foreign students' Faculty
Content module 5. Management of patients with endocrine disorders
LESSON
¹ 1 (PRACTICAL – 6 HOURS)
Theme 17: Management of patients
with hyperglycemia ( DM type 1, DM type 2).
Aim:
- to develop skills and to
acquire experience relevant to management of patients with diabetes mellitus
Professional Motivation.
It is probably fair to state
that about 2 to 4 percentage of the world population is affected with DM. The disease is more common in
persons after age
Primary DM is classified into
type 1 and type 2. DM can also be secondary to a variety of genetic syndromes,
pancreatic diseases, hormonal abnormalities, drug or chemical exposures and
insulin receptor abnormalities.
DM has diverse initial
presentations. Type I DM patients usually present with symptomatic
hyperglycemia or diabetic ketoacidosis. Type II DM may initially present with
symptomatic hyperglycemia or nonketonic hyperglycemic hyperosmolar coma, but is
frequently diagnosed in asymptomatic patients during a routine medical study or
when patients present clinical manifestation of a late complications.
The risk of
long-term clinical complications vary markedly in individuals but generally
increase with increasing duration of DM. Hyperglycemia causes the initial
metabolic alterations in the kidney, peripheral nervous and retina in
diabetics, but evidence suggests that once these structural alterations reach a
given stage, factors other than hyperglycemia determine the subsequent cause/
The signs and symptoms of late complications of DM mimic those of
pathologically similar or indistinguishable disease in the same organ or system
in nondiabetics. The manifestations may be present at diagnosis in those with
type II DM, but not in those with type I DM.
Atherosclerotic
coronary artery disease (manifested by angina pectoris and / or myocardial
infarction)and peripheral atherosclerotic vascular disease (manifested by
intermittent claudication and gangrene) are more common in diabetics than in
nondiabetics and occur at an earlier age.
Methodology
of Practical Class
Introduction by the
teacher, control the initial level of knowledge – 09.00-09.30
Individual
students' work with patients - 09.30-12.00
Break – 12.00-12.30
Seminar (discussion
of theoretical questions, practical work with patients) - 12.30-14.00
Break – 14.00-14.15
Individual work 1415-1500 (students who didn`t pass
the tests in Moodle system, complete the individual work).
Algorithm
of students’ communication with patients with pathology in subject
(communication skills):
During examination of the patient students have to use
such communicative algorithm:
Complaints and anamnesis taking in patients
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Take complaints and anamnesis in a patient.
5. Explain to the patient results of his/her lab
tests correctly and accessibly.
6. Explain to the patient your actions concerning
him/her (the necessity of hospitalization, certain examinations and
manipulations), which are planned in future.
7. Conversation accomplishment.
Objective examination:
Physical methods of examination of patients with internal diseases
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Explain to a patient, what examinations will be
carried out and get his/her informed consent.
5. Find a contact with the patient and make an attempt
to gain his/her trust.
6. Inform about the possibility of appearing of
unpleasant feelings during the examination.
7. Prepare for the examination (clean warm hands, cut
nails, warm phonendoscope, etc.).
8. Examination (demonstration of clinical skill).
9. Explain to the patient results of his/her lab tests
correctly and accessibly.
10. Conversation accomplishment.
Estimation of laboratory and instrumental investigations
Informing about the results of examination of patients with internal
diseases
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Explain to a patient results of his/her lab
tests correctly and clearly.
5. Involve the patient into the conversation (compare
present examination results with previous ones, clarify whether your
explanations are clearly understood).
Planning and prognosis the results of the
conservative treatment
Friendly facial expression and smile.
1. Gentle tone of speech.
2. Greeting and introducing.
3. Correct and clear explanation of necessary
treatment directions.
4. Discuss with a patient the peculiarities of taking
medicines, duration of their usage, possible side effects; find out whether
your explanations are clear for him/her or not.
5. Conversation accomplishment.
Work 1.
Work at the patient’s ward. The student
collects the complaints, anamnesis of disease and life, perform objective
examination of the patient, identify the main syndrome, formulate preliminary
diagnosis and prescribe plan of investigations.
Work 2.
The student estimates results of laboratory and instrumental investigations,
makes a differential diagnosis and formulates the clinical diagnosis, based on
the diagnostic criteria of the disease.
Work 3.
The student prescribes appropriate treatment and defines individual management
program for patient.
·
Under the tutor’s supervision
students should be able to elicit the patient’s chief complaint, history of
present illness, past medical history, social, family, occupational histories
and complete a review of systems.
·
Perform a physical examination
in a logical, organized and thorough manner.
·
Demonstrate the ability to
construct an assessment and plan for an individual patient organized by
problem, discussing the likely diagnosis and plan of treatment.
·
Demonstrate the ability to
record the history and physical in a legible and logical manner.
·
Demonstrate the ability to
write daily progress notes on the ward and appropriate outpatient progress
notes.
·
Orally present a new patient's
case in a focused manner, chronologically developing the present illness,
summarizing the pertinent positive and negative findings as well as the
differential diagnosis and plans for further testing and treatment.
