Endocrinology Clinic

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