Case : A woman with decreased body weight A woman 22 year old, complained of reduced body weight aggressively in a few weeks,
tremble, and diarrhea 2 or 3 times a day. She has slightly enlargement of her neck. Laboratory result showed high level of thyroid hormone FT4free thyroxine and very low
level of thyroid stimulating hormone TSHs.
Learning Task:
1. Explain the classical endocrine glands and each hormone be secreted.
2. Explain the concept of endocrine, paracrine, and autocrine in hormone action; and
each examples of hormone or molecules 3.
Explain the concepts of ligand, receptor, effector, and second messenger 4.
Based on location of receptor in hormone action, how many kinds of hormone are there? Explain briefly the mechanism each hormone action and example of its
hormones 5.
Explain two major types of control of endocrine gland function 6.
Associated with hypothalamic-pituitary-target gland system, what level of the disorder was occurred at hypothalamus, pituitary or thyroid gland in above case?
Draw a figure of the disorder and explain briefly.
Self assessment:
1. What is the hormone function in our body, and give example of hormone for each
function? 2.
Explain the differences between signaling by hormones, local mediators, and neurotransmitters
3. Describe the transport of hormone in the blood
4. What do you know about ligand, receptor, effector, first-second messenger?
5. Explain about the control of hormone secretion Give an example of feed back
negative mechanism of hormone secretion 6.
Make a list of the endocrine disease
Learning Task:
1. Discuss the structure of thyroid and parathyroid gland, include the vascularisation and identify their position in the neck
2. Discuss anatomical structures of pituitary gland and hypothalamus 3. Discuss anatomical structures of pancreas
4. Discuss anatomical structures of adrenal gland
Self assessment:
1. Decribe the structure of thyroid and parathyroid gland, include the vascularisation and identify their position in the neck
2. Describe anatomical structures of pituitary gland and hypothalamus 3. Describe anatomical structures of pancreas
4. Describe anatomical structures of adrenal gland
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12. LEARNING TASKS
Day 1. The hormone action
Day 2. Anatomy of The Endocrine System
Learning Task Histology:
1. Discuss the general characteristic of endocrine glands 2. Discuss pancreas as exocrine and endocrine organ Types of cells in its endocrine
part and hormone produced.
Case : a woman with increasing shoe size
A 40 year old female has noticed an increase in her shoe size from 38 to 42, and her weight also increased excessively from 62 to 84 kg. Her menstrual period has stopped 6 months
ago. Physical examination found her 158 cm. Although a large woman, she doesn’t look obese.
Her blood pressure was 14080 mmHg. Neck demonstrated diffuse thyromegaly, but the TSHs and FT4 test was normal. Her face demonstrated thickening of the nasolabial fold and
prominence of the supraorbital ridge. Compare to her picture 5 years before, her face showed a striking change in facial feature. She did not show hirsutism. Her hands and feet
had a rubbery consistency.
Learning task:
1. What is the most likely disorder of this woman? 2. What may cause this disorder?
3. What laboratory and radiology test would you do for the patient to workup the diagnosis?
4. Is she has thyroid problem? Why? 5. Why she stopped menstruating?
Self assessment:
1. Explain the hypothalamus – pituitary – target organ axis. 2. Summarize the course and the condition associated with pituitary adenoma,
including prolactinoma, acromegaly, gigantisme, growth hormone deficiency. 3. Summarize the normal physiologic function of posterior pituitary hormone.
4. Describe the clinical features of diabetes insipidus.
Learning Task:
1. Red blood cell is the simplest cell in the body in term of its structure and metabolism. Please elaborate that statement
2. What are the differences of carbohydrate metabolism in red blood cell compare to brain cell or hepatocyte?.
3. Explain what happened during investment stage, splitting stage and yield stage on glycolisis.
4. What enzymes are regulating glycolisis and what are their functions? 5. Explain about glycogenesis, glycogenolysis and hormonal control of glycogenolysis
6. Where is Pentosa phosphate pathway started and what are the main products? Explain why its called “shunt”?
7. How many ATP produced from one molecule glucose metabolized at Kreb’s cycle?
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Day 3. The Pituitary gland and disorders
Day 4. Carbohydrate metabolism
Self assessment:
1. Explain, why is NaF as the most preferred anticoagulant used for glucose examination?
2. Like in Munir case, as indicated by autopsy results undergone at Netherland, revealing arsenic concentration above normal level as the cause of death. Explain,
why arsenic can be so fatal if exist in high concentration in blood? 3. Explain, how the mechanism of bacteria extermination by phagocytosis?
