PROBLEM BASED LEARNING REFFERENCES

PBL: PROBLEM BASED LEARNING 2015 BLOCK: ENDOCRINE SYSTEM AND METABOLISSM AND ITS DISORDERS Objective 1. To understand that excessive urination and thirsty is one of chief complaints of patients in medical practice 2. Capable to search underlying diseases related to excessive urination and thirsty 3. To know several diseases as the most important causes of excessive urination and thirsty and capable to differentiate them based on the probability 4. Capable to confirm diagnosis the certain disease and exclude other diagnosis by history taking, physical examination and supporting studies electrocardiography, laboratory and imaging studies 5. Capable to manage the patient as a primary care physician 6. To understand the clinical course of the disease without treatment Learning Task There are four sessions to completely discuss the case, starts from distributing the trigger problem at the first meeting and ends by the plenary session to overcome the case problem based on students discussion. Trigger problem: Excessive urination and thirsty A female 22 years old, study in university, visited a general practitioner due to excessive urination since last two weeks. She had problem in concentrating to her campus activity since she need to go toilet many times. She was feeling thirsty all the time and almost every 30 minutes she had to drink a bottle of water about 750cc and preferred sugary drink. Her body weight lost 2 kg in 1 week. c. Search any information of health problems or diseases related to excessive urination and thirsty. d. Explain the mechanisms of excessive urination in each disease that you suggested. First Session Small Group Discussion: discuss Task 1a and 1b and prepare group presentation in plenary meeting. New data will be distributed after plenary meeting for next session Udayana University Departement of Medicine Education, DME 30

13. PROBLEM BASED LEARNING

BASIC CLINICAL SKILLS TEACHING PROGRAM BLOCK ENDOCRINE Topics: 1. Insulin injection 2. Self monitoring blood glucose 3. Measurement of Obesity: Waist circumference and BMI calculation 4. Thyroid gland physical examination 5. Laboratory result interpretation Clinical Skill 1. Insulin injection Udayana University Departement of Medicine Education, DME 31

14. CLINICAL SKILLS

Learning task: 1. Define the site of subcutaneous insulin injection 2. Practice preparing and administering insulin using insulin needle 1 cc 1. 8 unit of rapid human insulin 2. Mixed of 6 unit rapid insulin and 14 unit NPH insulin 3. Practice preparing and administering insulin using insulin pen solostar, humapen, or novoletflexpen, in this case try 6 unit. Clinical Skill 2. Self monitoring blood glucose Self monitoring blood glucose SMBG is an important component of modern therapy for diabetes mellitus. SMBG is recommended for people with diabetes and their health care professionals in order to achieve a specific level of glycemic control and to prevent hypoglycemia. The test most commonly involves pricking a finger with a lancet device to obtain a small number of blood sample, applying a drop of blood onto a reagent strip, and determining the glood glucose concentration by inserting the strip into a reflectamce photometer for an automated reading. Test results are then recorded in a logbook or stored in the glucose meter’s electronic memory. People with diabetes can be taught to use their SMBG to correct any deviations out of a desire range by changing their carbohydrate intake, exercising, or using more or less insulin. Udayana University Departement of Medicine Education, DME 32 Learning task: 1. Practice measuring blood glucose using glucometer. 2. Below are data of a diabetes patient. Mr. B, 48 years old, diabetes for 7 years. Now on glibenclamide 5 mg twice a day. He has tried metformin and acarbose for few months, then stopped due to diarrhea. Body weight 78 kg, height 168 cm. Laboratory result: - Fasting BS 198 mgdL, 2 hours post prandial 202 mgdL, A1C 12.0 - Urinalysis: protein +2, creatinin serum 2.0 mgdL Task: a. What do you think about his diabetes control? b. Do you think he needs a home monitoring blood sugar? Why? c. How would you suggest him for his diabetes medication? Clinical skill 3. Measurement of Obesity : Waist circumference and BMI calculation Obesity is defined as a condition in which there is an excess of body fat. The operational definition of obesity and overweight however are based on body size or body mass index BMI which is closely related to body fatness. These BMI cut off point are arbitrary along a continuum of increasing risk with increasing BMI. Cut offs used for the definition of obesity can be based on: 1. Statistical data from reference population 2. or on the excess morbidity and mortality associated with increasing body fat content.

