Patient details Referring clinician First Name: Referring Hospital: Surname: Ward (if applicable): NHS number: Referring Consultant: Address: Email: Patient Telephone: Telephone: General Practitioner: Date of referral: Current location: Provisional diagnosis: Patient aware of diagnosis? Is patient on a 62 day pathway? If Yes, 62 day target date: Presenting symptoms Bloods Questions for MDT & Additional information Abdominal Mass Bilirubin Altered bowel habit ALT Anaemia AlkP Ascites Albumin >60 Dark Urine/Pale Stools eGFR value if <60 Dyspepsia eGFR date: Encephalopathy Jaundice Prothrombin time Liver Decompensation Haemoglobin Nausea / Vomiting Platelets Pain Please specify site If available: PR bleeding CEA Pruritus AFP Heamatemesis/melaena CA125 Weight loss CA19-9 Other Please specify Viral Serology x Autoimmune screen Comorbidities & performance status Treatment Viral hepatitis Ischaemic heart disease Bowel resection (operation type, date) Chronic liver disease Respiratory disease Liver resection (operation type, date) Pancreatitis Anticoagulant therapy Chemotherapy (type, date) Autoimmune disease Alcohol excess Radiotherapy (type, date) Inflammatory bowel disease Diabetes Transplant PSC/PBC Haemochromatosis TACE (type, date) Obesity PVE (type, date) ECOG performance status Do you consider your patient fit for surgery? Do you consider your patient fit for chemotherapy? Intervention already performed Histopathology available ERCP +Plastic stent Biliary drain Histopathology summary (if available): +Metal stent Biopsy PTC
Patient details Referring clinician First Name: Surname: NHS number: Address: Patient Telephone: General Practitioner: Current location: Referring Hospital: Ward (if applicable): Referring Consultant: Email: Telephone: Date of referral: Provisional diagnosis: Patient aware of diagnosis? Is patient on a 62 day pathway? If Yes, 62 day target date: Presenting symptoms Bloods Questions for MDT & Additional information Abdominal Mass Altered bowel habit Anaemia Ascites Dark Urine/Pale Stools Dyspepsia Encephalopathy Jaundice Liver Decompensation Nausea / Vomiting Pain Please specify site PR bleeding Pruritus Heamatemesis/melaena Weight loss x Other Please specify Bilirubin ALT AlkP Albumin eGFR Prothrombin time Haemoglobin Platelets If available: CEA AFP CA125 CA19-9 Viral Serology Autoimmune screen >60 value if <60 eGFR date: Comorbidities & performance status Treatment Viral hepatitis Chronic liver disease Pancreatitis Autoimmune disease Inflammatory bowel disease PSC/PBC Obesity Ischaemic heart disease Respiratory disease Anticoagulant therapy Alcohol excess Diabetes Haemochromatosis Bowel resection (operation type, date) Liver resection (operation type, date) Chemotherapy (type, date) Radiotherapy (type, date) Transplant TACE (type, date) PVE (type, date) ECOG performance status Do you consider your patient fit for surgery? Do you consider your patient fit for chemotherapy? Intervention already performed Histopathology available ERCP PTC +Plastic stent +Metal stent Biliary drain Biopsy Histopathology summary (if available):