4. Why hemolytic anemia can be caused by deficiency of G6PDH enzyme? 5. Explain about HbA1c and its normal concentration. Why normal blood glucose
concentration result not directly follow by normal concentration of HbA1c? 6. Explain pathogenesis process of chronic complication of DM?
7. Explain the role of glycated protein to longterm complication of DM
Case : a man with weight loss and polyuria
Data 1 Mr. AB, 43-year-old male has no prior medical problems feel fatigue this last few months.
On further questioning, he admitted having incessant thirst, and polyuria over the last month with a 6-kgs weight loss before he was 76 kg, 160cm in height. He denied having any
history of diabetes. He did not realize any family history with diabetes. Generally examination is unremarkable. A rountine urinalysis demonstrates 4+ glycosuria.
Learning Task:
1. Does this man has diabetes mellitus? a. Explain why and why not?
b. What are other conditions may cause glycosuria? c. How to establish the diagnosis of diabetes?
Data 2 A glucometer reading was unmeasureable. This was confirmed by blood glucose serum 580
mgdL. He does not feel ill and this week he planned to start his new job.
Learning Task:
2. Does he have diabetes mellitus? If so, does he have type 1 diabetes or type 2 diabetes?
Self assessment:
1. Explain the cells types and hormone secreted by islets of Langerhans 2. Describe how insulin secretion is regulated
3. Describe the metabolic action of insulin 4. Describe how glucagon release is regulated and summarize its main action
5. What is the major symptom of diabetes mellitus? 6. Mention the diagnostic criteria of prediabetes and diabetes
7. What is the clinical features difference of type 1 and type 2 diabetes?
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Day 6. Insulin secretion, insulin action, pathogenesis and diagnosis of diabetes
Case: A man with diabetes
Mr. C, 45-year-old, has diabetes since 3 months ago, at that time his random blood glucose was 212mgdL .
His glucometer reading yesterday was unmeasureable. This was confirmed by blood glucose serum 580 mgdL. He feels like lack of energy during the day, and difficulty to sleep
due to frequent urinating. Generally examination is unremarkable.
Learning Task:
1. What should you do for Mr C: a. Should you admit him to the hospital or send him home with some
medication? Explain your answer. b. What is your plan for treatment?
c. What is the choice of treatment for his diabetes: insulin or oral antidiabetes?
Self assessment:
Explain the management of diabetes Refer to the available guideline.
PBL 1: A man with high blood sugar, fever and vomiting Introduce trigger
A man 52 years old, government employee, visited a general practitioner due to loss of body weight about 7 kg in last two months.
a. Search any information of some kind of health problems or diseases related relatively weight loss abruptly
b. How the mechanisms of weight loss in each suggested diseases
Case: A man with diabetes for 12 years.
Mr. B has been diagnosed with diabetes for 12 years. His fasting blood sugar normally between 90-120 mgdL, with medication: glibenclamide 5 mg twice a day. Sometime in the
day, he feels shaky and trembeling, followed by blurred visión and headache, which normally resolved after he has lunch.
Last laboratory result showed A1C was 9.1, urinalysis revealed a proteinuria +1. Other result, including lipid profile, renal function and liver function, still in aceptable range.
Learning Task:
1. What is the acute complication of diabetes? 2. What is the chronic complication of diabetes?
3. In above case, list the possible acute and chronic diabetes complication. 4. Mention the 4 strategy therapy in diabetes and explain the concept of each strategy
5. List the name of four major classes of OAD oral anti diabetic agents, and describe
the mechanism of action of each class. 6. What is the indication of intensive insulin therapy?
