foreign students' Faculty
Content
module 5. Management
of patients with endocrine disorders
LESSON
¹ 3 (PRACTICAL – 6 HOURS)
Theme 19: Management of patients with
hypothyroidism. Management of patients
with thyroid nodules.
Aim:
to
develop skills and to acquire experience relevant to management of patients
with pathology of thyroid gland,
in particular those with hypothyroidism and thyroid
nodules.
Professional Motivation.
Hypothyroidism is the condition resulting from a lack
of the effects of thyroid hormones on body tissues. Hypothyroidism is a common
condition. Congenital hypothyroidism is diagnosed in 1 of every 4000 newborns
by screening methods, in adults over 0,5 the frequency is approximately 2 - 4%.
The overall frequency in the population is approximately 0,5 – 1,0 %.
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.
Classification of hypothyroidism.
2.
Primary, secondary, tertiary
hypothyroidism: etiology and pathogenesis.
3.
Changes of the skin and subcutaneous adipose
tissue in patients with hypothyroidism.
4.
Changes of cardiovascular system,
nervous system and gastrointestinal tract in patients with hypothyroidism.
5.
Clinical peculiarities of congenital
hypothyroidism.
6.
Syndrome of galactorhea - amenorhea.
7.
Laboratory and instrumental signs of
hypothyroidism.
8.
Differential diagnosis of
hypothyroidism.
9.
Treatment of hypothyroidism.
10.
Myxedema coma: etiology, diagnostic
criteria, emergency.
11.
Nodules of thyroid gland:
etiology and pathogenesis.
12.
Classification of iodine deficiency
status
13.
The pathology of thyroid
gland accompanied with nodules.
14.
The main diagnostic criteria of iodine
deficiency status
15.
The main diagnostic criteria of nodules
of thyroid gland.
16.
Treatment and prevention of iodine
deficiency status
17.
Treatment
of nodules of thyroid gland
Multiple Choice.
Choose the correct answer/statement:
A.Low thyroid hormone levels but no symptoms
B.Classic symptoms of hypothyroidism but normal thyroid function test
results
C.Low free T4 levels but normal serum thyroid-stimulating hormone (TSH)
level
D.Low serum TSH but normal free T4 levels
E.Increased serum TSH but normal free T4 levels
2. What is the most
important in treatment of anemia in patients with hypothyroidism:
A.Iron containing preparations;
B.B12 containing preparations4
C.Thyroid preparations;
D.Androgens;
E.Correction of autoimmune disorders.
3. What we can’t use in
patients with myxedema coma:
A.Thyroid hormones.
B.Glucocorticoids.
C.Rehydration.
D.Symptomatic therapy.
E.Decreasing of hypoventilation.
A.Thyroglossal cyst
B.Hashimoto's
thyroiditis
C.Thyroid
carcinoma
D.Graves'
disease
E.Multinodular goitre
5. What
point, concerning myxedema coma is correct ?
A.Feeling
warm may provoke myxedema coma
B.Hypothermia
is common
C.Cause
is – increased sensitivity to T 3 and T4 receptors.
D.Hyperfunction of adrenal glands
E.Thyroid
cancer can provoke coma
6. Which
substances aren’t components of the colloid of the thyroid follicle?
A.Thyroxine (T4)
B.Triiodothyronine (T3)
C.Thyrotropin
D.Thyroglobulin
E.Thyroid peroxidase
7. Patient T. presents very high
concentration of antithyroid peroxidase antibody, it is most closely
associated with:
A.Graves'
disease
B.Hypothyroidism
C.Subacute thyroiditis
D.Chronic
autoimmune thyroiditis
E.Estrogen
therapy
8. Congenital
hypothyroidism is NOT characterized by:
A.Sexual
retardation
B.Growth
retardation
C.Retardation
of bone age
D.Mental
retardation
E.Signs
of hypopituitarism
9. The main cause of secondary
hypothyroidism is:
A.Inflammation
of the thyroid gland
B.Hypopituitarism
C.Thyrostatic therapy
D.Iodine
deficiency status
E.Disorders
of cells sensitivity to thyroid hormones
10. Patient F., 29 yr. old, presents with subacute thyroiditis. Treatment will include:
A.Antibiotics
B.Vitamins
C.Antithyroid drugs
D.Iodine
preparations
E.Corticosteroids
Real-life situations to be solved:
1.Patient D., 38 years old, 3 month ago has subtotal thyroidectomy. She complaints
on fatigue, somnolence, constipation, edema on the face, changing of the voice.
During examination was found: skin pale, thick and cold, face enlarged, pulse –
58/minute, blood pressure is decreased. Put previous diagnosis and make the
plan of examination.
2.Patient L., 40 years old, complaints on acute pain in the region of
anterior part of the neck, which irradiates into ears and mandibular, fever. During examination
was found increased and painful thyroid gland, the skin is red, lymphatic nodes
are increased. In blood there is leucosytosis and increase ESR. Put diagnosis and
make the plan of treatment.
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 gland.
2. Main mechanisms of thyroid hormones action: hormone
receptors, regulation of hormones synthesis and secretion, regulatory effects
of hypothalamic-pituitary axis.
2. Relevant terminology, definitions and
classifications of thyroid gland pathology.
3. Chief complaints of patients with pathology of
thyroid gland.
4. Evaluation of basic signs and symptoms in patients
with pathology of thyroid gland.
5. Specific signs and symptoms of patients with
hypothyroidism and thyroid nodules.
6. Methods of physical examination of patients with
hypothyroidism and thyroid nodules..
7. Methods of laboratory evaluation of patients with
hypothyroidism and thyroid nodules..
8. Methods of instrumental evaluation of patients with
hypothyroidism and thyroid nodules..
9. Principles of management of patients with
hypothyroidism and thyroid nodules..
Students
should be able to:
1. Perform a clinical exam of patients with thyroid
gland pathology.
2. Reveal main clinical syndromes of patients with
thyroid gland pathology.
3. Draft a plan of laboratory and instrumental evaluation of patients with thyroid gland pathology.
4. Assess the results of laboratory and instrumental
evaluation of patients with hypothyroidism and thyroid nodules.
5. Diagnose the condition and formulate the diagnosis
according to current classification of
patients with hypothyroidism and thyroid nodules.
6. Perform differential
diagnosis hypothyroidism and thyroid nodules.
7. Prescribe the appropriate
therapy for the patients with hypothyroidism and thyroid nodules.
Correct
answers of test evaluations and situational tasks:
Multiple Choice. 1 – E, 2 – C; 3 – C, 4-C, 5-B, 6-C, 7-D, 8-E, 9-B, 10-E.
Real-life situations. 1. Primary,
postoperative hypothyroidism. Level
of T4, T3, TSH, cholesterol.
2.
Acute thyroiditis. Patient have to be treated in surgical department
by antibiotics. If it is
necessary by surgical treatment.
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://www.endo-society.org/
·ATA/AACE Guidelines CLINICAL
PRACTICE GUIDELINES FOR HYPOTHYROIDISM IN ADULTS
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