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Endocrinology Clinic

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Endocrinology Referral Guidelines for MAP Handbook

Scope:

  • To provide consultations at a subspecialty level in endocrinology.

Appropriate patients for referral include:

  • Lipid Abnormalities in a patient with family or personal history of early CVD, inability to achieve fasting TG 500 or non-fasting >800
  • Thyroid Nodule
  • Thyroid Cancer
  • Hyperthyroidism
  • Difficult to Control Hypothyroidism
  • Osteoporosis and osteopenia
  • Calcium and Parathyroid Disorders
  • Pituitary Tumors and Disorders
  • Adrenal Masses and Disorders
  • Amenorrhea & Galactorrhea
  • Hypogonadism
  • Type 1 Diabetics
  • Type 2 Diabetics requiring ≥ 300 units of insulin daily or U-500 insulin
  • Diabetes being managed with an insulin pump

Please do NOT refer the following patients:

  • Pediatric patients < 18 years old
  • Patients with Type 2 Diabetes unless already using an Insulin Pump or requiring ≥ 300 units of insulin daily or U-500 insulin – this is a strict requirement
  • Obesity in absence of overt Endocrinopathy?
  • Gynecomastia in absence of hypogonadism

Documentation required for scheduling an appointment:

  • Past Medical History (PMH)
  • Current medication list
  • Most recent progress note describing condition for which patient is being referred
  • Recent pertinent labs (appropriate labs per worksheet, drawn within the past month, substantiating the disorder. Please send lab flow sheets if they exist.)
  • Recent pertinent scans or imaging reports


Brief summary of appropriate URGENT referrals:

Patients with symptoms that are both acute and severe should be referred to the Emergency Department. This list is for all other patients.

  • Pregnant patients with Endocrine conditions addressed in Endocrine Specialty Clinic
  • Uncontrolled Hyperthyroidism
  • Pituitary Macroadenoma (Pituitary adenoma 1cm or greater in size)
  • Biopsy-proven/newly diagnosed thyroid cancer or other endocrine cancers
  • Documented recent Adrenal Crisis/Addison’s Disease diagnosis

Brief summary of appropriate ROUTINE referrals:

Diabetes

  • Hgb A1C
  • CMP
  • Fasting Lipid Panel
  • Urine spot microalbumin and creatinine
  • 2 weeks’ blood glucose log
  • See clinical pharmacist prior to referral when possible

Difficult to Control Lipid Abnormalities

  • Fasting Lipid Panel
  • Fasting Glucose
  • HbA1c
  • CMP
  • TSH
  • Free T4

Adrenal Masses and Disorders

  • BMP
  • 24-hour urine for Free Cortisol, Creatinine, Metanephrines and Catecholamines
  • For Adrenal Insufficiency: Check 8am cortisol –

If <11, check ACTH (Cosyntropin) Stimulation test*
– Do not perform ACTH (Cosyntropin) Stimulation test if patient on glucocorticoids – refer to Endocrinology Clinic
– ACTH (Cosyntropin) Stimulation test: If neither 30 minute nor 60 minute cortisol measurement stimulates to 18, start Hydrocortisone 20mg QAM/10mg Q3pm and refer to Endocrinology Clinic

 Thyroid Nodule

  • Thyroid Ultrasound within past 12 months for nodules ≥ 1cm
  • TSH
  • Free T4

Thyroid Cancer (New Diagnosis)

  • Pathology report
  • Imaging studies (Ultrasound, CT, MRI, etc.)
  • Operative report (if pertinent)

Thyroid Cancer (History of)

  • Original pathology report with staging (if available)
  • Records of previous treatment (radioactive iodine, etc.)
  • Free TSH
  • Free T4
  • Thyroglobulin level
  • Thyroid ultrasound within past 12 months

Hyperthyroidism

  • TSH
  • Free T4
  • Free T3

Difficult to Control Hypothyroidism

  • TSH
  • Free T4
  • Ensure patient is medication-compliant with pharmacy refill check
  • Ensure patient is taking medication correctly: in morning, 30 minutes before other medications, food, or fluids other than water

Calcium and Parathyroid Disorders

  • Intact PTH
  • Serum Calcium
  • Serum Albumin
  • 24-hour urine for calcium and creatinine, including collection volume
  • Vitamin D 25-OH

Amenorrhea & Galactorrhea

  • Prolactin level
  • TSH
  • FSH
  • LH

PCOS and Hirsutism

  • TSH
  • FSH
  • LH
  • Prolactin level
  • Total Testosterone
  • DHEA-S
  • 17-hydroxyprogesterone
  • HbA1c
  • Lipid panel

Osteoporosis

  • DXA Scan Results
  • CMP
  • TSH
  • Intact PTH
  • 25 (OH) Vitamin D
  • SPEP
  • UPEP
  • 24-hour urine for calcium and creatinine

Pituitary Masses and Disorders including SIADH and Diabetes Insipidus

  • MRI of the pituitary/Sella Turcica with and without contrast
    • If MRI contraindicated, contact endocrinologist, through referral coordinator, for additional direction
  • Serum Prolactin Level
  • TSH
  • Free T 4
  • LH
  • FSH
  • IGF-1
  • 8am Serum Cortisol Level

Hypogonadism/Premature Ovarian Failure and Gynecomastia secondary to hypogonadism

Do all labs at 8:00am, no later than 9:00am:

  • Total Testosterone – two tests, on separate days, demonstrating low total testosterone are needed for referral; one to include free testosterone and sex hormone binding globulin
  • Prolactin level
  • TSH
  • FSH
  • LH
  • For patients age < 40: Ferritin, Serum Iron, TIBC, CBC

Have questions or comments about the specialty referral guidelines? Submit them here.