7. How to diagnose hypoglycemia? Describe the management of hypoglycemia
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Day 8. PBL 1 and Clinical skills 1: Insulin injection
n
Day 7. Management of Diabetes
Day 9. Acute and chronic complication of diabetes
n
Case: A lady with hypothyroid
Ms. N has been diagnosed with hypothyroid for 2 years, after a total thyroidectomy. She has levothyroxine a day for her thyroid hormone replacement.
Learning Task:
1. Describe the principles of hormonal and anti hormonal drugs used for patient with endocrine disorders
2. Describe the side effects of hormonal and anti hormonal drugs used for patient with endocrine disorders
3. In above case, when would be the best time to take levothryoxine? 4. Differentiate pharmacodynamic of insulin and OAD
5. Differentiate pharmacokinetic of insulin and OAD 6. Make a scheme which summarized the differences between pharmacodynamic and
pharmacokinetic of insulin and OAD 7. Describe pharmacodynamics and pharmacokinetic of hypolipidemic drugs
Learning Task:
1. Explain about beta and alpha oxidation of lipid metabolism 2. Explain the relation between carbohydrate and lipid metabolism
3. What are the function of carnitin and what happened if carnitin deficiency occured? 4. Explain the interrelation between obesity and lipid metabolism
Case Data 1
A 45 years, male patient with history of diabetes type 2 since 5 years carried out routine laboratory examination. Serum total cholesterol result is 259 mgdL
Learning Task: What other laboratory assay you will suggest to patient to complete lipid profile of this
patient? How to interpret each of it?
Data 2 Lipid profile results as follow :
Total cholesterol 250 mgdL Cholesterol LDL 110 mgdL
Cholesterol HDL 17 mgdL Trigliserida 210 mgdL
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Day 12. Lipid metabolism Day 11.
PBL 2 and Clinical skills 2: Self monitoring blood glucose
n
Day 13. Lipid metabolism disorders
Day 10. Drug treatment in endocrine disorders
n
Learning task:
1. Interpretate those results 2. Explain the treatment that you recommend to patient
3. Explain the targets to manage this patient lipid profile
Self assessment:
1. Describe the lipid transport and the role of plasma lipoprotein 2. Mention the disorders of lipoprotein metabolism
3. List the name of drugs treatment of lipid disorder and describe the mechanism of action of each class
Learning Task:
1. Explain adenosine triphosphast ATP functions as an “energy” in metabolism 2. Explain phosphocreatine functions as an accessory storage depot for energy and as
ATP buffer 3. Explain aerobic and unaerobic energy
4. Explain about metabolic rate 5. Explain energy metabolism –factors that influence energy output
6. Describe the mechanism of heat production 7. Explain the body temperature is controlled by balancing heat production against heat
loss 8. Explain the mechanism of bodily heat loss
9. Describe the pathogenesis of obesity
Data 1 A 45 years male patient, complain body weakness and sometime difficulty in breathing when
sleeping. On physical examination, body weight 92 kg, height 162 cm and waist circumference 105 cm. Patients has 1 brother and 1 sister. His brother died due to heart
attack at age of 52 year. All of them are fat since they were child. Patient weight increases since he married and starts to neglect exercise.
Learning Task:
1. What are the problems of this patient? 2. What are factors contribute to those problems?
3. What are the possible risks that this patient will face in the future?
Data 2 Further examination reveals that blood pressure 14590 mmHg, fasting blood glucose
concentration 129 mgdl, 2 hour post prandial blood glucose concentration 185 mgdl, trigliserida 165 mgdl, cholesterol-HDL 32 mgdl and cholesterol LDL- 235 mgdl.
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Day 14. The energy balance
Day 16. Obesity and metabolic syndrome
Day 15. PBL 3 and Clinical Skills 3: Measurement of obesity
Learning Task:
1. What syndrome is this patient suffered? 2. How the mechanism that this syndrome could occur?
3. What factors contribute to the increase of blood glucose in this patient? 4. Explain briefly about the management of this patient
Data 1 . A 36 years male patient, complain snoring and difficulty in breathing when sleeping. Almost
all patient family are fat. Patient himself alredy fat since he was child and his body weight even more increasing after he married. His present body weight is 98 kg with height 165 cm,
and waist circumference 108 cm. Patient feel less self confidence due to dark appearance on the neck skin just like untreated well..
