Endocrinology Resources for Physicians

Urgent referrals If you feel your patient needs to be seen as soon as possible, note “urgent” on your referral. All referrals marked “urgent” are triaged to help make sure patients are seen in a timely fashion. If you wish to speak to the on-call endocrinologist, call 404-785-DOCS (3627).

Generally, conditions that may warrant an urgent initial outpatient visit include, but are not limited to:

• New Type 1 or 2 diabetes.
• Congenital hypothyroidism (neonate).
• Goiter or palpable nodule, if clinical findings include asymmetric gland, increasing size or discomfort, abnormal thyroid biopsy.
• Abnormal height velocity or crossing percentiles and associated with severe headaches and/or blurry vision.
• Hypoglycemia and failure to thrive.

There are several conditions we see that may not warrant an urgent evaluation given the available resources. These may include, but are not limited to, the following:

• Short stature (current height less than 3rd percentile for age or crossing percentiles on repeated growth measurements)
• Precocious puberty >7 years of age
• Delayed puberty
• Non-palpable nodule on thyroid (seen on ultrasound) 
• Possible hypothyroidism with TSH <20 uIU/ml
• Congenital hypothyroidism (already on treatment)

For non-urgent medical requests, we offer e-consult via accessCHOA.

E-consult offers physicians the opportunity to receive timely guidance on lower-complexity and data-oriented clinical questions that may not require an in-person evaluation. One of our specialists will typically respond within three business days. Patient family consent is required.

We require growth curves for all referred patients prior to scheduling.

Note, it is very important to provide a visual line graph, ideally for both height and weight, although both are not required. Multiple points are preferred, if available. If you have only seen the patient once, we will accept graphs with single points.

Office notes are crucial in helping us determine the intricacies of your patient’s case.

• We require office notes beyond just the reason for referral.
• Whether you refer to them as Clinical Notes, History of Present Illness (HPI), Interval History or Notes, we need notes that the provider took during the last visit that explain the child’s case and chief concern for referral.
• A short “reason for referral” is not sufficient.

This can be difficult to diagnose. Look for features beyond obesity and striae, including short stature, hypertension, proximal limb muscle wasting or weakness, and diabetes.

The overnight dexamethasone suppression test is used to evaluate the risk of Cushing syndrome.

• One dose of 15 mcg/kg (max 1 mg) dex po at 11 p.m., and check cortisol the following morning between 7 a.m. and 9 a.m.
• Cortisol should be <2.0 mcg/dL.

• Screen for diabetes every three years in asymptomatic, obese children ages 10 to 19 years old with a family history of Type 2 diabetes, high-risk race or signs of insulin resistance. There is no agreed upon best test (fasting glucose, random glucose, HbA1c).
• Insulin levels do not effectively predict future Type 2 diabetes.
• Apart from lifestyle management, there is no approved therapy for children with prediabetes. Patients with prediabetes that persists after a serious effort to manage lifestyle for greater than six months may benefit from metformin treatment or an endocrine consult.
• A diabetes education consultation or a referral to Strong4Life can be arranged through Children’s for children with prediabetes.

High triglycerides with low HDL cholesterol is common in obese children. Children with severely low HDL (<20 mg/dL) may benefit from a lipid clinic consult.

• Ensure fasting sample was obtained.
• Take an average of two samples drawn two to 12 weeks apart when patient is not acutely ill.
• Check for primary disease-causing high triglyceride (i.e., fasting CMP, TSH and urinalysis).
• Abnormal levels that are <300 mg/dL may respond to lifestyle management plus or minus fish oil.
• Levels >300 mg/dL may benefit from a lipid clinic consult.

• Ensure a fasting sample was obtained.
• Take an average of two samples drawn two to 12 weeks apart when patient is not acutely ill.
• Check for primary disease-causing high LDL cholesterol (i.e., fasting CMP, TSH and urinalysis).
• For moderate elevation (130-189 mg/dL), lifestyle management is recommended for all patients. If no response within six months, evaluate for the following risk factors:
  • Hypertension
  • Smoking
  • Diabetes
  • Nephrotic syndrome
  • Renal failure
  • Renal transplant
  • History of Kawasaki disease
  • HIV
  • Chronic inflammation
  • Cancer survivor
  • Family history of premature cardiovascular disease
• If a high-risk factor is present, the child may benefit from lipid clinic consult.
• If LDL ≥190 mg/dL, a referral to the lipid clinic is recommended irrespective of risk factors present.

Normal variations in adolescents can make a PCOS diagnosis difficult using standard criteria. Minimum requirements for diagnosis include:

• Irregular or absent ovulation
• Clinical signs of high androgens (e.g., hirsute and severe acne)

Differential diagnosis of adrenal disease or an ovarian tumor can be evaluated with minimal investigation.

• 17-hydroxyprogesterone
• Free testosterone
• DHEA-S
• TSH
• Fasting complete metabolic profile
• Fasting lipid profile
• hCG (urine or serum)
• ± 25 (OH) vitamin D

A combined oral contraceptive pill (OCP) is the first line of therapy. Use OCP with low androgen activity. Consider the risk for thrombosis before starting oral contraceptive. Metformin is used by some, but it is not a Food and Drug Administration (FDA)-approved indication.