Ministry of Health of Ukraine

             Bogomolets National Medical University

                                               Department of Endocrinology

     WORKBOOK

                                       for self-study work of the 4th year students

                                       on a subject "Internal medicine"

                                               

                                Module 1 "Bases of Internal Medicine"

     Content module "Bases of diagnostics, treatment and prevention of major endocrine diseases"

Area of training "Medicine"

Speciality "Medical business"

                                                                     "Pediatrics"

                                                                     "Medical preventive care"

Authors prof. Petro M. Bodnar,

                                                                     docents Olexandr M.Prystupiuk , Galyna P.Mykhalchyshyn

Reviewed and approved by the methodical meeting of the Department,

                                                                   Protocol №37 as of 26.06. 2015

                                                                   Head of department. prof. Bodnar P.N.

                                                                   Cyclic methodical commission on therapeutic disciplines

                                                                   Protocol number ________________

                                                                   from "___" ____________ 2015.

                                                                   Chairman Prof.. Yaremenko O.B.

  Kyiv-2016
  INTRODUCTION

                                                    Criteria for workbook tasks evaluation

1 .50% of correct answers - satisfactory

2. 80-95% of correct answers - "good"

3. 96-100% correct answers - "excellent"

Content module 1 "Foundations of diagnosis, treatment and prevention of major endocrine diseases"

                                                                  Topic 1

Diabetes, classification, etiology, pathogenesis, clinical picture.

   Objective (learning objectives)

* Master the semiotics of diabetes depending on the type of the disease;

* To learn the methods of diagnosis of diabetes, the indications for their use, the method of
implementation and the diagnostic value of each of them;

*adequately assess and interpret research results.

Student has to know

*classification of glycemia disorders;

* the etiology and pathogenesis of diabetes mellitus types 1 and 2,

*risk factors for diabetes;

*clinical features of diabetes type 1, 2 and gestational diabetes.

Student has to be able to

* diagnose diabetes;

*assess glucose tolerance test;

*use methods of rapid diagnosis of glycemia, glucosuria, ketonuria;

*determine the type of diabetes.

 Basic terms of the topic

Тerm Definition
Hyperglycemia
Diabetes
Type 1 Diabetes
Type 2 Diabetes
Gestational diabetes
Glucose tolerance test
Glycosylated hemoglobin
Prediabetes
Impaired fasting glucose
Impaired tolerance of glucose
Glucosuriya
Ketone bodies
Кetonuriya
Insuline resistance
Antibodies to GGT(Gamma-glutamyl
transpeptidase)
С-peptide
Risk factors diabetes

Tasks for self-study work on the topic

Task 1

Fill in the table of Diabetes Classification

Categories Classification signs

Hyperglycemia
Diabetes
Type 1 Diabetes
Type 2 Diabetes
Gestational diabetes
Other types of diabetes
Task 2

Fill in the table of the main symptoms or clinical signs of organ systems for patients with diabetes

Оrgan/system Signs of organ / systems affection

Insular apparatus of the pancreas
The body weight of the patient
Changing the diet of the patient
Violation of diuresis
Carbohydrate metabolism disorders
Changes in hemoglobin glycation
Lipid metabolism disorders
 Task 3

Fill in the table of required laboratory examination of diabetes patients

№ Kind of research Research objective

1 Determination of glucose in plasma of
venous blood
2 Determination of glucose in capillary
blood
3 Determination of glycated hemoglobin
4 Determination of serum creatinine
5 Determination of liver transaminases
6 Determination lipidogram
7 Calculation of GFR (glomerular
filtration rate)
8 Calculation BMI
9 Measurement of blood pressure

Tests

1. 56 y.o. patient, obese, with an active study venous plasma glucose fasting blood glucose indicator
9mmol / L. Diagnose:

A Prediabetes

B Type 1 diabetes

C Type 2 Diabetes

D Violation control fasting plasma glucose

E Transient hyperglycemia

2. A boy, 12 y.o., during the glucose tolerance test were found such indicators of glucose: fasting -
4,5mmol / L, 1 hour. - 7,5mmol / l after 2 hours. - 5,6mmol / l. Your conclusion?

A Glucose tolerance is not broken

B Glucose tolerance is broken

C Further examination of glucose in plasma of venous blood is necessary

D You need additional research in plasma glucose venous blood postprandial

E It is necessary to define glycated hemoglobin

3. A patient, 39 y.o., over 20 years has asthma. Over the last 5 years because of the frequent attacks of
breathlessness he was prescribed prednisone. During hospitalization complained about polydipsia, dry
mouth, increased appetite, and polyuria. In the blood glucose level found - 10,9mmol / l. Your
preliminary diagnosis:

A Type 1 Diabetes

B Type 2 Diabetes

C Steroid diabetes

D Kidney Diabetes

E Diabetes mellitus associated with a genetic defect of insulin action

4. A patient, 22 y.o., suffering from diabetes for two years. Diabetic complications were not found.
Fasting Glycemia within 6.0-7.0 mmol / l. Married, she wants to have a healthy baby. To prevent fetal
abnormalities select the most informative method of diagnosis to allow fertilization

A Glycemic profile

B Research glycated hemoglobin

C Glucosuric profile

D C-peptide

E Costprandial glycemia

5. A girl's mother came to pediatrician. The mother of the child complains of lag in growth and sexual
development, frequent urination, poor healing of wounds on the skin. Objectively: a blush on the
cheeks, dry skin and mucous membranes. What examinations should be appointed for the child to
clarify the diagnosis?

A Blood test for glucose and glycated hemoglobin

B General blood analysis

C General Urinalysis

D Definition of liver function tests in the blood

E Determination of blood electrolytes

6. Male, 37 y.o., complains about weight loss (5-6kg during six months), moderate dry mouth, thirst,
polyuria. Sick 7-8 months. Height - 182cm, weight - 87kg. The skin and mucous membranes are
moderately dry. Glycemia venous plasma fasting blood - 10,1mmol / l, glucosuria - 20 g / l, the reaction
urine acetone - negative. What research will help to clarify the type of diabetes:
A. Finding the level of glucagon

B.Determination of HLA-B antigens

C.Glycemic profile

D.Measurement of C-peptide

E .Measurment of titer antibodies to insulin

7. Male, 35y.o., underwent surgery of the gastric ulcer. 10 kg Underweight . After the operation, blood
glucose capillary blood glucose - 6,7mmol / l after a meal -11,2mmol / l, glycated hemoglobin - 8%. Give
your interpretation of the given data of glucose:

A Normal values

B Patients is at risk for diabetes

C Impaired glucose tolerance

D Diabetes mellitus

E Prediabetes

8. Male, 26 y.o., complains about thirst, frequent stools incontinence, general weakness, weight loss.
The skin is dry, red cheeks. Vesicular breathing. Heart sounds normal sonority, no signs of peritoneal
irritation. What research is the most informative for diagnosis?

A Complete blood count

B General urine analysis

C Zimnitsky urine analysis

D Blood test for liver function tests

E Analysis of blood glucose

9. Girl, 13 y.o., got sick with diabetes after flu. Received 4 injections of short-acting insulin. After 2 weeks
after treatment hypoglycemia started. Insulin dose was gradually reduced to a complete cancellation.
There remains normoglycemia and aglucoseuria. Select the accounts for such a state:

A Body's response to viral infection

B Transient hyperglycemia

C Remission of diabetes

D Misdiagnosis of diabetes
E The period of puberty

10. The patient, 46 y/old, for 5 years have been treated for hypertension. The father is sick with diabetes
mellitus. The height of the patient - 170cm, weight - 96kg, blood pressure - 190/110 mm Hg Liver 3 cm.
Shin splints- pitting edema. Fasting blood glucose - 5.4 mmol / l Cholesterol - 6.2 mmol / l. What is
nessesary for the primary prevention of diabetes mellitus for the patient:

A Lose excessive weight

B Normalize blood pressure

C Prescribe hepatoprotectors

D Prescribe diuretics

E Prescribe hypolipidemics

References

1. Endocrinology: Textbook (P. Bodnar, G.P. Mykhalchyshyn, Y.I.Komisarenko et al.), Ed. Professor
P.M.Bodnar - Ed. 3, Revised. and add. - Vinnytsia. Nova Knyha, 2016 – 328p.

2. Endocrinology. (electronic edition): A textbook for students in russian language. (P.N. Bodnar, G.P.
Mykhalchyshyn, Y.I. Komisarenko, A.M.Pristupyuk et al.), Ed. Prof. PN Bodnar. Ed second Revised. and
Vinnytsia. Nova Knyha , 2015. – 496p.

3. Endocrinology: Textbook (Ed. By prof. Petro M. Bodnar. - 3th ed.,updated. - Vinnytsia. Nova Knyha,
2016. – 328p.

4. Clinical Endocrinology: the textbook / under. Ed. VN Hvorostynka. - M.: Fact, 2008. – 541p.

5. Basic & Clinical Endocrinology. Seventh edition. Edited by Francis S. Greenspan, David G. Gardner. -
Mc Grew - Hill Companies, USA, 2004. - 976p.

6. The clinical protocols for the treatment of patients with type 1 diabetes and type 2 diabetes.

7. Williams Textbook of Endocrinology / Ed. by Henry M. Kronenberg, Shlomo Melmed, Kenneth S.

Polonsky, P. Reed Larsen. - 12 ed / - Saunders, 2011 - 1920p.

