METHODICAL INSTRUCTION FOR STUDENTS OF THE 6 COURSE

foreign students' Faculty

Module 3. Current practice in internal medicine

Content module 5. Management of patients with endocrine disorders

LESSON ¹ 4 (PRACTICAL – 6 HOURS)

 

Theme 20: Management of patients with disorders of the hypothalamic-pituitary area.

 

Aim:

 - to develop skills and to acquire experience relevant to management of patients with pathology of adrenal glands, in particular those with chronic and acute adrenocortical insufficiency, hormonal active tumors of adrenal glands.

- to develop skills and to acquire experience relevant to management of patients with pathology of pituitary gland and hypothalamus, in particular those with acromegaly, gigantism, pituitary dwarfism, hypopituitarism, diabetes insipidus, Cushing’s syndrome.

- to develop skills and to acquire experience relevant to management of patients with primary and secondary hypogonadism, obesity.

 

 

Professional Motivation.

The anterior pituitary synthesize and release several polypeptide and protein hormones. These influence a variety of metabolic processes essential for normal growth and development; they also maintain the normal structure and activity of several target glands.

Age and sex play an important role in the frequency of a given type of Cushing’s syndrome. Adrenal carcinoma is the cause in 65 % of patients younger than 15, nonpituitary ACTH secretion predominates in males, and 75 % of patients with pituitary – dependent Cushing’s syndrome are females.

The frequency of acromegaly among male and female is nearly equal. The gigantism appears more often in boys in prepubertal and pubertal period. Pituitary dwarfism, diabetes insipidus and syndrome of inappropriate ADH secretion a quiet rare but need early diagnosis and substitution therapy.

The diseases of sexual glands are quiet frequent in the practice of endocrinologist. An early diagnosis and correct treatment are very important in these cases. The cessation of menstruation in women occurs at the median age 50,8 years. In the 5 years before there is a gradual increase in the number of anovulatory cycles. This period is referred to as the climacteric. Estrogen secretion falls and negative feedback results in increased pituitary secretion of LH and FSH.

Obesity adversely affects morbidity and mortality, primarily through cardiovascular complications. The death rate from many diseases, from accidents, and from surgery, is significantly higher among the obese, increasing with the magnitude of the obesity. Sudden death is also common.

 

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.

 

Individual Students Program

·                  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.                Etiology and pathogenesis of hypopituitarism and obesity.

2.                The diagnostic criteria of hypopituitarism and obesity.

3.                Treatment of patients with hypopituitarism and obesity.

4.                Etiology and pathogenesis of acromegaly, gigantism, pituitary dwarfism, diabetes insipidus, syndrome of inappropriate ADH secretion.

5.           The diagnostic criteria of acromegaly, gigantism, pituitary dwarfism, diabetes insipidus, syndrome of inappropriate ADH secretion.

6.           Treatment of acromegaly, gigantism, pituitary dwarfism, diabetes insipidus, syndrome of inappropriate ADH secretion.

7.           The diagnostic criteria of different forms of gonads (testes and ovarian) disorders.

8.           Etiology and pathogenesis of Cushing’s syndrome and hypothalamic syndrome of pubertal period.

9.           The diagnostic criteria of  Cushing’s syndrome and hypothalamic syndrome of pubertal period.

10.      Treatment of  Cushing’s syndrome and hypothalamic syndrome of pubertal period.

11.      Treatment of these disorders.

 

Test evaluation and situational tasks

Multiple Choice.

Choose the correct answer/statement:

1.     Which of these signs can’t be present in patient with pituitary insufficiency?

A.   Hypotension.

B.   Hyperpigmentation.

C.   Weight loss.

D.   Hypogonadism.

E.    Hypothyroidism.

2.     The anterior pituitary does not produce such hormone as:

A.   Growth hormone.

B.   Thyrotropin.

C.   Oxytocin

D.   Prolactin.

E.    Gonadotropins.

3.     Syndrome of inappropriate ADH secretion is not characterized by:

A.   Low serum osmolality.

B.   Low level of serum sodium.

C.   High urine osmolality.

D.   High serum osmolality.

E.    All of them

4.     Diabetes insipidus is not characterized by:

A.   Hyperglycemia.

B.   Polyuria.

C.   Polydipsia.

D.   Low urine osmolality.

E.    Hypostenuria

5.     What can be find in patient with Klinefelter’s syndrome?

A.   karyotype XY;

B.   low height;

C.   decreased weight;

D.   low level of serum testosterone and increased level of LH.

E.    Karyotype XX

6.     Where is localized pathologic process in patients with Cushing’s syndrome?

A.     The anterior pituitary.

B.     The posterior pituitary.

C.     Hypothalamus.

D.     The adrenal cortex.

E.      The adrenal medulla.

7. What is the therapy of choice in patients with pituitary-dependent Cushing’s disease?

A.  Transsphenoidal hypophysectomia.

B.  Bilateral adrenalectomia.

C.  An exploratory laparotomy.

D.  Start pituitary irradiation.

E.  Observe patient without treatment.

 

 Real-life situations to be solved:

1.A 45-year-oldmale complains of headaches, visual impairment, decreased libido, hair loss, weakness, and dizziness. His doctor attributes these symptoms to a mild anemia which he discovered on initial evaluation and which he has been treating with oral iron. Because diabetes mellitus diagnosed at age 25, he has been receiving 20 units of Insulatard (intermediate-acting insulin) in the morning and 10 units in the evening. He has noted recent increase in the frequency of hypoglycemic episodes despite reducing the insulin dose by half. Physical examination reveals a blood pressure of 100/60 recumbent and 80/40 standing, a pulse rate of 60, a weight of 70 kg, normal temperature, pale skin, sallow complexion of the face with prominent wrinkles of the forehead, and the lateral thinning of the eyebrows. The thyroid gland is not palpable. Lungs, heart, abdomen are without abnormalities. There is marked decrease in axillary and pubic hair, and the testes are 3 cm in the longest diameter. Vibratory sense in the lower extremities is decreased and relaxation phase of the Achilles tendon reflex is delayed. What is your diagnosis?

