Referral to emergency
If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region.
- suspected adrenal crisis, including unexplained hyponatraemia and hypoglycaemia
- suspected diabetes insipidus with hypernatraemia and dehydration
- suspected pituitary mass including symptoms of (visual field loss/central nervous system (CNS) signs)
- vomiting or altered level of consciousness in a youth with known adrenal insufficiency
For clinical advice, please telephone the relevant specialty service.
Women's and Children's Health Network
- Women’s and Children’s Hospital (08) 8161 7000
Category 1 - appointment clinically indicated within 30 days
- pituitary mass - consider referral to neurosurgery and ophthalmology
- suspected diabetes insipidus with mild hypernatraemia
- suspected primary adrenal insufficiency
Category 2 — appointment clinically indicated within 90 days
- suspected secondary adrenal insufficiency, or treated adrenal insufficiency
- hyperprolactinaemia
- stable polydipsia
- suspected Cushing syndrome
- septo-optic dysplasia or optic nerve hypoplasia
Category 3 — appointment clinically indicated within 365 days
- nil
Essential referral information
Completion required before first appointment to ensure patients are ready for care. Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.
History
- past medical/surgical history
- onset, duration, and progression of symptoms
- current medications and dosages
- allergies and sensitivities
- management history including treatments trialled/implemented prior to referral
Examination
- examination findings, including:
- Tanner staging
- presence of hyperpigmentation
- height/weight/body mass index (BMI)
- blood pressure
Investigations
Adrenal insufficiency
- urea, electrolyte, and creatinine (UEC)
- if primary adrenal insufficiency suspected:
- serum cortisol, 8.00 am to 9.00 am
- renin
- adrenocorticotropic hormone (ACTH)
Adrenal excess
- 24-hour urine free cortisol (UFC) or midnight salivary cortisol test
Pituitary
- thyroid stimulating hormone (TSH)
- free thyroxine (FT4)
- insulin-like growth factor-1 (IGF-1)
- serum cortisol (0800-0900h)
- prolactin
- If > 9 years of age:
- electrolytes
- luteinizing hormone (LH)
- follicle-stimulating hormone (FSH)
- oestrogen or testosterone
Clinical management advice
Examples of paediatric adrenal conditions include:
- primary adrenal insufficiency, e.g Addison disease, congenital adrenal hyperplasia
- secondary adrenal insufficiency, e.g. pituitary or hypothalamic disorder, exogenous glucocorticoids
- glucocorticoid excess, e.g Cushing syndrome
The hallmarks of primary adrenal insufficiency are fatigue, anorexia and weight loss, postural hypotension, and skin and mucosal hyperpigmentation:
- primary adrenal insufficiency requires lifelong glucocorticoid and mineralocorticoid replacement
- secondary adrenal insufficiency only requires glucocorticoid replacement; mineralocorticoid replacement is not required because the renin– angiotensin–aldosterone axis remains intact
- if you suspect adrenal insufficiency, early discussion with endocrinologist is essential.
Examples of paediatric pituitary conditions include:
- congenital and acquired pituitary disorders including prolactinoma
- diabetes insipidus
General information
Contact Women’s and Children’s Hospital (WCH) endocrinology on-call on (08) 8161 7000 for advice or to escalate and discuss any clinical concerns.
Recent pathology results will be required prior to outpatient appointment. Consider providing repeat pathology form to patient at time of referral.
Patients who have previously been seen by a specialist are encouraged to be referred back to their care for further review if required.
Referrals are accepted at the discretion of the triaging clinician. If you are concerned that your patient requires specialist review, but may not fit the criteria provided, you are encouraged to contact the specialist team to discuss your concerns.
Clinical resources
- Endocrine Society - Clinical Practice Guideline: Pituitary Incidentaloma
- Royal Children's Hospital Melbourne - Adrenal crisis and acute adrenal insufficiency
- Therapeutic Guidelines - Adrenal Insufficiency
- Therapeutic Guidelines - Pituitary Adenomas
Consumer resources
Reason for request
- to establish a diagnosis
- for treatment or intervention
- for advice and management
- for specialist to take over management
- for a specified test/investigation the General Practitioner cannot order
- for other reason (e.g. rapidly accelerating disease progression)
- transfer of care from another tertiary service
- clinical judgement indicates a referral for specialist review is necessary.
Patient demographic details
- full name, including aliases
- date of birth
- residential and postal address
- telephone contact number/s – home, mobile and alternative
- Medicare number, where eligible
- name of the parent or caregiver, if appropriate
- preferred language and interpreter requirements
- identifies as Aboriginal and/or Torres Strait Islander
Clinical modifiers
- impact on employment
- impact on education
- impact on home
- impact on activities of daily living
- impact on ability to care for others
- impact on personal frailty or safety
- identifies as Aboriginal and/or Torres Strait Islander
Other relevant information
- Willingness to have surgery, where surgery is a likely intervention.
- Choice to be treated as a public or private patient.
- Compensable status, e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.
- Relevant social history, including identifying if you feel your patient is from a vulnerable population, under guardianship/out-of-home care arrangements and/or requires a third party to receive correspondence on their behalf.
- Triage of a specialist outpatient referral is based on clinical decision making to allocate an appropriate urgency categorisation.
- Where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service. Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.
- A change in patient circumstance (such as condition deteriorating or pregnancy) may affect the urgency categorisation and should be communicated as soon as possible.
- All new referrals will be triaged by a consultant and appointment times scheduled according to clinical urgency.
Adolescents transitioning from paediatric to adult specialist services require a formal handover from paediatric specialist clinician to adult specialist clinician as well as a formal referral from the referring specialist to ensure initial transfer of care is completed.
The General Practitioners role in this process is to provide support to patients as part of holistic care. All ongoing referrals to specialists can subsequently be provided by the General Practitioner once the transfer of care has occurred.