Topic 2

                                     Type 1 and type 2 diabetes, modern methods of treatment.

   Learning Objectives:

*teach students a differential diagnosis of type 1 diabetes with other types;

* familiarize students with the methods of treatment of diabetes mellitus type 1, testimony to the use of
insulin;
* teach students to Prescribe traditional and intensify insulin therapy;

* teach students to do differential diagnosis 2 diabetes with other types;

* familiarize students with the methods of treatment of diabetes mellitus type 2,

* teach students prescribe oral hypoglycemic agents.

Student has to know:

* the criteria for compensation of carbohydrate metabolism in patients with type 1 diabetes;

* principles of treatment of diabetes mellitus type 1;

* indications for insulin;

* classification of insulin;

* insulin regimes: traditional and intensified;

* complications of insulin;

* compensation criteria metabolism in patients with type 2 diabetes,

* principles of treatment of type 2 diabetes mellitus,

* Principles of diet therapy;

* Prescribing rules dosed physical load;

* indications for oral hypoglycemic agents;

* classification of oral hypoglycemic agents;

* indications for insulin to patients with type 2 diabetes;

* methods of preventing the development of type 2 diabetes mellitus.

Student has to be able to:

* calculate the daily dose of insulin;

* carry out the correction insulin dose accordingly bread units;

* prescribe insulin therapy according to the traditional patterns and intensified;

* carry out the correction of insulin therapy, if not achieved target levels of compensation of
carbohydrate metabolism

* calculate daily caloric value of the food and bakery units Diabetics

* appoint oral hypoglycemic agents;

* carry out correction of hypoglycemic therapy in the absence of compensation of carbohydrate

metabolism.
A list of practical skills that students has to master:

* master the skills of insulin administration with a syringe and a syringe-pens;

* master the skills of calculating the daily calorie menu and patients with type 2 diabetes with normal
body weight and obesity.

Basic terms of the topic

Тerms Definition
Type 1 Diabetes
Type 2 Diabetes
Insulin preparation
Insulin analogues
Metformin
Hypoglycemis sulfa drugs
Inhibitors of dipeptidyl peptidase-4
Glucagon-like polypeptide
Acarbose
Medications that increase the sensitivity of
peripheral tissues to insulin
(insulin sensitizers)
Drugs that stimulate insulin secretion
The energy value of the daily diet
Bread units
Natural dietary fiber
Decompensation of Diabetes mellitus
Compensation of Diabetes mellitus
Self-monitoring of diabetes
Glucometers
Intensified insulin therapy
Conventional insulin therapy
Insulin pump therapy
Lipodystrophy
Insulin edema
Dapagliflozin(FORXIGA)

Tasks for self-study work on the topic

Task 1

Fill in the table of Diabetes Classification

 Categories Classification signs
Type 1 Diabetes
Type 2 Diabetes

Task 2

Fill in the table of required laboratory examination of patients with diabetes, depending on the type of
disease

№ Kind of research Research objective

1 Glycosylated hemoglobin
2 Glycemic profile
3 Ketonuria
4 Determination of creatinine in blood
plasma
5 Determination of liver transaminases
6 Determination lipidogram
7 Calculation of GFR (glomerular filtration
rate)
8 Calculation BMI
9 Measurement of blood pressure

Task 3

List the main ways of non-pharmacological treatment of diabetes

 ______________________________________________
 ______________________________________________
 ______________________________________________
 ______________________________________________
 ______________________________________________

Task 4

Fill in the table. The optimal combination of antidiabetic drugs

Group of the drug Combination with drugs other groups

 Task 5

Fill in the table patient treatment of patients with diabetes

Preparation Method of injection, dose Prescription

Tests

1. 20 y.o. patient complaints about dry mouth, thirst, urine output - 5-6 liters / day, significant weight
loss. The examination revealed dry skin, pyoderma, bleeding gums, increased liver 3 cm below the costal
arch. Glycosuria 15-20 g / l. Place a preliminary diagnosis:

A Diabetes insipidus

B Psychogenic polydipsia

C Renal Glycosuria

D Diabetes mellitus type 1

E Impaired glucose tolerance

2. Boy,15 y.o. with type 1 diabetes, is sick since he was 5 years old. Physical development is equivalent
to 10 years. An objective examination - hepatosplenomegaly. Laboratory tests indicate decompensation
of diabetes mellitus. What recommendation should be given to the patient?

A Compensate diabetes

B Determination of thyroid stimulating hormone

C Bone age definition

D Prescribe vitamin therapy

E Improve nutrition

3. The patient, 62 y.o., suffering from diabetes mellitus , type 2 and compensated by diet and gliclazide
60 mg per day. The patient should do surgery for inguinal hernia. What should be the tactics of
hypoglycemic therapy:

A Leave preliminary treatment regimen

B Cancel gliclazide

C To prescribed short-acting insulin

D To prescribed long-acting insulin

E Replace gliclazide with metformin

4. The patient, 22 y.o., after recovering from flu was diagnosed with diabetes. Glucose in plasma of
venous blood g - 10,2mmol / l, glucosuria - 20 g / l, glycated hemoglobin - 8%. What treatment should be
appointed:

A Insulin therapy

B Therapy with Sulfonylureas

C Therapy with Acarbose

D Therapy with Metformin

E Therapy with DPP-4 inhibitors

5. Patient N., 24 y/o, suffers from diabetes Type 1 is treated with insulin with prolonged action.
Fluctuations in glucose levels throughout the day from 15,2mmol / l to 22,0mmol / l on an empty
stomach -16,0mmol / l. Your treatment policy:

A. Add Sulfonylureas

B .Add Metformin

C .Long-acting insulin preparation is replaced by another manufacturer

D .To increase the daily dose of long-acting insulin

E Additional short-acting insulin before each meal

6. At the center of social and medical rehabilitation and vocational guidance has addressed the girl - a
graduate of a high school for 17 years. Sick with type 1 diabetes was 9 years old, it has a vascular
complications. It accepts different in terms of action insulin preparations. Current labile diabetes,
periodically during the day there are hypoglycemic state. They came for advice on choosing a profession.
What kind of profession and further education to offer the girl:

A Driver

B The work on sewing-machine

C Builder

D Nurse

E Cook

7. The woman, 45 y.o., obese(class I). found fasting glucose 1.0 mmol / l after a meal - 14.8 mmol / l
glucose 3% acetone in urine offline. The brother of a patient is suffering from diabetes. Type diabetes in
a patient:

A Hereditary diabetes

B Type 1 diabetes

C Diabetes mellitus type 2

D Diabetes is associated with a disease of the exocrine pancreas

E Diabetes associated with endocrinopathies

8. A patient, 52 y.o., during a baseline medical examination revealed fasting glycemia - 7.2 mmol / l,
glucosuria - 0.5 g / l. Height - 167 cm, weight -

92 kg. Determine the primary treatment strategy:

A Insulin therapy

B Diet therapy and dosed physical activity

C Derivatives Sulfonylureas

D Metformin

E Glucagon-like polypeptide

9. The patient, 48 y.o., height - 162 cm, weight - 90 kg. Diabetes mellitus type 2 for 2 years, diet therapy.
Fasting glucose - 12.4 mmol / L, glucosuria 21.5 g / l. Define further treatment:

A Insulin

B Diet therapy and dosed physical activity

C Derivatives sulfonylureas

D Metformin

E Acarbose

10. Female, 72 y.o., suffers from diabetes type 2, comorbidities –hypertension stage II., Heart
failure(NYHA class II,stage B-mild/moderate HF ). She uses metformin. On the eve suffered from a
hypertensive crisis after which there was a severe weakness, myalgia, increased thirst, dry mouth,
polyuria. AS - 140/95 mm Hg, heart rate - 98 min., Edema, and no smell of acetone. What measures
should be taken for the patient?

A In addition to appoint glimepiride

B To increase the dose of metformin

C To prescribe a DPP-4

D General to appoint a long-acting insulin

E Cancel metformin and insulin preparations to appoint

References

1. Endocrinology: Textbook (P. Bodnar, G.P. Mykhalchyshyn, Y.I.Komisarenko et al.), Ed. Professor
P.M.Bodnar - Ed. 3, Revised. and add. - Vinnytsia. Nova Knyha, 2016 – 328p.

2. Endocrinology. (electronic edition): A textbook for students in russian language. (P.N. Bodnar, G.P.
Mykhalchyshyn, Y.I. Komisarenko, A.M.Pristupyuk et al.), Ed. Prof. PN Bodnar. Ed second Revised. and
Vinnytsia. Nova Knyha , 2015. – 496p.

3. Endocrinology: Textbook (Ed. By prof. Petro M. Bodnar. - 3th ed.,updated. - Vinnytsia. Nova Knyha,
2016. – 328p.

4. Clinical Endocrinology: the textbook / under. Ed. VN Hvorostynka. - M.: Fact, 2008. – 541p.

5. Basic & Clinical Endocrinology. Seventh edition. Edited by Francis S. Greenspan, David G. Gardner. -
Mc Grew - Hill Companies, USA, 2004. - 976p.