a. BMI body mass index

Height and weight are the most simple and commonly used measures. A number of weight for height indices have been developed of which the body mass index BMI define as this following formula:

b. WC waist circumference and WHR waist to hip ratio

To determine the risk associ, we need to measured the distribution of body fat. Abdominal or visceral fat is associated with the cardiovascular rsik of the metabolic syndrome. For WC, the subject stands with feet 25-30 cm apart, weight evenly distributed. Measurement is taken midway between the inferior margin of the last rib and the crest of the ilium in the horizontal plane. The measurer sits by the side of the subject and fits the tape snugly but not compressing soft tissues. Circumference is measured to nearest 0.1 cm For hip circumference the measure is taken around the pelvis at the point of maximal protrusion of the buttocks. Ratio of waist to hip ratio WHR is calculate by: Tabel 1. Classification of Weight by BMI and Waist Circumference in Adult Asians Classification BMI kgm 2 Risk of co-morbidities Underweight 18.5 Low but increased risk of other clinical problem Normal range 18.5 – 22.9 Average Overweight At risk Obese I Obese II 23 23 – 24.9 25 – 29.9 30 Increased Moderate Severe Waist circumference Normal Abdominal obesity 90 cm men 80 cm women 90 cm 80 cm WHR 1.0 men 0.85 women Udayana University Departement of Medicine Education, DME 33 Body weight kg Height m = BMI kgm 2 Waist circumference Hip circumference = WHR Clinical skill 4. Thyroid gland physical examination

a. Inspect the neck for the thyroid gland

Tip the patient’s head back a bit. Using tangential lighting derected downward from the tip of the patient’s chin, inspect the region below the cricoid cartilage for the gland. Goiter is a general term for an enlarged thyroid gland. Ask the patient to sip some water and to extend the neck again and swallow. Watch for upward movement of the thyroid gland, noting its contour and symmetri The thyroid cartilage, the cricoid cartilage, and the thyroid gland all rise with swallowing and then fall to their resting positions.

b. Palpation

Steps for palpating the thyroid gland: - Ask the patient to flex the neck slightly forward to relax the sternomastoid muscles. - Place the fingers of both hands on the patient’s neck so that your index fingers are just below the cricoid cartilage - Ask the patient to sip and swallow water as before. Feel the thyroid isthmus rising up under your finger pads. It is often but not always palpable. - Displace the trachea to the right with the fingers of the left hand; with the right hand fingers, palpate laterally for the right lobe of the thyroid in the space between the displaced trachea and the relaxed sterbomastoid. Find the lateral margin. In similar fashion, examine the left lobe. The lobe are somewhat harder to feel than the isthmus, so practice is needed. The anterior surface of a lateral lobe is approximately the size of the distal phalanx of the thumb and feels somewhat rubbery. - Note the size, shape, and consistency of the gland and identify any nodules or tenderness. Soft in Grave’s disease Firm in Hashimoto’s thyroiditis, malignancy Benign and malignant nodules Tenderness in thyroiditis. Note: The thyroid gland is usually easier to feel in a long slender neck than in a short stocky one. In shorter necks, added extension of the neck may help. In some persons, however, the thyroid gland is partially wholly substernal and not amenable to physical examination. Udayana University Departement of Medicine Education, DME 34 Learning task: Check your body mass index, waist circumference and waist to hip ratio, and interpretate the result.

