foreign students' Faculty
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.
·
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.
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.
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
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
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. -
2. Harrison’s Principles of Internal Medicine
(18th edition) / D. Longo, A. Fauci, D. Kasper, S.
Hauser, J. Jameson, J. Loscalzo,. –
3. Kumar and
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. –
2. Oxford Handbook of Endocrinology and Diabetes ( 2nd Revised edition) / John
A. H. Wass, Helen Turner. –
3. Williams Textbook of Endocrinology (12th Revised edition) / Shlomo Melmed, Kenneth S. Polonsky, P. Reed Larsen, Henry M. Kronenberg,
2011. – 1897 p.
4.
5. Oxford Textbook of Endocrinology and Diabetes (2nd Revised edition) /
Edited by John A. H. Wass, Paul Stewart, Stephanie A.
Amiel, Melanie J. Davies. –
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