Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology

History taking Part 1

Khalil M Alsoutary ,MD

Asst professor ,Internal Medicine

American Board in Medicine and Endocrinology

Balqa Applied University, June 2019

Reasons why patients visit

doctors

• They have reached their limit of tolerance

• They have reached their limit of anxiety

• They have problems with living presenting as

symptoms

• For prevention

• For administrative reasons e.g sick leave,

employment physical exam

Patient centered medicine

• The first and major part of consultation is

talking with the patient

• Communication is integral to the clinical

examination,

• It is most important at the start of interview

to gather information and at the end of

interview to find common grounds and

engage your patient in their management

Effective communication skills

• 1.Improve patient satisfaction

• 2.Improve doctor satisfaction

▪ 3.Improve health by positive support and

empathy:

-Improve health outcomes

-Enhancing the relationship between physician

and patient

▪ 4.Use time more effectively

Active listening help the doctor reconize what is

wrong, and reduces patient complaints

Beginning• Setting up

• How long will you have usually 15 minutes for

follow up,30 min for new patient

• Seating arrangemen: non -confrontational way,

talk to patient face to face

• Non verbal communication:

• Your attitude and dress influence the patient

from the beginning ,all the time be professional

in dress and behaviour

• Avoid interruptions such as answering

telephone

Active listening

• Encourage patient to talk by looking

interested

• Good eye contact ,not being buisy with

writing on computer, or answering phone

• Give the patient time to tell his symptoms in

his own language with minimal interruption

• Open questions encourage patient to talk:

• E,g (can you tell me what happened to

bering you to the hospital ?)

• Closed questions e.g: have you had cough

today?, For how long do you have back

pain?

Understanding your patient context

• You must understand your patient`s context as

part of gathering information:

• Where they live

• Who they live with

• Where they work?,what actually tey do clerical

versus field work

• Explore your patient job,job details

• Who do their activities of daily living e.g

shopping,cooking,taking shower etc.

Engaging your patient

• Make sure your patient is involved in each

decision, make suggestions,and encourage

them to contribute their thoughts

Taking with patients

• Speak clearly and audibly

• Do not use jargon

• Do not use unnecessary emotive words

• Listen to their story

• Find out about them as people

• Clarity

• Negotiate mutual plan

• Summarize

Breaking Bad news

• It is one of themost difficult communication task

you will face

• Speak to the patient in a quiet, private environment

ideally with a partner or family member

• Be honest

• Go at the patient pace,find out how much they

want to know, and check their understanding

Communication difficulties

• To establish some form of communication

with deaf or patient who speaks foreign

language

• 1.use uinterpretor

• 2.write things down

• Employ sign language لغة االشارة

• Involve someone who is used to

communicate with the patient

Transcultual awareness

• Appropriateness of eye contact

• Appropriateness of hand gestures

• Personal space

• Physical contact between sexes: hand shake

• Cultures and beliefs surrounding illness

• What should happen as death approach

Terms used by patients that should

be clarified• Allergy Eczyma

• Angina Fits

• Arthritis Heart attack

• Diarrhea migraine

• Dizziness Vertigo

• Pleurisy

Pain threshold

DecreasedIncreased

Sleep deprivationExercise

DepressionAnalgesia

Financial and personal worriesPositive mental attitude

Anxiety and fearPersonality

Past experience

The effects of chronic pain

questions

Money

• Have you had lost money

• because of illness

•Leisure RelationshipsHave you had to give up any How have this affected

your Of your hobbies because your relationship with

of Pain ? your partner and family?

Work :Have you had to take

time off work

Thyroid Function Tests

interpretation

Khalil Alsoutary,MD,FACE

Endocrinologist

May 2019

Thyroid Function

•chemistry & pathophysiology

•causes of hyper-& hypothyroidism

•thyroiditis

•tests of thyroid function

•test strategies

•case studies

Chemistry & Pathophysiology

•T4 - 80 ug/d produced by the thyroid gland

•T3 - 30 ug/d; 80% by peripheral action of

5’ deiodinase

•T4 - 99.97% bound & T3 99.0% bound to

TBG, albumin & pre-albumin

•FT4 & FT3 exert negative feedback on TSH

•Hypothalamic TRH modulates feedback

setpoint

Thyroid Binding Proteins

•INCREASES

•estrogen/pregnancy

•methadone & heroin

•acute & chronic active

hepatitis

•hereditary

•DECREASES

•glucocorticoids

•androgens

•L-asparaginase

•nephrosis

•hereditary

Causes of Hyperthyroidism

•Graves Disease

•Functioning Thyroid Nodule (Plummer’s)

•Toxic Multinodular Goiter

•Thyroiditis

•Factitious Hyperthyroidism

•Drug Induced: iodine, amiodarone, lithium

•Pituitary-Hypothalamic origin

Causes of Hypothyroidism

•Chronic Thyroiditis (Hashimoto’s)