c. Auscultation

If the thyroid gland is enlarged, listen over the lateral lobes with a stethoscope to detect a bruit, a sound similar to a cardiac murmur but of noncardiac origin. A localized systolic or continuous bruit may be heard in hyperthyroidism. Clinical skill 5. Laboratory result interpretation Case 1. Female 15 years old came to hospital with decrease of consciousness. One day before admission, she through up everything she ate and had a very bad pain in her stomach. Since this last one month, she was very weak and could not do her daily activity very well. She had never been diagnosed with any specific illness before. Laboratory result: Blood sugar random 645 mgdL Urinalysis keton +3 Blood gas analysis pH 7.12 normal: 7.35-7.45 pO2 97 normal: 80 – 105 HCO3 - 3.00 mEqL normal: 21-30 Case 2. Male 44 years old came to outpatient clinic with an acute swelling and pain of his thyroid nodule. The first laboratory result was: TSHs 0.023 uIUml normal range: 0.25 – 5 uIUml FT4 20.51 ugdl normal range: 5.13 – 14.06 ugdl The second laboratory result after 3 months was: TSHs 7.23 uIUml normal range: 0.25 – 5 uIUml FT4 2.33. ugdl normal range: 5.13 – 14.06 ugdl Udayana University Departement of Medicine Education, DME 35 Learning task: Try the physical examination of your friend’s thyroid gland and note the size, shape, and consistency of the gland and identify any nodules or tenderness. Learning task: 1. What is the diagnosis of this case? 2. After insert the intravenous line and rehidration, you decide to give an insulin therapy. Is there any laboratory data that you need before administering insulin in this patient? Learning task: 1. What is the meaning of the first result and the second result? 2. Why this patient come up with the different result after 3 months? 3. What do you think the diagnosis of this case? Case 3. Female 22 years old, came to outpatient clinic with chief complain palpitation, nervous, and decrease of body weight. Her eyes look bigger than before since last 6 months. Laboratory result: TSHs 0.005 uIUml normal range: 0.25 – 5 uIUml FT4 12.51 ugdl normal range: 5.13 – 14.06 ugdl Udayana University Departement of Medicine Education, DME 36 Learning task: 1. What is the interpretation of laboratory finding? 2. What other laboratory examination do you suggest? Student Standard References: Basic Clinical Endocrinology, 9 th ed, Lange Medical Publication Additional Recommended Reading 1. Essential Clinical Anatomy, 2 nd ed. Lippincott Williams Wilkins, Philadelphia. 2002. 2. Fawcett DW, Jenish RP : Bloom and Fawcett`s Concise Histology, 2 nd ed, London, Arnold, 2002. p. 220-221, 251-266. 3. Guyton A. C and Jhon E. Hall Textbook of Medical Physiology:Page: 836-914 4. Harper, 25 ed.p.451-626 5. Baynes J; Dominiczak Marek H. Medical Biochemistry.1999. chapter 12, chapter 17, and chapter 23 page 297-304 6. Robbins Basic Phatology, 7 ed, 2003.p.221-225 7. Henry JB; Alexander ; Eng C D. Evaluation of Endocrine function In : Henry JB Ed. Clinical Diagnosis and Management by Laboratory Method. 19 th Ed.1996. p.322-373 8. Gartner LP, Hiatt JL : Color Text Book of Histology, 2 nd ed, Philadelphia, W.B. Saunders, 2001,p. 301-324. 9. Wales J.K H, 1996. Pediatric endocrinology and growth: Abnormal Genitalia; 99-116 10. Styne DM, 2004. Handbooks in Pediatric endocrinology: Disorders of sexual differentiation; 134-158 Reference Clinical Skills 1. Bickley LS, Szilagyi PG. Bates’ Guide to Physical Examination and History Taking. 8 th eds. Lippincott William Wilkins. Philadelpia, 2003. 2. American Diabetes Association. Clinical Practice Recommendations 2015. Diabetes Care 2015 3. The Asia-Pacific perspective: Redefining Obesity and its treatment, 2000. Udayana University Departement of Medicine Education, DME 37

15. REFFERENCES

Endocrine ,metabolism and disorders Endocrinological disorders Diabetes Mellitus tipe 1 4A Diabetes Mellitus tipe 2 4A DM tipe lain intoleransi glukosa akibat penyakit lain atau obat- obatan 3A Ketoasidosis diabetikum nonketotik 3B Hiperglikemia hiperosmolar 3B Hipoglikemia ringan 3B Hipoglikemia berat 4A Diabetes insipidus 1 Akromegali, gigantisme 1 Defisiensi hormon pertumbuhan 1 Hyperparathyroidism 1 Hypoparathyroidism 3A Hyperthyroid 3A Thyrotoxicosis 3B Goiter 3A Thyroiditis 2 Cushings disease 3B Adrenal Crisis 3B Addisons disease 1 Precocious puberty 2 Hypogonadism 2 Prolactinoma 1 Thyroid Adenoma 2 Thyroid Carcinoma 2 Expected level of competence: 1. Able to recognise and organized clinical features of disease. In case, it appeared in literature or correspondence, he knows how to organize these clinical features and how to get further information. This level indicates an overview level. If these clinical features found on patient, dNoper able to recognize it, suspect the diagnosis and reffered immediately. 2. Able to make clinical diagnosis based on physical examination and additional investigation requested by dNoper e.g. routine laboratory assay or X-ray. DNoper able to reffer patient to relevant specialist immediately and capable to follow up afterward. 3A. Able to make clinical diagnosis based on physical examination and additional investigation requested by dNoper e.g. routine laboratory assay or X-ray. DNoper able to decide and give initial treatment also reffer to relevant specialist for non-emergency cases. 3B. Able to make clinical diagnosis based on physical examination and additional investigation requested by dNoper e.g. routine laboratory assay or X-ray. DNoper able to decide and give initial treatment also reffer to relevant specialist for emergency cases. Udayana University Departement of Medicine Education, DME 38

16. STANDARD OF MEDICAL COMPETENCE