6. The clinical protocols for the treatment of patients with type 1 diabetes and type 2 diabetes.

7. Williams Textbook of Endocrinology / Ed. by Henry M. Kronenberg, Shlomo Melmed, Kenneth S.

Polonsky, P. Reed Larsen. - 12 ed / - Saunders, 2011 - 1920p.

Topic 3

Acute and chronic diabetes complications. Features of the course and treatment of diabetes mellitus
in surgical patients during pregnancy

Learning Objectives:

 teach students to recognize the main manifestations of urgent situations in diabetes;

 familiarize students with the methods of diagnosis of comatose states in diabetes, indications for
their use, the implementation method, the diagnostic value of each of them;

 teach students to independently interpret the results of research to learn the etiology and
pathogenesis of diabetic angiopathy, neuropathy, diabetic foot syndrome.

Student has to know:

 Classification of emergency conditions;

 the cause and pathogenesis of diabetic, hypercetonemic coma ,hyperosmolar coma and lactic
acidosis;

 clinical manifestations of diabetic hyperosmolar coma and hypercetonemic coma;

 causes, pathogenesis, clinical signs of hypoglycemic states and coma;

 tactics and methods of treatment of urgent conditions in diabetes.

 clinical manifestations and classification of diabetic retinopathy, diabetic chronic kidney disease,
diabetic foot, diabetic polyneuropathy.

Student has to be able to:

 diagnosis and differential diagnosis hypercetonemic coma, hyperosmolar and hypoglycemic coma;

 determine the tactics of treatment and prophylaxis of comatose states in diabetes;

 own method of diagnosis and differential diagnosis of the emergency conditions in diabetes and
other endocrine and not endocrine disorders, to analyze the data obtained in the survey and the direct
examination of patients with chronic complications of diabetes,

 to appoint the necessary tests for the detection of diabetic retinopathy, nephropathy, diabetic foot,
diabetic polyneuropathy.

A list of practical skills, the student should learn:

- Learn how to analyze data from laboratory studies (glucose tolerance test, blood glucose and
glucosuria profile, C-peptide, HbA1c)

- Prescribe treatment for each type of angiopathy and neuropathy;

- Master the skills training of people with diabetes to surgical interventions;

- Treat diabetes in pregnant women.

Basic terms of the topic

Теrm Definition
Diabetic coma
Hyperosmolar coma
Lactate acidosis
Hypoglycemia
Мicroangiopathy
Neuropathy
Diabetic neuropathy peripheral
Diabetic neuropathy autonomic
Diabetic amyotrophy
Diabetic radiculopathy
Diabetic retinopathy
Diabetic maculopathy
Chronic diabetic kidney disease
Diabetic albuminuria
Nonalcoholic fatty liver disease
Thioctic acid derivatives
Gestational diabetes,diagnostic
Diabetic fetopathy
 Tasks for self-study work on the topic

Task 1

Fill in the table of classification of acute and chronic complications of diabetes

Category Classification signs

Ketonuria
Diabetic precoma
Diabetic coma
Hypoglycemic condition
Lactic acidosis
Hyperosmolar coma
Rehydratation theraphy
The technique of small doses of
insulin
GlucagenHypoKit
Diabetic microangiopathy
Diabetic neuropathy
Peripheral sensory-motor
polyneuropathy
Diabetic autonomic neuropathy
heart
Diabetic gastroenteropathy
Autonomic neuropathy of the
excretory and reproductive
system
Diabetic maculopathy
Diabetic neuropathy
Albuminuria
Chronic diabetic kidney diseas
Non-alcoholic fatty liver disease

Task 2

Fill in the table the main symptoms and clinical signs of organ systems for acute and chronic
complications of diabetes

Оrgan/System Signs of organ/system affection

Сardiovascular system
The peripheral nervous system
central nervous system
The autonomic nervous system
Kidney
Liver
Eyes
Lower extremities
Reproductive Organs
Skin
Muskulocutaneus
 Task 3

Fill in the table of mandatory laboratory testing diabetic patients with acute and chronic
complications

№ Examination method Examination objective

1 Daily monitoring of blood glucose
2 Monitoring of glycated hemoglobin
3 Determination ketonuria
4 Liver function tests
5 Kidney samples
6 The calculation of glomerular filtration
rate
7 Determination of BMI
8 Determination of albuminuria
9 Sonography of the kidneys
10 Sonography and liver elastography
11 Funduscopy
12 Determination of the sensitivity of all
types
13 Electrocardiography and
cardiorhythmography
14 Holter ECG monitoring and blood
pressure
15 Doppler vessels of the lower extremities
with the calculation of bone-brachial
index
16 X-rays of bones and damaged vessels
17 MRI of the spine, vascular
18 Bone densitometry

Task 4

List the main ways of non-pharmacological treatment of chronic complications of diabetes

 ______________________________________________
 ______________________________________________
 ______________________________________________
 ______________________________________________
Task 5

Fill in the table. The optimal combination of drugs for the treatment of acute and chronic
complications of diabetes
 Medication group The combination with other medication
groups

Task 6

Fill in the table of differential treatment for patients with complications of diabetes

Medication Method of injection, dose Prescription

Test questions

1. Patient K., who suffers from diabetes for 12 years, is in a coma. Objectively: skin is dry, noisy
breathing, the smell of acetone breath. AO 105/60 mmHg Pulse 100 per / min., Blood pH - 7.0. What
type of coma is possible in patient?

A Hypoglycemic

B Ketoacidotic

C Hyperosmolar

D Lactic acid

E Brain (stroke)

2. Patient A., 58 y.o., had diabetes for 7 years. After suffering from food poisoning his condition
worsened. Objectively: skin is dry, white coating on the dry tongue, shallow respiration, acetone smell in
the air is not felt. The patient has nausea, diarrhea. Blood glucose - 41 mmol / L. The probable
diagnosis?

A Cerebral coma

B Ketoacidotic coma

C Lactacidemic coma

D Hypoglycemic coma

E Hyperosmolar coma

3. Patient S., 32 y.o., lost consciousness in the intensive care unit. The patient card is identified with
diabetes. Insulin is not found. Noisy breathing, Kussmaul type, the smell of acetone breath, dry skin,
reduced turgor, facial features are sharp, periosteal reflexes are absent, the tone of eyeballs reduced.
The blood lactic acid content of 1.2 mmol / L (normal 0,62-1,3 mg / dL) Glycemia 29 mmol / l. The
probable diagnosis?

A Hyperosmolar coma

B Brain coma

C Ketoacidotic coma

D Hypochloremic coma

E Lactacidemic coma

4. Patient 49 y/o was taken to a hospital in an unconscious state. Skin, icteric sclera. Ascites. The edge of
the liver compact, 4 cm., Spleen 2 cm. Deep noisy breathing, BH - 20 / min. fruity breath. Tongue dry.
Eyeballs palpation soft. According to relatives of the patient is abusing alcohol. Recently, the patient felt
thirst, frequent urination, lost 5 kg. 3 days ago reduced the amount of urine, there was nausea and
vomiting. The urine density - 1,032, acidic reaction, positive reaction to acetone. Your diagnosis?

A Hepatic coma.

B Ketoacidotic coma.

C Uremic coma.

D Cerebral coma.

E Alcoholic coma.

5. Patient M., 28 y.o., has diabetes for 3 years. Gets 54 IU of insulin throughout the day. After
undergoing ten days ago angina condition worsened. Grew general weakness, increased thirst, were
nausea, vomiting, drowsiness, and lost consciousness. Hospitalized. On examination: The unconscious, a
rare and noisy breath, the smell of acetone breath. The skin, dry tongue, reduced skin turgor. Pulse is
114 min., Little AO 85/50 mmHg The lower edge of the liver at 3 cm below the costal arch. Blood glucose
- 32 mmol / l. Reaction to acetone sharply positive. Which of the following measures should treatment
start with?

A Rehydration therapy
B Correction of electrolyte balance

C Warning iatrogenic hypoglycemia

D Restoring acid-base balance

E Prevention of infectious complications

6. A woman of 59 y.o. has diabetes for 20 years. Previously was treated with oral hypoglycemic agents,
insulin therapy started last year. Diabetes is in compensation state. Disturb pains in the abdomen,
bloating, decorated chair, chair compelling dream. A presumptive diagnosis?

A Chronic hepatitis

B Chronic cholecystitis

C Diabetic steatosis

D Chronic gastritis

E Diabetic enteropathy

7. A patient 21 y.o. ,is suffering from diabetes for eight years .Fasting glucose 10.2 mmol / l, prandial
14.3 mmol / l, glucosuria daily 41.1 g / l, albuminuria 230 mg per day, BP 110/70 mmHg. Define the
diagnosis?

A Diabetes mellitus type 1,decompensate state,chronic diabetic

kidney disease

B Diabetes mellitus type 1 ,decompensate state, chronic diabetic kidney disease, microalbuminuria
moderate severity

C Diabetes mellitus in a state of decompensation, severe microalbuminuria

D Diabetes mellitus type 1 in a state of decompensation

E Diabetes mellitus type 1 in the state of decompensation, chronic renal failure

8. A woman 21 y.o. is suffering from diabetes 2 years , complicated by progressive diabetic retinopathy
and nephropathy, patient consults about the possibility of pregnancy. Give recommendations to the
patient.