Learning Task:
1. What are the problems of this patient? 2. What are additional data that you need to diagnose this patient?
Data 2. Patient blood pressure 15090 mmHg.
Random blood glucose concentration 130 mgdL, 2 hour post prandial 180 mgdL, but he never complain frequent urinating or thirsty. Trigliserida 170 mgdL, HDL 25 mgdL,
cholesterol LDL 250 mgdL
Learning Task:
1. What is the síndrome that this patient suffered? 2. What are the causes of this syndrome?
3. Explain the management of this patient?
Self assessment:
1. Define the criteria of obesity for Asia Pacific region 2. Explain the pathogenesis of obesity nutrient balance or homeostatic model
3. What is the complication of obesity? 4. Mention the criteria of metabolic syndrome by adult treatment panel III – National
Cholesterol Education Program ATP III-NCEP 5. Explain the treatment of metabolic syndrome
Learning Task:
1. Explain step by step the synthesis of thyroid hormone 2. What is thyroglobulin? What is the function in synthesis of thyroid hormone?
3. What is meant by iodinize and deiodinize in thyroid gland? 4. Explain the secretion process of tiroksin
5. Explain the transport of thyroid hormone 6. Explain how thyroid secretion is controlled
7. Explain the main action of thyroid hormone 8. Describe the main consequence s of abnormal thyroid function
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Day 17. Iodine metabolism, thyroid hormone synthesis and
secretion, thyroid hormone function
Self assessment:
1. Explain about the axis of hypothalamic-pituitary-thyroid system and its regulatory function of thyroid hormone secretion
2. Describe the schema of biosynthesis of thyroid hormone 3. Explain about transport of thyroid hormone in the blood
Learning Task:
1. Explain about secretion and mechanism of action of parathyroid hormone 2. Explain about the synthesis and mechanism of action of vitamin D.
3. What do you know about calcium as second messenger and why extracellular Ca
++
in tightly regulation main consequences of abnormal Ca control? 4. List the essential mineral and vitamin for normal bone growth and osteoporosis
prevention 5. Describe the main consequence s of abnormal parathyroid function
Case : a lady with increasing body weight and first degree AV block
Data 1. A 45 year female patient come clinic with complaining weakness, difficult to concentrate and
increase of body weight. On physical examination, blood pressure 10070mmHg, pulse 52 xminutes,regular with edema at both legs. Laboratory result reveal that total cholesterol 460
mgdL.
Learning Task:
1. What is the diagnose of this patient? 2. What are other examinations that you need to confirm the diagnose? 3 items
Further laboratory examination reveals FT4, FT3, TSHs concentration below normal value. ECG reveal first degree AV block.
Learning Task:
3. What is the diagnose of this patient? 4. What other examination requiered to locate the disorder?
Data 3. Serum TRH level within normal range.
Learning task:
5. What is your conclusion regarding the location of hormonal disorder of this patient?
Case: a young female with sweating and decreasing body weight
Data 1. 22 years, young female patient come with palpitation, both hands shaking frequently with
sweating although the environment not too hot. Her body weight decreasing eventhough
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Day 18. The Parathyroid hormone function Calcium and phosphate metabolism
Day 19. Thyroid and parathyroid gland disorder
she eats a lot. She felt her neck enlarge since 3 month but she can’t palpate any lump. She also feel that her eyes are more prominent than her coworkers that made her less confident.
Learning Task:
1. What is the possible diagnose of this patienti? 2. What are other examination required to confirm the diagnose?
Data 2. ECG reveal AF atrial fibrilation with fast response 130 times per minutes.
Laboratory examination result FT4 serum concentration is high and TSHs concentration below normal value.
Learning Task:
3. What is the posible diagnose of this patient? 4. What are other examination required to determine the cause of this case?
