General Surgery - Breast referral

General Surgery - Breast referral

Breast Referral

SCI Gateway Protocol text tab

 

Urgent Referral Conditions (select one)

Non-Urgent Conditions (select one)

  • Lump - Suspected Malignancy , Patient older than 30
  • Abscess 
  • Persistent Nodularity  
  • Nipple or skin change  
  • Other evidence of cancer
  • Lump - Pt younger than 30  
  • Nipple Discharge (refer only if single-duct or bloodstained)  
  • Persistent Mastalgia (if patient over 50 years) 
  • Unilateral Mastalgia 
  • Recurrent Cyst 
  • Other

If 'Other' please give details in the 'Referral Text' tab
Remember to set 'Priority' to 'Urgent' or 'Non Urgent' in the 'Referral Text' tab.

Lesion

Position (lump only)

Size (lump only)

Axillary Lymph Nodes

Main Lesionright/left 

Main Lesionclock position/central/Axillary nodes 

Main Lesion0-1cm/ 1-2cm / 2-5cm / 5-10cm/ >10cm

Main Lesion Palpable /Not Palpable

Other Lesion right/left 

Other Lesion clock position/central/Axillary nodes 

Other Lesion0-1cm/ 1-2cm / 2-5cm / 5-10cm/ >10cm 

Other LesionPalpable /Not Palpable 

Duration* <1 month1-2 months3-4 months5-6 months>6 months

Previous Breast History*Not Known /None /Breast Cancer /Cyst /Benign Breast Change /Other

Menopausal Status*Not Known /Pre /Post /Peri 

Mammogram, if done - approx date and where done  

Please add any additional relevant information in the Referral Text tab