·
Orally present a followup
patient's case, focusing on current problems, physical findings, and diagnostic
and treatment plans.
·
Diagnostic Decision Making
·
Formulate a differential
diagnosis based on the findings from the history and physical examination.
·
Use the differential diagnosis
to help guide diagnostic test ordering and its sequence.
·
Participate in selecting the
diagnostic studies with the greatest likelihood of useful results.
·
Recognize that tests are
limited and the impact of false positives/false negatives on information.
·
Test Interpretation
·
Describe the range of normal
variation in the results of a complete blood count, blood smear, electrolyte
panel, general chemistry panel, electrocardiogram, chest X-ray, urinalysis,
pulmonary function tests, and body fluid cell counts.
·
Describe the results of the
above tests in terms of the related pathophysiology.
·
Understand test sensitivity,
test specificity, pre-test probability and predictive value.
·
Understand the importance of
personally reviewing X-ray films, blood smears, etc., to assess the accuracy
and importance of the results.
·
Therapeutic Decision Making
·
Describe factors that
frequently alter the effects of medications, including drug interactions and
compliance problems.
·
Formulate an initial
therapeutic plan.
·
Access and utilize, when
appropriate, information resources to help develop an appropriate and timely
therapeutic plan.
·
Write prescriptions
accurately.
·
Monitor response to therapy.
Seminar discussion of
theoretical issues
1. Definition of term “DM”.
2.
Epidemiological aspects of DM,
risk factors of DM.
3.
The
main causes of increasing frequency of DM.
4.
Pathogenesis
of type I DM, type II DM.
5.
Differential
diagnosis between type I and type II DM.
6.
Classification
of DM by WHO (1999).
7.
Pathogenesis
and signs of gestation diabetes and DM which developed due to some status and
syndromes.
8.
Types
of impaired glucose tolerance.
The main signs and symptoms of DM and pathogenesis of them.
9.
Stages
of severity of DM, diagnostic criteria of each stage.
10.
Diagnostic
criteria DM compensation.
11.
Pathogenetic mechanisms of development of long-term
complications of DM.
12.
Classification
of angiopathy in DM patients and diagnosis of each form (retinopathy,
nephropathy, low extremitas angiopathy, “diabetic foot”).
13.
Classification
of neuropathy in DM patients and diagnosis of each form (polyneuropathy,
encephalopathy, visceral (autonomic) neuropathy, “diabetic foot”).
14.
The
main principles of DM therapy.
15.
Diet therapy in patients with
DM.
16.
The role of exercise program in
diabetics.
17.
Plant’s hypoglycemic agents.
18.
The main principles of patient’s
education.
19.
Indications and contraindications to
oral hypoglycemic agents’ administration.
20.
Other hypoglycemic agents in
treatment of DM.
21.
Insulin preparations, indications for
insulin therapy.
22.
The main principles of insulin
administration: daily dose; regimens (traditional and intensive
multiple component insulin therapy).
23.
Side effects of insulin therapy.
24.
Somogyi effect and down phenomenon: causes and
methods of liquidation.
25.
The main particularities of treatment
pregnant diabetics.
26.
Treatment of diabetic long-term
complications.
Multiple Choice.Choose the correct answer.
1. What organ is not responsive to
insulin?
A.
Liver.
B.
Muscle.
C. Brain.
D. Connective
tissue.
E. None of them
2. The effects of insulin include:
A. Inhibition of proteolysis.
B.
Inhibition of glycogenesis.
C. Stimulation
of glycogenolysis.
D. Stimulation
of glyconeogenesis.
E. Stimulation of lipolysis.
3. A 30-year-old female in her
first trimester of pregnancy complains on polyuria, polydipsia, nausea,
vomiting, and anorexia. One year ago, a fasting plasma glucose 8,8 mmol/L was
found. At the time she is obese. She was treated with a diet and an oral hypoglycemic
agent which resulted in a reduction in plasma glucose to normal. She had
pregnancy and delivery 3 years ago, and glucose level was normal diagnosis of
the current pregnancy was made 9 weeks ago. A grandmother and uncle have
diadetes. What is your diagnosis?
A. Type I DM and pregnancy.
B.
Type II DM and pregnancy.
C. Gestation
diabetes.
D. None
of the above.
E. Healthy
4. The results
of the glucose tolerance test: a fasting serum glucose is 6,6 mmol/l , 2-hour
postprandial serum glucose is 14,1 mmol/l. What is your diagnosis?
A. Normal.
B.
Impaired glucose tolerance.
C. Diabetes mellitus.
D. Impaired
fasting glucose
E. None of them
5. The results
of the glucose tolerance test: a fasting serum glucose is 6,6 mmol/l , 2-hour
postprandial serum glucose is 9,8 mmol/l. What is your diagnosis?
A.
Normal.
B.
Impaired glucose tolerance.
C. Diabetes mellitus.
D. Impaired
fasting glucose
E. None of them
6. The results
of the glucose tolerance test: a fasting serum glucose is 5,4 mmol/l , 2-hour
postprandial serum glucose is 7,6 mmol/l. What is your diagnosis?
A. Normal.
B.
Impaired glucose tolerance.