A Pregnancy is undesirable

B Pregnancy is possible iin the case of stable compensation of diabetes

C Pregnancy possible after retinal photocoagulation

D Pregnancy is possible while reducing proteinuria

E Pregnancy is contraindicated

9. What are the most suitable antihypertensive agents for the treatment of diabetic patients with
nephropathy?
A. blockers ACE(angiotensin-converting enzyme)

B .Loop diuretics

C .β-Blockers

D .Calcium channel blockers

E .Thiazide diuretics

10. A patient with type 1 diabetes mellitus has "diabetic foot,neuropathic form." Which of these drugs is
advisable to appoint a patient?

A Derivative Pentoxifylline

B Statins

C Thioctic acid derivatives

D Antiaggregants

E Antiplatelet drugs

References

1. Endocrinology: Textbook (P. Bodnar, G.P. Mykhalchyshyn, Y.I.Komisarenko et al.), Ed. Professor
P.M.Bodnar - Ed. 3, Revised. and add. - Vinnytsia. Nova Knyha, 2016 – 328p.

2. Endocrinology. (electronic edition): A textbook for students in russian language. (P.N. Bodnar, G.P.
Mykhalchyshyn, Y.I. Komisarenko, A.M.Pristupyuk et al.), Ed. Prof. PN Bodnar. Ed second Revised. and
Vinnytsia. Nova Knyha , 2015. – 496p.

3. Endocrinology: Textbook (Ed. By prof. Petro M. Bodnar. - 3th ed.,updated. - Vinnytsia. Nova Knyha,
2016. – 328p.

4. Clinical Endocrinology: the textbook / under. Ed. VN Hvorostynka. - M.: Fact, 2008. – 541p.

5. Basic & Clinical Endocrinology. Seventh edition. Edited by Francis S. Greenspan, David G. Gardner. -
Mc Grew - Hill Companies, USA, 2004. - 976p.

6. The clinical protocols for the treatment of patients with type 1 diabetes and type 2 diabetes.

7. Williams Textbook of Endocrinology / Ed. by Henry M. Kronenberg, Shlomo Melmed, Kenneth S.

Polonsky, P. Reed Larsen. - 12 ed / - Saunders, 2011 - 1920p.

Topic 4

Iodine Deficiency Disorders of the thyroid gland. Symptoms of endemic ways with WHO. The clinic,
diagnosis, prevention and treatment. Hypothyroidism and thyroiditis. Classification, diagnosis, clinical
features, treatment

Learning Objectives:
 To help students recognize the basic symptoms and syndromes that accompany iodine deficiency
disorders and hypothyroidism.

 To familiarize students with the methods of their study, indications for use, techniques of
performance.

 To help students interpret the results of their own studies of the thyroid gland.

The student should know:

 distribution of iodine deficiency disorders in the world, the health consequences of iodine deficiency;

 etiology and pathogenesis, clinical endemic goiter, the indications for surgical treatment of goiter;

 tactics and treatment of endemic goiter;

 International Classification of goiter;

 etiology and pathogenesis, clinical hypothyroidism and thyroiditis;

 tactics, methods of treatment and Iodine Deficiency

states and hypothyroidism;

 International Classification of hypothyroidism.

Student has to be able to:

 Diagnose nontoxic goiter, determines treatment and preventive measures.

 Using the methodology of the individual, group and mass iodine prophylaxis nontoxic goiter.

 To diagnose hypothyroidism, determine the tactics of treatment and preventive measures.

 palpate the thyroid gland and regional lymph nodes.

Learning Objectives:

 To help students recognize the basic symptoms and syndromes accompanying hypothyroidism.

 To familiarize students with the methods of diagnosis of hypothyroidism, thyroiditis, the indications
for their use, methods of execution.

 To help students interpret the results of their own research.

Student has to know:

 The etiology, pathogenesis, clinic, methods of diagnosis of hypothyroidism.

 Etiology and pathogenesis, clinical thyroiditis.

 Tactics and methods of treatment and thyroiditis.

 International Classification of thyroiditis.

Student has to be able to:

 To diagnose hypothyroidism, determines treatment.

 To conduct differential diagnostics of hypothyroidism with other diseases.

 To diagnose thyroiditis, determine the tactics of treatment and preventive measures.

Basic terms of the topic

Term Definition
Goiter
Degree of goiter
Sonography of the thyroid gland
Echo-Doppler thyroid
Elastography thyroid
Diffuse Goiter
Thyroid Scan
Goiter hub
Thyroid nodule
Nontoxic goiter
Iodine Deficiency Disorders
Geoendemicheskie Province
Ioduria
Iodine prophylaxis
Iodine prophylaxis mass
Iodine prophylaxis group
Individual iodine prophylaxis
Iodinated salt
Hypothyroidism
Subclinical hypothyroidism
post manipulation hypothyroidism
Thyroid-stimulating hormone
Thyroxine
Thyroglobulin
Antibodies to thyroglobulin
Antibodies to thyroid peroxidase
Hashimoto's thyroiditis
Subacute thyroiditis
Chronic thyroiditis

Tasks for self-study work on the topic

Task 1

Fill in the table classification of goiter, hypothyroidism, thyroiditis

Categories Classification attributes

Goiter
Diffuse Goiter
Goiter nontoxic
Goiter hub
Goiter endemic
Hypothyroidism
Subclinical hypothyroidism
Post manipulation hypothyroidism
Compensated hypothyroidism
Hashimoto's thyroiditis
Chronic thyroiditis
postpartum thyroiditis
Subacute thyroiditis
Acute thyroiditis

Task 2

Fill in the table of the main symptoms and clinical signs of the organs and systems in
hypothyroidism

Organ / System Signs of organ / systems affection

Cardiovascular
Digestive
hematopoiesis
Musculoskeletal
Reproductive
Nervous
Endocrine
Skin and skin
appendages

Task 3

Fill in the table of mandatory laboratory and instrumental examination of patients with goiter,
hypothyroidism and thyroiditis.

№ Examination method Examination objective

1 Palpation of the thyroid gland
2 Sonography of the thyroid gland
3 Doppler ultrasound of the thyroid gland
4 MRI of the neck and retrosternal space
5 Determination of the concentration of
thyroid hormone in the blood
6 Determination of the concentration of
antibodies in the blood of thyroid
7 Determination of the concentration in
the blood thyroglobulin
 8 Lipidogram
9 General blood analysis
10 ECG
11 Reo-encephalography

12 Fine-needle aspiration biopsy of

nodules

Task 4

List the main ways of non-pharmacological treatment

 ______________________________________________
 ______________________________________________
 ______________________________________________
 ______________________________________________
 ______________________________________________

Task 5

Fill in the table

Medication for the treatment of goiter, hypothyroidism, thyroiditis

Medication Prescription objective

Task 6
 Fill in the table of the differential diagnosis and treatment patients with goiter, hypothyroidism,
thyroiditis

Medication Method of injection, dose Prescription

Iodides
L-thyroxine
Glucocorticoids
Steroidal anti-inflammatory
Medication
Antianaemia Medications
Medication stimulating
peristalsis

Test questions

1. Patient 50 y.o., complains of general weakness, drowsiness, memory loss, weight gain, constipation.
Sick for about two years, was not treated. Objectively: the pulse of 56 per minute, blood pressure
100/60 mm Hg. The thyroid gland second degree, with increased density. TSH levels in the blood of 26
mIU / l. What caused such condition of patient?

A. Hypoparathyroidism

B. Heart failure

C. Nephrotic syndrome

D. Menopausal syndrome

E. Hypothyroidism

2. Patient 57 y.o., complaining of general weakness, insomnia, palpitations, hand tremors, sweating.
Surgery for nodular toxic goiter. After surgery, he was appointed a L-thyroxine 150 mcg / day.
Objectively: the pulse of 100 per minute, blood pressure 150/70 mm Hg TSH levels in the blood of 0.07
mIU / L.What caused this condition?

A. Overdose of L-thyroxine

B. Relapse toxic goiter

C. Insufficient dose of L-thyroxine

D. Iodine deficiency

E. Development of Heart Failure

3. A woman of 70 y.o., which has coronary artery disease and HD II stage. Was first diagnosed with
primary hypothyroidism. TSH level in the blood plasma of 40 mIU / l. Which initial dose of L-thyroxine
should be appointed for the state compensation?
A. 25 mcg / day

B. 50 mcg / day

C. 100 mcg / day

D. 150-200 mcg / day

E. You should not prescribe L-thyroxine, treatment of accompanying illnesses is nessesary

4. Patient, 28 y.o.,has in the left lobe of the thyroid gland node size of 20x16 mm, setected by palpation.
What additional tests is necessary to conduct to confirm the diagnosis?

A Fine-needle aspiration biopsy

B Reflexometry

C ECG

D Thermography

E MRI of the neck

5. A pregnant 25 y.o. (10 weeks of pregnancy), lives in iodindefficiency endemic zone and wants to have
a healthy baby.Which of medical tactics you choose?

