foreign students' Faculty
Content module 5. Management of patients with endocrine disorders
LESSON
¹ 2 (PRACTICAL – 6 HOURS)
Theme
18: Management of patients with thyrotoxicosis. Management of
patients with hyperparathyroidism.
Aim:
- to
develop skills and to acquire experience relevant to management of patients
with pathology of thyroid and
parathyroid glands, in particular those with hyperthyroidism and hyperparathyroidism
Professional Motivation.
Hyperthyroidism
is the condition resulting from the effect of excessive amounts of thyroid
hormones on body tissues. Thyrotoxicosis is a main syndrome. Sometimes the term
hyperthyroidism can be used in a narrower sense to denote this state when the
thyroid gland is producing too much thyroid hormones
in contrast with excessive ingestion of thyroid hormone medication. At one time
or another, approximately 0,5 % of the population
suffers from hyperthyroidism. Grave’s disease is the most common cause of
hyperthyroidism and is fairly common in the population. It is responsible for
over 80 % of hyperthyroid cases. It occurs most often in young women, but it
may occur in men and at any age.
Hyperparathyroidism
(is characterized by hypercalcemia, associated with damaging of the bones,
kidneys and gastrointestinal tract) occurs in 0,15 –
0,52 % of adults.
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.
The term “hyperthyroidism”.
2.
Predisposing factors of
hyperthyroidism.
3.
Pathogenesis of
hyperthyroidism.
4.
Degrees of the thyroid
gland enlargement.
5.
Stages of thyrotoxicosis
severity.
6.
Changes of the
cardiovascular system in patients with hyperthyroidism.
7.
Changes of the nervous system in patients with
hyperthyroidism.
8.
Changes of the
gastrointestinal tract in patients with hyperthyroidism.
9.
Changes of the other endocrine organs in patients with
hyperthyroidism.
10.
Ophthalmologic signs and
symptoms of hyperthyroidism.
11.
Endocrine ophthalmopathy.
12.
Pretibial mixedema.
13.
Differential diagnosis of
hyperthyroidism.
14.
Particularities of
hyperthyroidism in young, adult and pregnant patients.
15.
Nodular hyperthyroidism:
etiology, pathogenesis, diagnostic criteria, differential diagnosis.
16.
Complications of
hyperthyroidism.
17.
The main methods of
treatment patients with hyperthyroidism.
18.
Antithyroid medications: mechanism of action, side
effects.
19.
Usage of β-blockers, glucocorticoids, thyroid hormones.
20.
Surgical treatment.
21.
Radioiodine therapy.
22.
Treatment of endocrine ophthalmopathy.
23.
Hyperparathyroidism:
etiology and pathogenesis.
24.
Classification of
hyperparathyroidism.
25.
What are the main
diagnostic criteria of hyperparathyroidism?
26.
What kinds of diseases
can differential diagnosis be made with hyperparathyroidism?
Differentiate them, please.
27.
What does treatment of
hyperparathyroidism include?
Multiple Choice.
Choose the correct answer/statement:
1. Clinical
sign of hyperthyroidism which is very rare in old patients:
A.
large goiter;
B.
parkinsonic’ trembling of the fingers;
C.
nodular forms of goiter;
D.
prominent heart failure;
E. atrial fibrillation.
2. A 24-year-old woman is referred to you
by an ophthalmologist who discovered bilateral cataracts. Patient is product of
normal pregnancy and delivery. Childhood was uncomplicated, and she has done
well at school. During the past 5 years, she has been complaining of decreased
visual acuity, tingling and numbness of hands and legs, and constipation. The
patient married at age 21, and she had a normal child at age 22. During
pregnancy, tingling and numbness of the extremities worsened, and she had
several seizure episodes necessitating intravenous calcium administration. Two
sisters have been treated forhypocalcemia with
vitamin D. The patient takes no medications. The physical examination is
unremarkable. Laboratory: the complete blood count, urinanalysis and examination of the stools for ova
and parasites are normal; serum calcium is decreased, serum phosphate is
increased, serum alkaline phosphatase is normal.
What is
your diagnosis?
A. Inappropriate
PTH secretion.
B.
Osteomalacia.
C.
Vitamin D deficiency.
D.
Hypoparathyroidism.
E. Vitamin
D intoxication.
3.
Which is the most important test to evaluate the mechanism of the hypocalcemia?
A. Bone
X-rays.
B. Serum
magnesium concentration.
C. Plasma PTH concentration.
D.
Plasma 25-(OH)D.
E.
Urinary calcium.
4. How would
you treat this patient?
A.
Intramuscular PTH.
B.
Subcutaneous calcitonin.
C. Oral
phosphates.
D.
Vitamin D.
E.
Thiazide diuretics.
