khalil m alsoutary ,md asst professor ,internal medicine€¦ · history taking part 1 khalil m...
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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