A. Prescribe iodides at a dose of 250 mcg / day

B. Inspection iodides at a dose of 50 micrograms / day

C. Iodides Prescribe 100 mcg / day

D. Inspection iodides at a dose of 150 mcg / day

E. Observation of the patient in dynamics

6. Patient D., 40 y.o. 2 months after surgical treatment for diffuse toxic goiter,complains of chilliness,
drowsiness, lethargy, loss of appetite, and constipation. Objectively: skin feels dry, cold, pale, somewhat
bloated face, swelling of the lips tight. The thyroid gland is not palpable, heart sounds are muffled. Pulse
- 53 per minute, blood pressure - 100/65 mm Hg .What caused this patient's condition?

A Hypoparathyroidism

B Heart Failure

C Recurrence toxic goiter

D Nephrotic Syndrome

E Hypothyroidism

7. Patient 45 y.o., 2 months after suffering from subacute thyroiditis complained of progressive and
general muscle weakness, fatigue, sensitivity to cold, drowsiness, weight gain on the background of
swelling of the face and extremities, constipation, dry skin, hair loss. She was treated with
corticosteroids. On examination: the patient flaccid, adynamic, the skin has a yellow hue palely cold.
Face puffy, swollen eyelids, lips thickened. The body temperature of 35,8 ° C in a 58 minute pulse. An.
Blood Society.: Hb 100 g / L, Er - 3.5 1012 / L, L - 3.5 * 109 / L, erythrocyte sedimentation rate 25 mm / h.
The content of TSH in the blood is elevated, and T3 and T4 - reduced. Your diagnosis?

A Subclinical hypothyroidism

B Primary hypothyroidism

C Center hypothyroidism

D Autoimmune thyroiditis

E Side effect of medication

8. Patient, 40 y.o., operated for pituitary tumors. Complains of weakness, drowsiness, constipation,
reduced blood pressure, chest pain, amenorrhea. The content in the blood T4 free. – 3.3nMol / L
(normal 11, 8 -24, 6 nmol / L), TSH - 0.3 mIU / L.What type of hypothyroidism the patient has?

A. Primary

B. Central

C. Peripheral

D.Transitory

E. Postoperative

9. Patient D., 40 y.o. 2 months after surgical treatment for diffuse non-toxic goiter complains of
chilliness, drowsiness, constipation. Objectively: skin to the touch, pale, puffy face. Sonority heart
sounds low. Puls- 56 min., Blood pressure - 100/65 mm Hg .What caused this patient's condition?

A Hypoparathyroidism

B Heart Failure

C Recurrence toxic goiter

D Nephrotic Syndrome

E Hypothyroidism

10. Patient N., 55 y.o., complains of an increase in thyroid gland size, which is observed in the last two
years. Objectively: the signs of hypothyroidism, the thyroid gland by palpation has increased density.
Regional lymph nodes are not enlarged. The patient's serum antibodies to thyroid peroxidase are in high
titers. Specify the preliminary diagnosis.

A Autoimmune thyroiditis. Hypothyroidism

B Diffuse goiter. Hypothyroidism

C Endemic goiter. Hypothyroidism

D Chronic thyroiditis. Hypothyroidism

E Primary hypothyroidism

References

1. Endocrinology: Textbook (P. Bodnar, G.P. Mykhalchyshyn, Y.I.Komisarenko et al.), Ed. Professor
P.M.Bodnar - Ed. 3, Revised. and add. - Vinnytsia. Nova Knyha, 2016 – 328p.

2. Endocrinology. (electronic edition): A textbook for students in russian language. (P.N. Bodnar, G.P.
Mykhalchyshyn, Y.I. Komisarenko, A.M.Pristupyuk et al.), Ed. Prof. PN Bodnar. Ed second Revised. and
Vinnytsia. Nova Knyha , 2015. – 496p.

3. Endocrinology: Textbook (Ed. By prof. Petro M. Bodnar. - 3th ed.,updated. - Vinnytsia. Nova Knyha,
2016. – 328p.

4. Clinical Endocrinology: the textbook / under. Ed. VN Hvorostynka. - M.: Fact, 2008. – 541p.

5. Basic & Clinical Endocrinology. Seventh edition. Edited by Francis S. Greenspan, David G. Gardner. -
Mc Grew - Hill Companies, USA, 2004. - 976p.

6. The clinical protocols for the treatment of patients with type 1 diabetes and type 2 diabetes.

7. Williams Textbook of Endocrinology / Ed. by Henry M. Kronenberg, Shlomo Melmed, Kenneth S.

Polonsky, P. Reed Larsen. - 12 ed / - Saunders, 2011 - 1920p.

Topic 5

Thyrotoxicosis. Clinical forms. Diagnosis, treatment. Thyroid cancer. Classification, clinic, diagnostics,
treatment. Diseases of the parathyroid glands

Learning Objectives:

 To help students recognize the basic symptoms and syndromes that accompany hyperthyroidism.

 To familiarize students with the methods of diagnosis thyrotoxicosis, indications for their use,
methods of execution.

 To help students interpret the results of their own research.

 To help students recognize the basic symptoms and syndromes that accompany thyroid cancer,
hyperparathyroidism, hypoparathyroidism.

 To help students interpret the results of their own studies of the thyroid and parathyroid glands.

Student has to know:

 etiology, pathogenesis, clinic, diagnostic methods of hyperthyroidism, the indications for surgical
treatment.

 International Classification of thyroid cancer.

 etiology and pathogenesis, clinical thyroid cancer.

 tactics and methods of treatment of thyroid cancer.

 etiology, pathogenesis, main clinical signs of hyperparathyroidism and hypoparathyroidism, methods

for their treatment.

Student has to be able to:

 To diagnose hyperthyroidism, to determine the treatment strategy.

 Conduct a differential diagnosis of hyperthyroidism with other diseases of the thyroid gland.

 To render the first aid in thyrotoxic crisis.

 To establish the diagnosis and differential diagnosis of thyroid cancer.

 palpate the thyroid gland and regional lymph nodes.

 Conduct a differential diagnosis of hyperparathyroidism and hypoparathyroidism with other diseases,

to determine the appropriate treatment plan.

 To render the first aid in hypercalcemic and hypocalcemic crisis.

Basic terms of the topic

Term Definition
Hyperthyroidism
Toxic goiter
Thyrotoxic crisis
Thyroxine
Triiodothyronine
TSH receptor antibody
Tionamidy
Follicular Thyroid Cancer
Papillary Thyroid Cancer
Medullary Thyroid Cancer
Anaplastic thyroid cancer
Thyroid cancer metastatic
Calcitonin
Fine-needle aspiration biopsy
Parathyroid hormone
Osteoporosis
Hypercalcemic crisis

Tasks for self-study work on the topic

Task 1
Complete the table of classification of hyperthyroidism, thyroid cancer, hyperparathyroidism and
hypoparathyroidism

Categories Classification attributes

Hyperthyroidism
Subclinical
hyperthyroidism
Hyperthyroidism
symptomatic
Hyperthyroidism
complicated
Diffuse toxic goiter
Nodular toxic goiter
Toxic thyroid adenoma
Iodine-induced
thyrotoxicosis
Pretibial edema
Ophthalmopathy
Thyrotoxic crisis
Thyroid Cancer
Hypercalcemia
Pseudohyperparathyroidism

Task 2

Fill in the table of the main symptoms and clinical signs of the organs and systems of
hyperthyroidism, thyroid cancer, hyperparathyroidism, hypoparathyroidism

Organ / System Signs of organ / systems affection

Cardiovascular
Digestive
Musculoskeletal
Reproductive
Excretory
Nervous
Endocrine
Eyes

Task 3

Fill in the table of mandatory laboratory and instrumental examination of patients with
hyperthyroidism, thyroid cancer, hyperparathyroidism, hypoparathyroidism.

№ Examination method Examination objective

1 Determination of thyroid hormones in the
 blood
2 Determination of the concentration of
thyrotropin
3 Determination of the concentration of
antibodies to the thyrotropin receptor
4 General blood analysis
5 Determination of glucose and glycated
hemoglobin
6 Sonography of the thyroid gland
7 Echo-Doppler of thyroid
8 MRI of the neck and retrosternal space
9 Determination of PTH concentration in
blood
10 Determination of the concentration of
calcium and phosphorus in the blood
11 X-ray of the skull bones and long bones
12 Skeleton Densitometry
13 Determination of the concentration of
vitamin D in the blood
14 Thyroid Scan

Task 4

List the main ways of non-pharmacological treatment

 ______________________________________________
 ______________________________________________
 ______________________________________________
 ______________________________________________
 ______________________________________________

Task 5

Fill in the table of medication for the treatment of hyperthyroidism, thyroid cancer,
hyperparathyroidism, hypoparathyroidism

Medication Prescription objective

 Task 6

Fill in the table of differential diagnosis of patients with hyperthyroidism, thyroid cancer,
hyperparathyroidism, hypoparathyroidism.

Medication Method of injection, dose Prescription

Tionamyds
Iodides
ß-blockers
glucocorticoids
Medications calcium
Medications Vitamin D
L-thyroxine
Medicationy calcium

Tests

1. Patient, 30 y.o., after suffering flu is constantly present weakness, irritability, sweating. The patient
lost weight, there was a tremor, palpitation, exophthalmos. On examination: skin moist, exophthalmos,
pulse - 120 in 1 min., The thyroid gland is enlarged, soft, painless. TSH blood - 0.2 mIU / L (N - 0,4-4
mIU / L). Your diagnosis?

