (e.g. CKD & ACE/ARBs)
If NO to all of the above questions, please detail why would you like your patient to be seen?
Please ensure the following have been addressed prior to referral




BP measurement is accurate

Lifestyle advice given

Drugs which increase BP have been stopped

SLCSN treatment algorithm has been followed

Adherence issues have been addressed

Associated conditions have been addressed? (Obstructive Sleep apnoea, obesity & insulin resistance)




Y/N
Accurate technique & cuff size?
Arrhythmia excluded by manual pulse palpation?
Diet, salt intake, physical activity, weight loos,
alcohol moderation, smoking
E.g.: NSAIDs, oral contraceptive pill & ciclosporine.
Especially check OTC medications!
http://www.slcsn.nhs.uk/files/prescribing/hypertensi
on-012012.pdf
Ask patient & check issues and quantities
Simplify & optimize drug regimen, discuss / use
dosette box
If this referral is not accepted for the hypertension pharmacist community clinic would you be happy for this
referral to be considered for a consultant lead hypertension clinic? Y/N
HYPERTENSION COMMUNITY CLINIC - Referral guidance
Referral criteria – definitions:


Resistant hypertension: defined as BP not controlled despite 3 drugs at max dose or max tolerated dose.
Pseudo hypertension in the elderly:
o Overestimation of BP by sphygmomanometer measurement due to arteriosclerosis and/or calcification in arteries.
o When to suspect:
 Absence of end-organ effects in long-standing "hypertension"
 Treatment-resistant hypertension
 Development of hypotensive symptoms on medications
 Calcification of brachial artery on radiological examination
 Palpable radial artery pulse despite an upper arm inflated cuff occluding the brachial artery
When to suspect secondary hypertension?
Suspect
a secondary cause
resistant
treatment,
BP increasing for no reason after being well controlled, and/or severe onset.
Hypertension:
whoif to
refertoand
where?

1.




2.
Renal artery stenosis:
o In young resistant to treatment hypertension
o Deteriorating
renal functionService:
with ACE/ARBs inhibitors, especially in patient with PVD
Community
Hypertension
o Abdominal bruit
 Resistant hypertension (defined as BP not controlled despite 3 drugs at maximum dose or maximum tolerated dose)
Phaeochromocytoma:
anxiety,topostural
hypotension,
headaches, palpitations, pallor, excessive sweating.

Multiple adverse reactions
antihypertensive
therapies
Conn's
syndrome:
hypokalaemia
with increased
or normal
sodium.

Patients
in whom
prescribing decisions
are complex
dueplasma
to co-morbidities
Cushing:
truncal
obesity,
moon
face,
purple
striae,
muscle
weakness,
easyGP
bruising,
 Persistent non-adherence to drug therapies despite best efforts of the
practicehirsutism, hyperglycaemia,
hyperlipidaemia.
To note, the community clinic will also undertake follow up of specific patients reviewed in secondary care specialist
Gynaecomastia:
can be seen
patients with
chronic
renalfor
failure,
andcare.
adrenal hyperplasia tumors. But do
hypertension services
and in
discharged
withhyperthyroidism,
a management plan
suitable
primary
exclude drug-induced gynaecomastia (amphetamines, calcium antagonists, anabolic steroids, cyclosporine methyldopa,
angiotensin-converting-enzyme
(ACE) inhibitors, and alpha-1 blockers).
Secondary
care specialist services
o
Emergency referral (A&E)

Accelerated or malignant hypertension (BP>180/110mmHg), especially if evidence of grade III-IV retinopathy
(papilloedema / retinal haemorrhages)

Suspected TIA

Suspected Aortic dissection
o
Hypertension clinic:

Suspected secondary hypertension: Phaeochromocytoma, Coon's syndrome, Cushing syndrome, Diagnosed
obstructive sleep apnoea syndrome,

Rapidly worsening hypertension,

Hypertension in young individuals (<40 years) especially with no FH of hypertension & where a secondary
cause is suspected.

Labile hypertension

Pseudo-hypertension in the elderly
o
Other relevant services:
o Renal: renal disease, renal artery stenosis
o Obs & Gynae: hypertension in pregnancy
o Fall clinic: postural hypotension after exclusion of common causes