5. What are your management plan to this patient?
Self assessment:
1. Identify the diseases caused by: over secretion and under secretion of thyroid hormone
2. Mention the clinical condition associated with thyrotoxicosis 3. Describe the clinical features symptoms, signs, and laboratory findings of Graves’
disease 4. List the drug treatment of Graves’ disease and explain the mechanism of action and
side effect of each drug 5. Describe the course and complication of hyperthyroidism thyroid crisis
6. Describe the diagnostic algorhythm of hypothyroidism 7. Explain about the treatment of hypothyroidism
Learning Task:
1. Explain the gross structure of the adrenal gland and mention the adrenal hormone produced by each part
2. Describe the regulation of cortisol synthesis and secretion through hypothalamus, pituitary and adrenal axis
3. Explain the inflammatory properties of cortisol 4. Explain the role of physical and emotional stress in cortisol secretion
Learning Task: Case: A young lady with moon face
Data 1. A 22 years,female patient come with complaining her cheek getting fatter moon face and
in some of her body like shoulder,upper part of her back and tummy, also getting fatter than before. On skin of her tummy also appear lines like pregnant woman.
Blood pressure was 14090 mmHg, random blood sugar was 220 mgdL.
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Day 20. The Adrenal gland and Adrenal Hormone Function .
The adrenal gland and adrenal hormone function
Day 21. Cushing Syndrome .
The adrenal gland and adrenal hormone function
Learning Task:
1. What is the possible syndrome that this patient suffered? 2. Is there any additional information that you need from this patient?
Data 2. Before these symptoms appear, she often complains a lot of sneezing and running nose in
the morning, along with allergic symptoms whole bodies: redness and itchy. Each time she felt this symptom she always see a dNopor at Primary Health Centre. She has been treated
with dexametasone. This tablet worked good on her symptoms. She did not visit the dNopor regularly. Each time she stopped the tablet, symptoms often recurrent. She increased the
dose by herself. She prepared herself with this tablet that she bought from pharmacy. Therefore, if she suffered from her allergic symptoms, instead of visited the dNopor, she
treated herself.
3. What is the most possible diagnosis to this patient? 4. What would you do to confirm the diagnosis?
5. What is your plan toward for this patient?
Self assessment:
1. Mention the classification of cushing syndrome 2. Explain the pathophysiology of cushing syndrome
3. Describe the clinical features of cushing syndrome
Learning Task:
1. Explain factors to determine gender 2. Explain gender differentiation process intrauterine
3. Explain about DSDinterseks classification 4. Explain the etiology of neonatal DSD
Case:
A 23 days baby referred to Child endocrine outpatient clinic with diagnose Ambigous Genitalia. When the baby turns to 14 days, heshe vomiting, less drinking and very weak.
One week later heshe vomit again and hospitalized. Laboratory result revealed low natrium and high kalium concentration. On physical examination age 3 month, general appearance
is fine, no abnormality in ear, nose and throat as well as lung, heart and abdomen. On
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Day 25. Congenital hypothyroid and ambiguous genital Day 22.
Clinical skill 4: Thyroid gland physical examination
and student project presentation 1
Day 23. Clinical skills 5: Lab result interpretation and student project presentation 1
Day 24. Student Project Presentation 3, PBL 4 .
The adrenal gland and adrenal hormone function
external genetalia examination finding reveal enlargement of clitoris, hipospadia and unpalpable testicles.
From the following statements, which are TRUE and FALSE? 1. First step must be done is evaluating blood 17-OH progesterone concentration.
2. Chromosome assay unnecessary to be performed. 3. Others supporting evaluation are ultrasound and genitography examination.
4. This baby possibly suffering Congenital Adrenal Hiperflasia CAH 5. This baby categorized as 46XX DSD female pseudhermaphroditism according to
DSDintersex classification. 6. This baby does not need surgery.
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Day 26: Evaluation
PBL:
PROBLEM BASED LEARNING 2015 BLOCK: ENDOCRINE SYSTEM AND METABOLISSM AND ITS DISORDERS