A Endemic goiter

B Graves' disease

C Autoimmune thyroiditis

D Diffuse toxic goiter

E Thyroid Cancer

2. In the first hours after subtotal resection of the thyroid gland on the toxic goiter patient had
developed an expressed mental and motor agitation,sudden redness of face, neck, upper and lower
extremities. T body - 40-41 ° C, increased sweating. Rapidly growing tachycardia to 140-200 min., Atrial
fibrillation. What kind of complication develops in the patient?

A Asphyxia

B Anaphylactic shock

C Hypoparathyroidism

D Myocardial Infarction
E Thyreotoxic crisis

3. A woman, 37 y.o., was treated in a hospital due to severe hyperthyroidism, goiter stage II, endocrine
ophthalmopathy.She takes Mercazolilum dose of 60 mg / day. After 3 weeks of treatment the feeling of
compression in throat had developed.Choose possible cause of the deterioration of the patient.

A Neurotic condition

B Allergy Mercazolilum

C Medical hypothyroidism

D Ineffective treatment Mercazolilum

E Goitrogenic influence of Merkazolilum

4. Patient, 40 y.o., who is ill with autoimmune thyroiditis, developed frequent PVCs. Doctors prescribed
Amiodarone for the long term. What laboratory parameters should be monitored once a year, in
patient?

A Indicators of complete blood count

B Indicators of ionogram

C Level of thyroid hormones

D Concentration of thyroid antibodies

E Level of uric acid in blood plasma

5. Female, 32 y.o., asked about the increase in thyroid gland. From history we know that at the time of
the Chernobyl accident are at high radioactive fallout. Enlarged thyroid notes for 1 year, it gradually
progresses. OBJECTIVE: thyroid increased to grade II.,high density,sedentary,painless knot is palpated.
Submandibular lymph nodes are enlarged, painful. When thyroid ultrasonography revealed a
hypoechoic formation without clear boundaries with calcifications. BP 120/70 mmHg Pulse 78 min. On
the basis of the data presented in the patient may be suspected

A Thyroid Cancer

B Diffuse toxic goiter

C Thyroid adenomas

D Subacute thyroiditis

E Graves' disease

6. Patient, 55 y.o., refered to endocrinologist in connection with the occurrence of tumor formation in
the neck. During thyroid ultrasound was found hypoechoic node in right lobe without a clear outline
with a diameter of 2.5sm.Which of the study methods will allow you to select the correct treatment
policy?

A Neck thermography
B Magnetic resonance imaging of the neck

C Radioiodine scintigraphy

D Fine-needle aspiration needle biopsy of thyroid nodule

E Computed tomography of the neck

7.Patient, 50 y.o., refered to endocrinologist in connection with tumor formation on the right side of the
neck, which came one month ago. Objectively: the thyroid gland grade II., In the right lobe is palpated
dense section diameter of about 1.5 cm,thyroid gland painless. On the back surface of the right m.
sternocleidomastoideus palpable enlarged lymph node. What research is necessary to conduct to clarify
the diagnosis?

A. Needle aspiration biopsy

B. Ultrasound examination of the thyroid gland

C. Neck thermography

D. Thyroid scintigraphy 99tTs

E. Determining the level of thyroid hormones in blood plasma

8. Patient, 47 y.o., 4 years appealed to different specialists with complaints of weakness in the limbs,
constant pain in the calf muscles and back. On radiographs revealed bone osteoporosis, pathological
fractures. The calcium level in the blood increased. Which of the diagnoses is most likely?

A. Multiple myeloma

B. Primary hyperparathyroidism

S.Osteoblastoma

D.Postmenopause osteoporosis

E. Young's Sarcoma

9. A 32-y.o. patient several hours after removal of the parathyroid glands originated attack, which was
followed by convulsions, laryngospasm, spasms of the respiratory muscles. What medication first aid is
necessary to provide to the patient?

A Neostigmine i/v 0.05%, 0.5-1 ml

B Calcium chloride i/v 10%, 5-10 ml

C Atropine sulfate i/v 0.1% 0.5-1 ml

D Potassium chloride 10%, 1 table. spoon

E Dibazol i/m 0.5%, 2 ml

10. Patient was operated in connection with diffuse toxic goiter. 2 weeks after surgery he developed
intermittent twitching of the limbs, paresthesia. Seizures occurred 1 to 2 times a day, often while
working. OBJECTIVE: pulse - 72 in 1 min, blood pressure 120/70 mm Hg The internal organs
abnormalities were detected. Positive symptoms Chvostek, Trusso.Choose possible diagnosis.

A Polyneuropathy

B Hypothyroidism

C Hypoparathyroidism

D Asthenoneurotic syndrome

E Epilepsy

References

1. Endocrinology: Textbook (P. Bodnar, G.P. Mykhalchyshyn, Y.I.Komisarenko et al.), Ed. Professor
P.M.Bodnar - Ed. 3, Revised. and add. - Vinnytsia. Nova Knyha, 2016 – 328p.

2. Endocrinology. (electronic edition): A textbook for students in russian language. (P.N. Bodnar, G.P.
Mykhalchyshyn, Y.I. Komisarenko, A.M.Pristupyuk et al.), Ed. Prof. PN Bodnar. Ed second Revised. and
Vinnytsia. Nova Knyha , 2015. – 496p.

3. Endocrinology: Textbook (Ed. By prof. Petro M. Bodnar. - 3th ed.,updated. - Vinnytsia. Nova Knyha,
2016. – 328p.

4. Clinical Endocrinology: the textbook / under. Ed. VN Hvorostynka. - M.: Fact, 2008. – 541p.

5. Basic & Clinical Endocrinology. Seventh edition. Edited by Francis S. Greenspan, David G. Gardner. -
Mc Grew - Hill Companies, USA, 2004. - 976p.

6. The clinical protocols for the treatment of patients with type 1 diabetes and type 2 diabetes.

7. Williams Textbook of Endocrinology / Ed. by Henry M. Kronenberg, Shlomo Melmed, Kenneth S.

Polonsky, P. Reed Larsen. - 12 ed / - Saunders, 2011 - 1920p.

Topic 6

Diseases of the adrenal glands. Chronic adrenal insufficiency. Etiology, pathogenesis, clinical picture,
diagnosis, prevention and treatment. Hormonally active adrenal tumors

Learning Objectives:

 teach students to recognize the basic symptoms and syndromes in diseases of the adrenal glands;

 familiarize students with the methods of research in the pathology of the adrenal glands, the
indications for their use, the implementation method, the diagnostic value of each of them;

 teach students to independently interpret the results of studies conducted

Student has to know:

 classification of diseases of the adrenal glands;

 the etiology, pathogenesis, clinic and methods of diagnosis of primary chronic disease and hormone-
active tumors of the adrenal glands;

 tactics and methods of treatment of chronic adrenal insufficiency, a hormonally active adrenal
tumors.

Student has to be able to:

 diagnose adrenal disease and determine the tactics of treatment and prevention;

 carry out dispensary care and expertise of disability in patients with chronic adrenal insufficiency and
hormonally active adrenal tumors;

 master the technique of diagnosis and differential diagnosis of diseases of the adrenal glands;

 diagnose and treat acute and chronic adrenal failure under stress.

Basic terms of the topic

Term Definition
Hypotension
Hypotension
Hyperpigmentation
Hypoglycemia
Primary chronic adrenal insufficiency
Pheochromocytoma
Catecholamines
Hromafinoma
Adrenalin
Norepinephrine
Metanephrine
Vanillylmandelic acid
Cortisol
Desoxycorticosterone
Aldosterone
17 oksiprogesteron
Cushing's syndrome
Kona syndrome
Hyperkalemia
Hypernatremia
Corticosteroma
Kortikoestroma
Androsteroma
Congenital adrenal hyperplasia
Pseudohermaphroditism
Salt wasting syndrome
Stretch marks
Addison’s crisis

Tasks for self-study work on the topic

Task 1

Fill in the table of classification adrenal insufficiency and hormone-active tumors of adrenal glands

Categories Classification attributes

Primary chronic adrenal
insufficiency
Secondary chronic adrenal
insufficiency
Aldosteronoma
Corticosteroma
Kortikoestroma
Androsteroma
Cushing's syndrome
Pheochromocytoma
Hromafinoma
Congenital adrenal
hyperplasia
Salt wasting syndrome
Addison’s crisis

Task 2

Fill in the table of the main symptoms and clinical signs of the organs and systems in chronic
adrenal insufficiency and hormone-active tumors of the adrenal glands.

Organ / System Signs of organ / systems affection

Cardiovascular
Digestive
Hematopoiesis
Leather
Endocrine
Reproductive
Musculoskeletal

Task 3
 Fill in the table of mandatory laboratory and instrumental examination of patients with chronic
adrenal insufficiency and patients with hormonally active adrenal gland tumors

Number Examination method Examination objective

1 General blood analysis
2 Glycemia
3 Corticotropin
4 Cortisol blood
5 Potassium, sodium blood
6 Aldosterone blood
7 Renin blood
8 Testosterone blood
9 17 oksiprogesteron blood
10 Estrogens blood
11 Epinephrine, norepinephrine
blood
12 Metanephrine
13 Urine catecholamines
14 MRI of the retrosternal
space

Task 4

List the main ways of non-pharmacological treatment

 ______________________________________________
 ______________________________________________
 ______________________________________________
 ______________________________________________
 ______________________________________________

Task 5

Fill in the table.