 

2.As a part of a general check-up obesity and hypogonadism was found in a 16-year-old male. The patient has no complaints. What is your diagnosis?

 

3.A 35-year-old male has noted a progressive increase in size of the head, hands and feet. His finger ring is tight and he noticed an increase in shoe size. Headaches, visual difficulties, increase sweating, polyuria, and polidipsia have been present for 2 years. Other complaints include joint pain, decreased libido, numbness, and tingling of both hands. On physical examination, blood pressure is 150/100. The head, hands, and feet aare large and prognatism is present. Examination of the eyes reveals bitemporal hemianopsia and papilledema. The thyroid gland is diffusely enlarged but without tendeness. The skin is thick and dry and the hands are warm. Testicular size is 3 cm. 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. Main mechanisms of pituitary gland, hypothalamus hormones action.

2. Relevant terminology, definitions and classifications of pathology of pituitary gland, hypothalamus and obesity.

3. Chief complaints of patients with pathology of of pituitary gland, hypothalamus and obesity.

4. Evaluation of basic signs and symptoms in patients with pathology of pituitary gland, hypothalamus and obesity.

5. Specific signs and symptoms of patients with pathology of pituitary gland, hypothalamus and obesity.

6. Methods of physical examination of patients with pathology of pituitary gland, hypothalamus and obesity.

7. Methods of laboratory evaluation of patients with pathology of pituitary gland, hypothalamus and obesity.

8. Methods of instrumental evaluation of patients with pathology of pituitary gland, hypothalamus and obesity.

9. Principles of management of patients with pathology of pituitary gland, hypothalamus and obesity.

 

Students should be able to:

1. Perform a clinical exam of patients with pathology of pituitary gland, hypothalamus and obesity.

2. Reveal main clinical syndromes of patients with pathology of pituitary gland, hypothalamus and obesity.

3. Draft a plan of laboratory and instrumental evaluation of patients with pathology of pituitary gland, hypothalamus and obesity.

4. Assess the results of laboratory and instrumental evaluation of patients with pathology of pituitary gland, hypothalamus and obesity.

5. Diagnose the condition and formulate the diagnosis according to current classification of patients with pathology of pituitary gland, hypothalamus and obesity.

6. Perform differential diagnosis of pathology of pituitary gland, hypothalamus and obesity.

7. Prescribe the appropriate therapy for the patients with pathology of pituitary gland, hypothalamus and obesity.

 

Correct answers of test evaluations and situational tasks:

Multiple Choice. 1– B. 2 – C. 3 – D. 4 – A. 5 – D, 6-D, 7-A.

Real-life situations. 1. Panhypopituitarism. 2.Babinsky-Frelych’s disease (adipose-genital dystrophy). 3.Acromegaly.

 

References.

À – Basic:

1.  Davidson's Principles and Practice of Medicine (1st Edition) / Edited by  N. R. Colledge, B. R. Walker,   S. H. Ralston. - Philadelphia : Churchill Livingstone, 2010. – 1376 p.

2.  Harrison’s Principles of Internal Medicine (18th edition) / D. Longo, A. Fauci, D. Kasper, S. Hauser, J. Jameson, J. Loscalzo,. – New York : McGraw-Hill Education - Europe, 2011. – 4012 p.

3. Kumar and Clark's Clinical Medicine (8th Revised edition) (With studenrconsult Online Access) / Edited by P. Kumar, M. L. Clark . – London : Elsevier Health Sciences, 2012. – 1304 p.

4. Web-sites: http://intranet.tdmu.edu.ua: Management of patients with pathology of hypothalamic-pituitary area.

 

B – Additional:

1. Greenspan's Basic and Clinical Endocrinology ( 9th Revised edition) / David G. Gardner, Dolores M. Shoback. – New York : McGraw-Hill Education - Europe, 2011. -  880 p.

2. Oxford Handbook of Endocrinology and Diabetes ( 2nd Revised edition) / John A. H. Wass, Helen Turner. – Oxford : Oxford University Press, 2009.  – 952 p.

3. Williams Textbook of Endocrinology (12th Revised edition) / Shlomo Melmed, Kenneth S. Polonsky, P. Reed Larsen, Henry M. Kronenberg, 2011. – 1897 p.

4. Harrison's Endocrinology (2nd edition) / J.Larry Jameson. - New York : McGraw-Hill Education - Europe, 2010. – 560 p.

5. Oxford Textbook of Endocrinology and Diabetes (2nd Revised edition) / Edited by John A. H. Wass, Paul Stewart, Stephanie A. Amiel, Melanie J. Davies. – Oxford : Oxford University Press, 2011. – 2160 p.

6. Web-sites: http://emedicine.medscape.com/endocrinology

 

 

 

Methodical instruction has been worked out by:  assist. prof. I.I. Svystun

Methodical instruction was discussed and adopted at the Department sitting “27” August, 2013. Minute ¹ 1