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.

  • hyperthyroidism complicated by cardiac, respiratory compromise or other indications of severe illness (fever, vomiting, labile blood pressure, altered mental state)
  • neutropenic sepsis in patient taking carbimazole or propylthiouracil
  • symptomatic hyperthyroidism
  • stridor associated with a thyroid mass
  • possible tracheal or superior vena cava obstruction from retrosternal thyroid enlargement

For clinical advice, please telephone the relevant metropolitan Local Health Network switchboard and ask to speak to the relevant specialty service.

Women's and Children's Health Network

Exclusions

  • children with a thyroid stimulating hormone (TSH) < 10 mU/L and a normal free thyroxine (FT4) and/or positive anti-thyroid peroxidase (anti-TPO) antibodies
    • TSH levels should be monitored every 6 to 12 months, with a referral indicated only if TSH is > 10 mU/L

Triage categories

Category 1 - appointment clinically indicated within 30 days

  • newly diagnosed symptomatic thyrotoxicosis, please contact the endocrine registrar/doctor on-call at (08) 8161 7000 for advice about initiating treatment

Category 2 — appointment clinically indicated within 90 days

  • newly diagnosed hypothyroidism, please contact the endocrine registrar/doctor on-call at (08) 8161 7000 for advice about initiating treatment if uncertain of dosing
  • newly diagnosed mild or known hyperthyroidism
  • thyroid nodules

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
  • family history of thyroid disease
  • management history including treatments trialled/implemented prior to referral
  • identification as Aboriginal and/or Torres Strait Islander

Examination

Examination results including:

  • assessment of growth
  • palpation of thyroid for enlargement, thyroid nodule or cervical lymphadenopathy
  • assessment for signs of hypo or hyperthyroidism

Investigations

Hypothyroidism
  • thyroid stimulating hormone (TSH)
  • free thyroxine (FT4)
  • thyroid peroxidase (TPO) antibodies
  • thyroid ultrasound not required
Hyperthyroidism
  • TSH
  • FT4
  • thyroid stimulating hormone receptor antibody (TRAb) test
  • thyroid peroxidase (TPO) antibodies
  • complete blood examination (CBE)
  • liver function tests (LFTs)
  • thyroid ultrasound not required
Thyroid nodule
  • TSH
  • FT4
  • TPO antibodies
  • ultrasound of thyroid gland and cervical lymph nodes

Additional information to assist triage categorisation

Thyroid ultrasound not required for hypo/hyperthyroidism.

Clinical management advice

Thyroid problems in children may present as hypothyroidism, hyperthyroidism or a thyroid nodule.

Referral for children with a thyroid stimulating hormone is indicated only if TSH is > 10 mU/L.

Unless a thyroid nodule is palpable, an ultrasound does not need to be requested. Thyroid nodules with normal thyroid function tests (TFTs) should be referred to a thyroid surgeon.

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

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.