A. Radioactive iodine
B. Subtotal
thyroidectomy
C. Metaprolol
D. Carbimazole
E. Radiotherapy
A. Propylthiouracil
therapy with the goal of maintaining her thyroid function tests in the highnormal
B. Radioactive iodine to
ablate her thyroid gland or slightly high range
C. Methimazole therapy
D. A beta blocker
E. Propylthiouracil
therapy with care taken to maintain her thyroid function tests in the midnormal range
7. The most important regulator of serum 1,25(OH)2 vitamin D concentration is:
A. Serum
calcium
B. Serum
magnesium
C. Serum 25(OH) vitamin
D
D. TSH
E. Parathyroid
hormone
A. Hypokalaemia
B. Hyperkalaemia
C. Hypocalcaemia
D. Hypercalcaemia
E. Hyponatraemia
9. Which of the following is the most active form of
thyroid hormone:
A. Thyroxine (T4)
B. Triiodothyronine (T3)
C. Thyrotropin
D. Thyroglobulin
E. Thyroid peroxidase
10. Which of the following is the most characteristic
eye sign in dysthyroid status?
A. Exophthalmus
B. Ptosis
C. Optic neuropathy
D. Myopathy
E. Retinopathy
Real-life situations to be solved:
1. Patient F, 38 years old,
complaints on general weakness, increased sweating, palpitation. Physical
examination shows: skin is moist, hot; trembling of the fingers, thyroid gland
is enlarged, positive eye’s symptoms, pulse rate 116/minute, systolic murmur on
the region of the heart and thyroid. Put previous
diagnosis and make the plan of the examination.
2. Patient R, 29 years old, complaints on
general weakness, increased sweating, palpitation, decreased weight. Physical
examination shows: skin is moist, hot; trembling of the fingers, thyroid gland
is enlarged to II stage, positive eye’s symptoms, pulse rate 130/minute, blood pressure is 150/50 mm of Hg. TSH level
is decreased, T4 - increased. Put diagnosis and prescribe the treatment.
3. As a part of a
general check-up hypercalcemia is discovered in 46-year old female. The patient
has no complaints. What is your previous diagnosis?
4. Patients
complains on polydipsia, polyuria, general
weakness, weight loss. Three years age stones in kidneys were found. What is
your previous diagnosis? Make a plan of investigations.
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 thyroid and parathyroid glands.
2. Main
mechanisms of thyroid and parathyroid hormones
action: hormone receptors, regulation of hormones synthesis and secretion, regulatory
effects of hypothalamic-pituitary axis.
3.
Relevant terminology, definitions and
classifications of hyperthyroidism and hyperparathyroidism.
4.
Chief complaints of patients with hyperparathyroidism and hyperthyroidism.
5.
Evaluation of basic signs and symptoms
in patients with hyperparathyroidism and hyperthyroidism.
6.
Specific signs and symptoms of
patients with pathology of parathyroid
glands and hyperthyroidism.
7.
Methods of physical examination of
patients with hyperthyroidism and hyperparathyroidism.
8.
Methods of laboratory evaluation of
patients with hyperthyroidism and hyperparathyroidism.
9. Methods
of instrumental evaluation of patients with hyperthyroidism and hyperparathyroidism.
10.
Principles of management of patients
with hyperthyroidism and hyperparathyroidism.
Students
should be able to:
1.
Perform a clinical exam of patients with hyperthyroidism and hyperparathyroidism.
2.
Reveal main clinical syndromes of
patients with hyperthyroidism and hyperparathyroidism.
3.
Draft a plan of laboratory
and instrumental evaluation of patients with hyperthyroidism and hyperparathyroidism.
4.
Assess the results of laboratory and instrumental
evaluation of patients with hyperthyroidism
and hyperparathyroidism.
5.
Diagnose the condition and formulate
the diagnosis according to current
classification of patients with hyperthyroidism
and hyperparathyroidism.
6.
Perform differential diagnosis of hyperthyroidism
and hyperparathyroidism.
7.
Prescribe the appropriate
therapy for the patients with hyperthyroidism
and hyperparathyroidism.
Correct
answers of test evaluations and situational tasks:
Multiple Choice. 1– A, 2 – D, 3 – C, 4 – D, 5-B, 6-A, 7-E, 8-C, 9-B,
10-A.
Real-life situations. 1. Hyperthyroidism,
moderate stage of thyrotoxicosis. Ultrasonic examination of the thyroid gland, the
levels of TSH, T3,T4.
2.
Diffuse goiter II, severe stage. Antithyroid drugs (tiamazole 40 mg/day 10 – 14 days, then dose have
to be decreased to 10 – 15 mg till 1,5 –
2,0 years), β – blockers).
3. This
a typical presentation of primary hyperparathyroidism.
4. Hyperparathyroidim. The level of serum calcium, phosphate,
alkaline phosphatase, examination
of kidneys function, bones X-rays.
References.
À – Basic:
3.
Kumar
and Clark's Clinical Medicine (8th Revised edition) (With
STUDENTCONSULT Online Access) / P. KumarM.L. Clark . –
4.
Web-sites: www.tdmu.edu.ua: Management of patients with
thyrotoxicosis.
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. –
3. Web-sites:
a) http://emedicine.medscape.com/endocrinology
b)
http://aace.com/ ATA/AACE
Guidelines Hyperthyroidism and ther causes of
thyrotoxicosis:guidelines // Endocrine practice. – 2011. - Vol. 17, No. 3 May/June.
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 sitting16.06.2011, Minute ¹ 13
Methodical instruction was adopted and
reviewed at the Department sitting12.06.2012, Minute ¹ 12
Methodical instruction was adopted and
reviewed at the Department sitting 25.06.2013, Minute ¹ 17