Medications for the treatment of chronic insufficiency of adrenal cortex glands hormonally active
adrenal gland tumors
 Medication Prescription objective

Task 6

Fill in the table of the differential treatment of patients with chronic insufficiency of adrenal cortex
glands hormonally active adrenal gland tumors

Medication Method of injection, dose Prescription

Cortisone
Deoxycorticosterone acetate
Hydrocortisone
Ascorbic acid
ß-blockers
α-blockers
Dexamethasone
Fludrocortisone
Glucose

Tests

1. Patient R., who is treated for septic states suddenly emerged a significant weakness, weakness,
vomiting, and diarrhea. Sopor. Pulse thready, 110 in 1 min.., BP 60/40 mm Hg ECG: tachycardia,
decrease the voltage. Laboratory data: hyponatremia, hypochloremia, hyperkalemia, hypoglycemia.
Specify the reason for the development of this state:

A Hypothalamic crisis

B Acute adrenal insufficiency

C Hypoglycemic coma

D Panhypopituitarism

E Acute myocardial infarction

2. Patient D., 42 y.o., after a physical overwork lost consciousness fainted. Blood pressure decreased to
40/20 mm Hg In the anamnesis(5 years) use of glucocorticoids, due to the fact that suffers from
bronchial asthma. The last 4 days does not take glucocorticoids. Objectively: the patient has inhibited,
consciousness,normal skin color, normal humidity, heart sounds dull, Pulse 100/min., Weak, rhythmic.
Blood glucose - 3.0 mmol / l sodium - 117 mmol / L, potassium - 6.0 mmol / l. What is preliminary
diagnosis?

A Cardiogenic shock

B Adrenal crisis

C Acute adrenal insufficiency

D Hypovolemic shock

E Hypoglycemic coma

3. Patient K., 29 y.o., with satisfactory compensated type 1 diabetes frequent hypoglycemia, nausea,
bowel disorders, skin hyperpigmentation (bronze color), had developed BP - 70/50 mm Hg, Hb 100 g /
L .What is the reason of pressure decrease?

A Chronic adrenal insufficiency

B Diabetic enteropathy

C Diabetic gastropathy

D Overdose antidiabetic drugs

E Development of diabetes insipidus

4. Patient B., 18 y.o., was taken to hospital by ambulance in unconscious. Additional research: elevated
level of potassium in the blood serum of up to 8 mM / L, the level of cortisol - 18 micrograms per 100 ml
of plasma. On an electrocardiogram - shargteeth T. CT - signs of adrenal calcification. What is the most
likely diagnosis?

A Insufficiency of the adrenal cortex

B Hyperosmolar coma

C Hyperlactatacidemic coma

D Thyrotoxic crisis

E Hypoglycemic coma

5. Patient, 43 y.o., was delivered in a serious condition. From the words of her husband, she has
Addison's disease. Constantly take 5 mg of prednisone. During the last week, the drug is not taken
because there was a pain in the stomach, appetite worsened. Yesterday she did not eat because of
nausea and vomiting. Patients is in the soporous state. Skin and mucosal hyperpigmented. Skin turgor
and muscle is reduced. Heart sounds are muffled, accelerated, BP - 60/40 mm Hg, heart rate - 96 / min.
Sodium Blood - 130 mmol / L, potassium - 5.5 mmol / l. What hormone deficience plays a leading role in
the development of this complication?

A Aldosterone

B Corticotropin (ACTH)
C Adrenaline

D Noradrenaline

E Cortisol

6. Patient S., 52 years old, is delivered by emergency care to the clinic and complaining of severe
weakness, dizziness, weight loss, lack of appetite, nausea, vomiting, severe pain in the epigastric region,
diarrhea, increased skin pigmentation. What is the most likely diagnosis?

A Pellagra

B Addison’s crisis

C Meningoencephalitis

D Acute gastroenteritis

E Scleroderma

7. Patient, 47 y.o., is in the hospital for examination in connection with frequent episodes of increased
blood pressure up to 280/140 mm Hg in the last few months. A family history of hypertension is not
burdened. In the morning complains about intense headache, palpitations, anxiety. BP 300/160 mm Hg,
heart rate - 128 in 1 min. Previously, these states recorded hyperglycemia, leukocytosis, after removing
the patient from the crisis polyuria were marked. Choose class of drugs for elimination of hypertensive
crisis:

A α-blockers

B β- Blockers

C Calcium antagonists

D ACE inhibitors

E Diuretics

8.In 38-y.o. woman after a quarrel arose dizziness, weakness. In anamnesis-anorexia, weight loss,
nausea, diarrhea. Hypotension 50/30 mmHg upright. Pulse is 110 min., small, rhythmic. Blood glucose -
3.3 mmol / L. Hyponatremia. Hyperkalemia. Hyperpigmentation of the skin. Excretion of 17- OKS urine
reduced. Preliminary diagnosis:

A Concealed internal bleeding

B Pregnancy, hypotonic state

C Vascular dystonia, hypotonic type

D Collapse when adrenal insufficiency

E Diabetes, hypoglycemic condition

9. Determine endocrine disease, which is always accompanied by a decrease in body weight:

A Insuloma
B Hyperparathyroidism

C Hypothyroidism

D Addison's disease

E Type 2 Diabetes

10. The patient, 40 y/o, with primary adrenal insufficiency, constantly taking prednisone to 7.5 mg per
day. In connection with the worsening of pulmonary tuberculosis reduced the prednisone dose to 5 mg
per day. After 2 days, the condition worsened; there was a sharp weakness, nausea, vomiting, decreased
blood pressure to 80/40 mm rt.st. The medication of choice for the treatment of patient currently is:

A Prednisolone

B Ftivazid

C Dexamethasone

D Hydrocortisone

E Rifampicin

References

1. Endocrinology: Textbook (P. Bodnar, G.P. Mykhalchyshyn, Y.I.Komisarenko et al.), Ed. Professor
P.M.Bodnar - Ed. 3, Revised. and add. - Vinnytsia. Nova Knyha, 2016 – 328p.

2. Endocrinology. (electronic edition): A textbook for students in russian language. (P.N. Bodnar, G.P.
Mykhalchyshyn, Y.I. Komisarenko, A.M.Pristupyuk et al.), Ed. Prof. PN Bodnar. Ed second Revised. and
Vinnytsia. Nova Knyha , 2015. – 496p.

3. Endocrinology: Textbook (Ed. By prof. Petro M. Bodnar. - 3th ed.,updated. - Vinnytsia. Nova Knyha,
2016. – 328p.

4. Clinical Endocrinology: the textbook / under. Ed. VN Hvorostynka. - M.: Fact, 2008. – 541p.

5. Basic & Clinical Endocrinology. Seventh edition. Edited by Francis S. Greenspan, David G. Gardner. -
Mc Grew - Hill Companies, USA, 2004. - 976p.

6. The clinical protocols for the treatment of patients with type 1 diabetes and type 2 diabetes.

7. Williams Textbook of Endocrinology / Ed. by Henry M. Kronenberg, Shlomo Melmed, Kenneth S.

Polonsky, P. Reed Larsen. - 12 ed / - Saunders, 2011 - 1920p.

Topic 7

Diseases of the hypothalamic-pituitary system. Obesity. Diseases of the sexual glands.

Learning Objectives:

* Read the polymorphism pathology, combined the concept of "hypothalamic syndrome" and
"hypopituitarism".

* To get to the concepts of growth disorders and sexual differentiation.

* Read the prevalence of obesity in Ukraine.

Student has to know:

* Etiology, pathogenesis, clinical and diagnostic methods Cushing's disease, obesity, hyperprolactinemia,
hypopituitarism, acromegaly, diabetes insipidus, learn the tactics and methods of treatment of the
aforementioned diseases;

* Etiology, pathogenesis, clinical and diagnostic techniques certain disorders of growth and sexual
development of children (hypopituitarism with the overwhelming growth hormone deficiency, primary
and secondary hypogonadism and premature puberty), the clinical symptoms of disorders of growth and
sexual development of children, the impact of embryotoxic factors on the occurrence of the
disadvantages of sexual differentiation ; physiological effects of sex hormones, the reasons for violations
of their secretion and action; diagnostic value karyotyping;

* Etiology, pathogenesis, clinical and diagnostic methods of obesity, indications for surgical treatment;
tactics and methods for the treatment of obesity; international classification of obesity.

Student has to be able to:

* To conduct differential diagnostics of diseases of the hypothalamic-pituitary axis; master the

technique of determining the "bone age"; According to kraniogramme determine intracranial
hypertension, abnormal sella; determine the type of body (gynoid, android, intersex) to determine the
type of obesity;

* Examination of the patient charts; diagnose disorders of growth and sexual development of the
diagnosis and differential diagnosis of hypopituitarism with suppressing growth hormone deficiency,
primary and secondary hypogonadism, identify diseases and conditions caused by disorders of sexual
differentiation, or deviations due to the action of sex hormones; Prescribe the necessary tools and
laboratory tests for diagnosis; differential diagnosis between the disorders caused by pathological
course of menopause and syndromes inducing diseases ensure adequate treatment of patients with
climacteric syndrome.