•After radioiodine,surgery or antithyroid

drug therapy

•Drugs: amiodarone, lithium,

•Congenital - 1in 4000 births:

Free T3Free T4TSHcondition

highV.highundetectablePrimary

hyperthyroid

v.highnormalundetectableT3 toxicosis

highhighincreasedSecondary

hyperthyroidism

NNlowSubclinical

hyperthyroidism

Thyroid hormone tests in

various disorders

IncreasedIncreasesIncreased

or N

Thyroid H

Resistance

Decreased or

N

decreasedIncreasedPrim

hypothyroidi

sm

Decreased or

N

DecreaseDecreased

or N

Secondary

hypothyroidi

sm

Free T3Free T4TSHcondition

Risk of Overt Hypothyroidism in

a 60-Year-Old WomanAb neg

Ab pos

Hy

po

thy

roid

ism

(%

)

2 5 10TSH

Vanderpump Met al: 2003

Thyroiditis

•Acute suppurative

•Subacute: granulomatous

•Subacute: lymphocytic

- 10% postpartum (silent)

- hamburger toxicosis

•Chronic Thyroiditis (Hashimoto’s)

Subacute Thyroiditis

•Granulomatous

•post viral

•painful thyroid

•systemic symptoms

•high sed rates

•Lymphocytic

•painless

•simulates Graves

•normal or slightly

elevated sed rates

Thyroid Function tests

•TSH-2sd generation

•FT4

•TSH-3rd generation

•Total T3

•RAI uptake

•antithyroid antibodies

•Total T4

•T3 Resin Uptake

•Free T4 Index

•TRH Stimulation Test

•Thyroglobulin

TSH

•Immunometric Assays

- Analytical Sensitivity (CV </= 20%)

- 1st generation: 1.0 uU/mL

- 2sd generation: 0.1 uU/mL

- 3rd generation: 0.01uU/mL

TSH•INCREASES

•hypothyroidism

•inadequate T4 Rx

•lithium, iodine, antithyroid drugs

•nonthyroidal illness

•DECREASES

•hyperthyroidism

•L-dopa, dopamine,

steroids

•excessive T4 Rx

•2sdry hypothyroidism

•nonthyroidal illness

•Primary:

–Principal Cause and Largely Autoimmune

•Central

–Secondary + Tertiary

•More recently recognized etiologies

–Chemotherapeutic Agents

•Ipilimumab, Bexarotene, Sunitinib (tyrosine kinase

inhibitors)

–Consumptive hypothyroidism

Causes of Hypothyroidism

Anti-Thyroid Antibodies

•Markers of Chronic Thyroiditis

•Anti- Thyroglobulin Antibodies

–Does not Correlate with hypothyroidism

•Anti-Thyroid Peroxidase Antibodies

(formerly known as Anti-microsomal

Antibodies)

–Correlate with the development of

hypothyroidism

Principal Lab Tests to Diagnose and Monitor

Hypothyroidism

•Free Hormone Hypothesis

–Only free hormone metabolically active and determines

thyroid status (not total which is largely bound to

binding proteins)

–Gold standard: Equilibrium Dialysis

Estimates

Free Thyroxine Assays - Use anti T4 Antibodies

–Free Thyroxine Index = Total T4 x T3 UPTAKE

–T3 Uptake ESTIMATES % free hormone

Severity of Primary Hypothyroidism by

Thyroid Levels

TSH rises first and abruptly

Decline of T4 and

T3 slower and later

Approach to SC HypothyroidismSerum TSH

5-10 mIU/L >10 mIU/L

Repeat TSH, FT4, TPOAb Begin T4 Rx

Normal tests

Follow

TSH & TPOAb+

FollowT4 Rx if...• Goiter• Hyperlipide

mia• Infertility• Young pt

Rising TSH By Age in Cross-sectional Studies

• The MEAN rises with age

• The upper limit of normal

• A “natural” rise of TSH

•

• Should Be USED a BMD for

0

8

7

6

5

4

3

2

1

20-29 30-39 60-69 70-79 80+

NHANES IIINormal Range (2.5 - 97.5 Centile) by Decade

lower TSH limit stayrelatively constant with age

MEAN

rises with age

with age? (survivalBenefit?)Is there a progression toatrophic hypothyroidismwith age that is included innormal

the normal range in

40-49 50-59

AGE

Thyroid Function: References

•Klee, G & Hay, I: Biochemical Thyroid Function Testing. Mayo Clin Proc

1994;69:469-70

•Lazarus, JH: Hyperthyroidism. Lancet

1997;349: 339-43

•Lindsay, RS, Toft, AD: Hypothyroidism. Lancet

1997; 349:413-17

•Smith, SA: Commonly asked questions about Thyroid Function

Mayo Clin Proc 1995; 70:573-577

•Dayan, C: Interpretation of Thyroid Function Tests

Lancet 2001; 357:619-624

•Fatourechi, V: Subclinical Thyroid Disease

Mayo Clin Proc 2001;76:413-417