13.11.27 2 week rule referral guidelines

Bones

• Palpable lump that is either:

  • Greater than 5cm in diameter

  • Deep to fascia, fixed or immobile

  • Increasing in size

  • Painful

  • A recurrence after previous excision

  • Xray suspicious of cancer

Neuro

• • Progressive development of:

    • Limb weakness

    • Visual impairment

    • Ataxia

    • Dysphasia

  • Focal seizures with:

    • Post-ictal deficit

    • Progressive neurological signs

  • Progressive recent headache with:

    • Vomiting

    • Papilloedema

  • History of specific malignancies within 10 years:

    • Melanoma

    • Breast

    • Renal

    • Lung

  • New onset of:

    • Non-migraine headache

    • Epilepsy

Breast

• Any age with a discrete, hard lump with fixation with or without skin tethering

• Discrete lump – Patient > 30 year persisting after next period or after menopause

• Breast skin distortion / ulceration / nodule

• New nipple retraction / distortion / eczema

• Spontaneous unilateral & / or Bloodstained nipple discharge

• Asymmetrical nodularity persisting after period in Patient > 30 years old

• Axillary lymphadenopathy

• Suspicion of recurrent breast cancer

Colorectal

• Rectal bleeding with change of bowel habit of 6 weeks duration (age 40 and over)

• Rectal bleeding without change in bowel habit with no obvious cause 6 weeks duration (age 60 and over)

• Change of bowel habit persisting for 6 weeks or more without bleeding (age 60 years and over)

• Right Lower Abdominal mass consistent with involvement of large bowel (any age)

• Palpable rectal (not pelvic) mass (any age)

• Males of any age with Hb less than 110

• Non menstruating female with Hb less than 100

Gynae

• Suspicion of cervical cancer

• Suspicion of Vulval cancer

• Postmenopausal bleeding in women with a uterus

• Suspicious bleeding on HRT

• Suspicious mass on pelvic ultrasound (multilocular or solid mass with or without ascites)

• IMB in women age after 45

Haematology

• Persistent unexplained splenomagaly

• Immediate referral:

  • Blood count/film reported as acute leukaemia

  • Spinal cord compression or renal failure suspected cause myeloma

Head and neck

• Unexplained lump in the neck, of recent onset

• Previously undiagnosed lump that has changed over a period of 3 to 6 weeks

• Unexplained persistent swelling in the parotid or submandibular gland

• Unexplained persistent sore or painful throat

• Unilateral unexplained pain in the neck and neck area for more than 4 weeks, associated with otalgia but a normal otoscopy

• Unexplained ulceration of the oral mucosa or mass persisting for more than 3 weeks

• Uexplained red and white patches (including suspected lichen planus) of the oral mucosa that are painful or swollen or bleeding

Lung

• Smokers or ex-smokers >40 years with persistent haemoptysis

• Chest X-ray suggestive of lung cancer

• Normal chest X-ray where there is a high suspicion of lung cancer

Neuroblastoma

• Child with:

  • Proptosis

  • Unexplained back pain

  • Leg weakness

  • Unexplained urinary retention

• Wilm’s tumour (all ages)

  • Abdominal mass with persistent/progressive abdominal distention (immediate referral)

  • Haematuria

  • Suspicious symptoms unable to undertake abdominal examination

Skin

• • Pigmented skin lesion scoring 7 or more:

    • Change in size (2)

    • Irregular shape (2)

    • Irregular colour (2)

    • Largest diameter 7mm or more (1)

    • Inflammation (1)

    • Oozing (1)

    • Change in sensation (1)

  • Lesion suspected to be melanoma

• Non-healing keratinizing or crusted tumours larger than 1cm with significant induration on palpation

  • Immunosuppressed patients with new or growing cutaneous lesions

• Histological diagnosis of squamous cell carcinoma

Soft tissue sarcoma

• Unexplained mass with following features:

  • Deep to fascia

  • Non-tender

  • Progressively enlarging

  • Enlarging regional lymph node

  • Mass greater than 2 cm

Thyroid

• Thyroid swelling plus:

  • Solitary nodule, typically hard, increasing in size

  • Unexplained hoarsness/voice change

  • Enlarged cervical nodes

  • Family history of endocrine tumour

  • History of neck radiation

  • Aged 65+

  • Prepubertal patients

Upper GI

• Dysphagia

• Over 45 with:

  • Unintentional weight loss with dyspepsia P

  • Persistent vomiting/anorexia/ early satiety

  • Iron deficiency anaemia and dyspeptic symptoms

  • Painless obstructive jaundice

  • Persistent new-onset dyspepsia (despite 1/12 therapy)

Urology

• Prostate

  • Hard, irregular prostate

  • Rising/raised age-specific PSA with normal prostate

  • Symptomatic with high PSA

• Bladder and renal

  • Painless macroscopic haematuria without UTI

    • Over 40 with persistent/recurrent urinary tract infection associated with macroscopic haematuria

  • Clinical/imaged urinary tract mass

  • Over 50 with unexplained microscopic haematuria on urine microscopy without infection

• Testicular

  • Swelling/mass in body of testis

• Penile

  • Symptoms/signs of penile cancer

Urgent OGD

• Chronic gastrointestinal bleeding

• Progressive unintentional weight loss

  • Dysphagia

• Persistent vomiting

• Iron deficiency anaemia

• Epigastric mass

• Suspicious barium meal

• Recent/Unexplained/Persistent symptoms in a patient over 55

Children under 16

• Leukaemia

  • Unexplained petechiae

  • Hepatosplenomegaly

• Lymphomas

  • Hepatosplenomegaly

  • Mediastinal or hilar mass on chest X-ray

  • Unexplained shortness of breath and unexplained petechiae or hepatosplenomegaly

  • Non-tender, firm or hard lymph nodes

  • Lymph nodes greater than 2cm in size

  • Lymph nodes progressively enlarging

  • Other features of general ill-health, fever or weight loss

  • Axillary node involvement (in the absence of local infection or dermatitis)

  • Supraclavicular node involvement

• Brain and CNS

  • Reduced level of consciousness

  • Headache and vomiting that cause early morning waking or occur on waking

  • Children younger than 2 years with:

    • New-onset seizures

    • Bulging fontanelle

    • Extensor attacks

    • Persistent vomiting

  • Abnormal increase in head size

  • Arrest or regression of motor development

  • Altered behaviour

  • Abnormal eye movements

  • Lack of visual following

  • Poor feeding/failure to thrive

  • Squint, urgency dependent on other factors

• Neuroblastoma

  • Children younger than 6 months with:

    • Lump in the abdomen

    • Small lumps on the skin

  • Proptosis

  • Unexplained back pain

  • Leg weakness

  • Unexplained urinary retention

• Wilm’s tumour

  • Lump

  • Haematuria

• Soft Tissue Sarcoma

  • Unexplained mass at almost any site that has one or more of the following features:

    • Deep to the fascia

    • Non-tender

    • Progressively enlarging

    • Associated with a regional lymph node that is enlarging

    • Greater than 2cm in diameter

• Bone Sarcoma (osteosarcoma and Ewing’s sarcoma)

  • Persistent localised bone pain/swelling with X-ray showing signs of cancer

  • Rest pain, back pain and unexplained limp

• Retinoblastoma

  • White papillary reflex (leukocoria)

  • Suspicious new squint or change in visual acuity if cancer is suspected

  • Family history of retinoblastoma and visual problems

• General

  • • Presents several times with the same problem, but with no clear diagnosis