C.
Diabetes
mellitus.
D. Impaired
fasting glucose
E. None of them
7. How many stages of diabetic nephropathy do you know?
A.
1.
B.
2.
C.
3.
D.
4.
E.
5.
Real-life situations to be
solved:
1. The patient R., 20 years, complains on polydipsia,
polyurea, weight loss. The disease begins after mumps. During examination was found dry skin,
furunculosis, liver enlargement.
1) Previous diagnosis?
2) What is the most obvious
pathogenetic mechanism of the development of the disease?
3. Patient K., 56years, has DM for 2 years. He
is treated by diet. In last two month he breaks dietary regimen. During
examination was found: the glycemia achieves to 10,5 mmol/l, daily glucosuria
is 25 gr. What is your diagnosis?
4. Patient U.,22 years, has DM for 6 years. He
is treated by insulin (42 Units daily). Duration of diabetes is labile. Three
years ago was diabetic coma. Glycemia level is18,3 mmol/l. Glucosuria –30 g/l.
Acetonurea. What is your diagnosis?
5.Patient G., 62 years,
(growth is 154 sm., weight is
7. Patient Í., 30 years, has DM for 10 years and
takes insulin in dose 46 OD per day, in
two injections. In anamnesis frequent hypoglycemic commas, decreasing of visual acuity, pain in the lower
extremities. At the background of the eyes During ophthalmoscopic examination
was found: microaneurisms, hemorrhages, distension
of retinal veins. On the rheovasogram
of the lower extremities is lowering of pulse amplitude. Fast serum glucose level is 13,2 mmol/l. What is your diagnosis?
Initial
level of knowledge and skills are
checked by solving situational tasks for each topic, answers in test
evaluations and constructive questions (the instructor has tests &
situational tasks)
Students
should know:
1.
General
anatomy and physiology of endocrine system.
2.
Pathogenesis
of insulin lack.
3.
Etiology,
pathogenesis and diagnostic criteria of DM.
4.
Relevant
terminology, definitions and classifications of long-term complication of
patients with diabetes mellitus.
5.
Chief
complaints of patients with long-term complication of patients with diabetes
mellitus.
6.
Evaluation
of basic signs and symptoms in patients with diabetes mellitus and its
complication.
7.
Specific
signs and symptoms of patients with diabetes mellitus and its complication.
8.
Methods
of physical examination of patients with diabetes mellitus and its
complication.
9.
Methods
of laboratory evaluation of patients with diabetes mellitus and its
complication.
10.
Methods
of instrumental evaluation of patients with diabetes mellitus and its
complication.
11.
Principles
of management of patients with diabetes mellitus.
Students
should be able to:
1. Perform a clinical exam of patients with diabetes
mellitus and its complication.
2.
Reveal main clinical syndromes
of patients with diabetes mellitus and its complication.
3. Draft
a plan of laboratory and instrumental evaluation of
patients with diabetes mellitus and its complication.
4. Assess
the results of laboratory and instrumental evaluation of
patients with diabetes mellitus and its complication.
5. Diagnose
the condition and formulate the diagnosis according to current classification of patients with diabetes
mellitus and its complication.
6.
Perform differential diagnosis of diabetes mellitus.
7. Prescribe the appropriate therapy for the patients with diabetes
mellitus and its complications.
Correct
answers of test evaluations and situational tasks:
Multiple Choice. 1 – C. 2 – A, 3 –B, 4- C. 5.
– B. 6. – A, 7-E.
Real-life situations.
1: 1). Diabetes mellitus. 2).
Virus.;
2. Non-insulin-dependent DM.
3. Type II DM, mild degree of
severity in subcompensation stage.
4. Type I DM, hard degree of
severity in decompensation stage.
5. Diabetes mellitus, type 2.
6. Diabetes mellitus, type 1.
7.Type I DM, hard (severe)
degree, stage of the subcompensation. Diabetic preproliferative retinopathy
(maculopathy) II stage. Diabetic angiopathy
of lower extremities (functional stage) II stage.
References.
À – Basic:
3.
Kumar
and Clark's Clinical Medicine (8th Revised edition) (With
STUDENTCONSULT Online Access) / P. KumarM.L. Clark . –
B – Additional:
1. Greenspan's
Basic and Clinical Endocrinology ( 9th
Revised edition) / David G. Gardner, Dolores
M. Shoback. –
2. Oxford Textbook of Endocrinology and Diabetes2nd
Revised edition) / John A. H. WassP.StewartS. A. AmielM. J.
Davies. –
a)
http://emedicine.medscape.com/endocrinology
b)
http://care.diabetesjournals.org
·
Management of
Hyperglycemia in Type 2 Diabetes
Methodical
instruction has been worked out by:
Martynyuk L.P.
Methodical instruction was discussed and adopted at
the Department sitting “
Methodical instruction was adopted and
reviewed at the Department sitting 16.06.2011, Minute ¹ 13
Methodical instruction was adopted and
reviewed at the Department sitting 12.06.2012, Minute ¹ 12
Methodical instruction was adopted and
reviewed at the Department sitting 25.06.2013, Minute ¹ 17