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04-10-2023-Y3-Clinical-OSCE-Teaching CODE-BLUE-OSCE Diabetes and Endocrine disorders Jasmine Spinks and Eva DennisIn Partnership with Enrolled activity under the International Federation of Medical Students’ Association (IFMSA) Teaching Medical Skills programme. In Partnership with Comprehensive, accessible OSCE resources, notes, videos and OSCE stations for practice. Use CODEBLUE23 at checkout on GeekyMedics.com for 20% their paid resources **not an affiliate code** Disclaimer • Code Blue OSCE Crew is a platform created by Manchester medical students, independently of the University of Manchester and Manchester Students’ Union • This teaching should not replace any formal teaching provided by the university - Any changes to CCAs would be communicated by your university, follow their guidance • Content is generated by students with input from senior doctors Session Structure 2 4 1 3 Group Explanation stations recap practice Common Data conditions and Breakout rooms explanations interpretation for 1 hour of OSCE practiceLearning Objectives Recall common endocrine conditions and be able to suggest differentials such as: •Diabetes •Thyroid conditions •Addison's disease Understand and apply the general sharing information structure to explanation of a disease Interpret clinical data relating to the aboveExplanation - BUCES - Brief history - PMH and current condition, why are they here, what are you going to discuss - Understanding – prior disease knowledge - Concerns – any initial concerns and ICE - Explanation of the disease: - Summarise and planExplanation - BUCES - Explanation of the disease: oNormal anatomy and physiology of the bowel/affected structure oSymptoms – rectal bleeding, diarrhoea, abdo pain… oWhat the disease is (chunk and check, diagrams to aid understanding, metaphors and analogies) oCauses of the disease – genetic and environmental oComplications oManagementExplanation - Athletics Hyperthyroidism Overactive thyroid – everything speeds up Features: • Anxiety and irritability • Sweating and heat intolerance • Tachycardia • Weight loss • Fatigue • Insomnia • Loose stool Hyperthyroidism Causes – GIST ➢ G – Graves disease ➢ I – Inflammation (thyroiditis) ➢ S – Solitary thyroid nodules ➢ T – Toxic multinodular goitre Thyroiditis has an initial hyperthyroid state before becoming hypo Causes of thyroiditis can be De Quervain’s, Hashimoto’s, Postpartum and drug induced Hyperthyroidism Treatment • Propranolol for symptom control – works fast • Carbimazole (take for 12-18 months) • Radioactive iodine, followed by levothyroxine • Surgery Hypothyroidism Underactive thyroid – everything slows down Features: • Weight gain • Fatigue • Dry skin • Coarse hair and hair loss • Heavy or irregular periods • Constipation Hypothyroidism Causes of primary hypothyroidism ➢ Hashimoto’s thyroiditis – most common cause in the developed world ➢ Iodine deficiency – most common cause in the developing world ➢ Treatment of hyperthyroidism – carbimazole, propylthiouracil, radioactive iodine and thyroid surgery ➢ Other treatments – lithium Hypothyroidism Causes of secondary hypothyroidism ➢ Tumours ➢ Surgery ➢ Radiotherapy ➢ Sheehan syndrome ➢ Trauma Hypothyroidism Treatment • Oral levothyroxine – synthetic T3/4 Explain Levothyroxine A - Replaces the free thyroxine which are missing in hypothyroidism T - Once a day before breakfast H- Tablet L - Lifelong E - 3 weeks T - Test levels of thyroxine after 2 weeks and then every 3 months I - Can cause hyperthyroidism, constipation, heat intolerance, weight loss. C – Contraindicated in thyrotoxicosis S - Free on the NHS Explain Carbimazole A - Blocks the way the body processes iodine and so less thyroid hormones are made. There are 2 ways it works on its own (O), or block and replace (BR) T - BR = 1-3 times daily the reduced to 1-2 times daily (could be more than one tablet) O = 1-3 dose daily H - Tablet L - BR = 4-8 weeks on a higher dose until euthyroid and then reduced dose for 12 to 18 months O = 18 months E - effects after 4-8 weeks T - TFTs need to be done after 2 weeks? then every so often I - Nausea, headache, skin rash. C - Need to be aware of agranulocytosis, should explain to the patient rare complication that reduced the number of blood cells that fight infection and stop bleeding. So important if have any of these to see GP: sore throat, mouth ulcers, fever, bruising or bleeding, and tiredness S - Don't use if pregnant or liver problems • Check the patient details match those on the investigations • Take your time to read through the information • When your ready you can verbalise your findings • Describe the results in turn and use clinical Data Intepretation terminology where relevant e.g. Hb is low indiciating anaemia, WCC is normal, MCV is high indicating macrocytic cells etc. • When you have described all your results give your overall impression supported by evidence in the resultsHypothalamic Pituitary Thyroid axisThyroid Function Tests These tests must always be interpreted within the clinical context as things like concurrent illness can cause false results. (as is the same with a lot of test results!)Thyroid Function Tests Primary Hyperthyroidism: • Thyroid itself produces excess thyroid hormones (T3 and T4) • Results in negative feedback – causing a low TSHThyroid Function Tests Secondary Hyperthyroidism: • The pituitary produces excess TSH • This stimulates the thyroid gland to produce excess thyroid hormone • Negative feedback does not occur , so TSH stays raised • Example of this is a pituitary adenomaThyroid Function Tests Primary Hypothyroidism: • The thyroid behaves abnormally and produces inadequate thyroid hormones – low T3/4 • No negative feedback occurs so there is an increase in TSH to try and increase the T3/4Thyroid Function Tests Secondary Hypothyroidism: • The pituitary produces inadequate TSH • Under stimulation of the thyroid gland and so low T3/4 • Could be due to surgical removal of pituitary Other tests Antibodies • Anti-TPO antibodies, antibodies against the thyroid gland in autoimmune thyroid disease e.g. Graves and Hashimoto's thyroiditis • Anti-thyroglobulin antibodies, antibodies against a protein produced in the thyroid gland, can be present in normal individuals or in Graves, Hashimoto's and thyroid cancer • TSH receptor antibodies, mimic TSH, can be present in Graves Other tests Imaging • USS of the thyroid gland – diagnose thyroid nodules, and can be used to take a biopsy • Radioisotope scans, investigate hyperthyroidism and thyroid cancer. Measures the uptake of iodine to help diagnose Graves, toxic multinodular goitres, adenomas and cancerExamples TSH T3/4 High Low HypothyroidismExamples TSH T3/4 High High HyperthyroidismExamples TSH T3/4 Low Low hypothyroidExamples TSH T3/4 Low High HyperthyroidismExamples TSH T3/4 Low/normal Low Sick Euthyroid Recently been been ill in hospital, no previous thyroid history Inappropriately normal TSH - should be high in response to low T3/4 T3 especially is lowExamples TSH T3/4 Subclinical high normal hypothyroidism No symptoms, no history of thyroid pathologyExamples TSH T3/4 high normal compliance with levothyroxine Under treatment for hypothyroidismDid you learn something new?Resources used/recommended 0 to Finals Teach me Surgery Geeky Medics Passmed NHS websiteGive us feedback to get the slides linktr.ee/codeblueteaching cbosceteaching@gmail.com SPACE FOR QR CODE IG: @codeblueteaching facebook.com/cbosceteaching Now for OSCE practice!