* Diagnosing obesity by class, to determine body mass index, Task treatment and preventive measures;
appoint a scheme reducing diets, drug therapy.

Basic terms threads

Теrm Definition
Аcromegaly
Growth hormone
Insulin-like growth factor
Liberins
Statins
Тropins
The dopamine agonist
Growth hormone deficiency
apituitarism
hyperprolactinemia
Pituitary basophilia
Diabetes insipidus
hypogonadism
Climax
Partial androgen deficiency syndrome
Obesity
Body mass index
Bone age

Tasks for independent work on the topic

Task 1

Fill in the table of “Classification of Diseases hypothalamic-pituitary system”

Categories Clinical signs

Acromegaly
Growth hormone
deficiency
Apituitarism
Hypogonadism
Menopause(Climacteric
syndrome)
Syndrome
Pituitary basophilia
Hyperprolactinemia
Diabetes insipidus
Obesity

Task 2

Fill in the table of the main symptoms or clinical signs of organ systems for diseases of the
hypothalamic-pituitary system

Organ / System Signs of organ / systems damage

Musculoskeletal
Nervous
Digestive
Cardiovascular
Excretory
Endocrine
Reproductive
Skin

Activity 3

Fill in the table of mandatory laboratory and instrumental examination of patients with diseases of the
hypothalamic-pituitary system

№ Examination method Examination objective

1 Determination of growth hormone
2 Determination of IGF
3 Determination of glucose
4 Determination vahopressina
5 Determination of corticotropin
6 Determination of gonadotropins
7 Determination of cortisol
8 Determination of thyrotropin
9 Determination of PTH
10 Determination of calcium, phosphorus
blood
11 Determination of nitrogen, renal
excretory function
12 Study of plasma osmolality
13 Urinalysis for Zimnitsky
14 Determination of prolactin
15 Determination of hormone
antimyullerovogo
16 MRI-hypothalamic brain areas
nipofizarnoy
17 MRI of the retroperitoneal space
17 Sonography and MRI of the pelvic organs
18 X-rays of bones
19 Calculating BMI
20 Calculation of the index of insulin
resistance
21 Measuring waist circumference and hip
22 Determination of bone age

Task 4

List the main ways of non-pharmacological treatment

 ______________________________________________
 ______________________________________________
  ______________________________________________
 ______________________________________________
 ______________________________________________

Task 5

Fill in the table.

Medication used in the treatment of disorders of the hypothalamic-pituitary system

Medication Prescription objective

Task 6

Fill in the table of the differential treatment of patients with diseases of the hypothalamic-pituitary
system

Preparation Method of injection, dose Prescription

Growth hormone
Dopamine agonists
Synthetic analogues of
vasopressin

Tests

1. Patient S., 30 y.o., complains about obesity, which has developed gradually, increased appetite, thirst,
polyuria, constant drowsiness, amenorrhea. Often there is an increase in body temperature to 38-39 ° C
with chills, sweating, tachycardia, increased blood pressure. Which parts of the nervous system are
damaged?

A Hypothalamus

B Cortex

C Thalamus

D Medulla oblongata

E Cerebellum
2. Patient complaints about thirst, polyuria. This condition patient connects with a brain injury. Urine
specific gravity 1,002.O What disease one should thinks?

A Neurogenic polydipsia

B Diabetes

C Chronic nephritis

D Diabetes insipidus

E Enuresis

3. A woman, 34 y.o., has obesity, mainly on the shoulders and torso,also has purple-cyanotic band
stretching the skin on the chest, abdomen. What diagnosis is most likely?

A Hypothyroid obesity

B Cushing's disease

C Hypooval obesity

D Alimentary obesity

E Pubertal obesity

4. In the endocrinology department surveyed female, 42 y.o., is examined over a sharp increase (in the
past 6 months to 20 kg) of body weight, menstrual irregularities, headaches. The symptoms appeared
after a viral infection. Ambulatory was determined the level of TSH, T3, T4, adrenal hormones. ECG was
conducted, no significant abnormalities were noted. What further examination is necessary to conduct
for determine the cause of the patient weight gain?

A US adrenal

B Chest X-ray

C X-ray of the skull

D Determine the level of creatinine in the blood

E Determine the level of potassium in the blood sodium

5. Patient K., 43 y.o., complains about moderate weight gain, dyspnea on exertion. No complaints about
any disease in the past,. Body weight - 124 kg, height - 176 cm. Patient has normal body build and
regular fat distribution. What disease can the patient have?

A Alimentary obesity

B Hypothalamic obesity

C Dysgonadal obesity

D Cushing's disease

E Adiposogenital dystrophy
6. Patient, 15 y/o, complains of excessive body weight, headache, irritability, fatigue. Significant weight
gain occurred at the age of 14 years. Body weight - 90 kg, height 160 cm, right physique. The distribution
of fat evenly. On the thighs, abdomen and the breasts - pink thin stretch marks. AS - 145/90 mm Hg.Your
preliminary diagnosis?

A Vascular dystonia

B Alimentary-constitutional obesity

C Pubertal-youth dispituitarism

D Cushing's disease

E Cushing's syndrome

7. The patient 37 years old complains the doctor about overweight and has wish to lose weight.
OBJECTIVE: height 160 cm, weight 125 kg. Distribution of adipose tissue is evenly. What method of
treatment would be most appropriate?

A Medication

B Subcalorific diet

C Subcalorific diet and physical task

D Bariatric Surgery

E Psychotherapeutic correction of eating behavior

8. Patient S., 28 y.o., complained of lack of sexual development, reduced potency and sterility.
OBJECTIVE: eunuchoid body proportions, height 185 cm, weight 75 kg, gynecomastia. External genitalia
are formed correctly, the size in accordance with age. The testicles are reduced in size, are sealed. Sex
chromatin 32%. Karyotype 47HHU / 46HU .Your diagnosis?

A Pure gonadal dysgenesis

B Klinefelter Syndrome

C Turner Syndrome

D Primary hypogonadism

E Mayer-Rokitansky-Küster-Hauser syndrome

9. Patient B., 20 y.o., was sent by military enlistment office to determine gender. At birth gender was
identified as male. OBJECTIVE: height 174 cm, weight 75 kg, body proportions intersex, mammary gland
sare developed, body hair on the female type, voice high, regular spotting 15 years, the external
genitalia are presented penis 5 cm, the urethra opens at the scrotum, which is satisfactory developed in
the left part of the testicle is palpated to 2.5 cm. Ultrasound examination of the pelvic organs is found
unicorn uterus to the ovary on the right. Written 46, XY karyotype / 46HH. Possible diagnosis?

A Primary hypogonadism

B Pure gonadal dysgenesis

C Turner Syndrome

D True hermaphroditism

E Mayer-Rokitansky-Küster-Hauser syndrome

10. Patient V., 18 y.o., was sent by military enlistment office to determine the suitability for military
service. Objectively: the proportions of the body of men, height 175 cm, weight 105 kg, obesity, fat
distribution relatively uniform, with a predominant deposition of fat on the face, abdomen, and
extremities, determined bilateral gynecomastia, skin thighs shoulders, abdomen, a significant number of
pale pink stripes stretching . HR - 78 min., Blood pressure - 155/90 mm Hg internal organs intact.
External genitalia are formed correctly, age-appropriate, on the radiograph sella - without destructive
changes. Prolactin, cortisol, LH, FSH, testosterone within norm. What is the cause of obesity in patient?

A Adipozo-genital dystrophy

B Prolaktinoma

C Cushing's disease

D Alimentary-constitutional type

E Hypothalamic syndrome

References

1. Endocrinology: Textbook (P. Bodnar, G.P. Mykhalchyshyn, Y.I.Komisarenko et al.), Ed. Professor
P.M.Bodnar - Ed. 3, Revised. and add. - Vinnytsia. Nova Knyha, 2016 – 328p.

2. Endocrinology. (electronic edition): A textbook for students in russian language. (P.N. Bodnar, G.P.
Mykhalchyshyn, Y.I. Komisarenko, A.M.Pristupyuk et al.), Ed. Prof. PN Bodnar. Ed second Revised. and
Vinnytsia. Nova Knyha , 2015. – 496p.

3. Endocrinology: Textbook (Ed. By prof. Petro M. Bodnar. - 3th ed.,updated. - Vinnytsia. Nova Knyha,
2016. – 328p.

4. Clinical Endocrinology: the textbook / under. Ed. VN Hvorostynka. - M.: Fact, 2008. – 541p.

5. Basic & Clinical Endocrinology. Seventh edition. Edited by Francis S. Greenspan, David G. Gardner. -
Mc Grew - Hill Companies, USA, 2004. - 976p.

6. The clinical protocols for the treatment of patients with type 1 diabetes and type 2 diabetes.

7. Williams Textbook of Endocrinology / Ed. by Henry M. Kronenberg, Shlomo Melmed, Kenneth S.

Polonsky, P. Reed Larsen. - 12 ed / - Saunders, 2011 - 1920p.

Resume

Peculiarities of teaching endocrinology at undergraduate level .

43 years of teaching experience.

Textbooks and methodical recommendations which developed during the period, provide modern
study of endocrinology.