TTUHSC School of Medicine at Amarillo
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Rotation: Endocrinology elective

Site:

Instructors:

Makeup of team (responsibility of each team member):

Days per week (night call):

Usual time of attending rounds (meeting place):

Types of patients encountered:

Educational goals/competencies:

Patient care:

Emphasis is on the history and physical exam for diagnosing endocrine diseases and their complications, and on modern therapy, both curative and preventive. Important physical exam skills are:

  1. Diabetes mellitus--ophthalmoscopy to identify retinopathy and open-angle glaucoma; Biothesiometer to evaluate peripheral neuropathy; recognition of acanthosis nigricans; bedside tests for autonomic neuropathy
  2. Thyroid disease--palpation of the thyroid gland for size of the gland; Werner maneuver to identify and evaluate thyroid nodules; evaluation of eye changes of Graves disease, DTR testing for hypothyroidism; tremor evaluation; thyroid nodule biopsy
  3. Use of growth chart for children's and adolescent diseases esp. Cushing's syndrome, thyroid disease, chronic inflammatory diseases
  4. Differentiation of hirsutism and masculinization
  5. Use of tests for hypocalcemia--Chvostek and Trousseau

Medical Knowledge:

  1. Diabetes mellitus
    1. Identify the causes of T2DM ie pathogenesis
    2. What are the treatable causes of T2DM
    3. What is the natural history of T2DM
    4. What are the secondary causes of T2DM
    5. How do you diagnose T2DM
    6. How do you treat T2DM
    7. When do you start oral agents in T2DM
    8. When do you start insulin in T2DM
    9. How do you evaluate control of T1DM or T2DM
    10. What are the oral agents for T2DM, when are they used, and what are adverse drug reactions
    11. What is state of the art insulin therapy today
    12. What is the role of diabetes mellitus in CAD
    13. How do you prevent CAD in diabetics
    14. How do you prevent diabetic neuropathy
    15. How do you prevent diabetic nephropathy
    16. How do you prevent diabetic retinopathy
    17. How do you diagnose and prevent diabetic foot problems
    18. How do you diagnose and treat gestational diabetes mellitus
    19. How do you prevent DKA
    20. What are pitfalls in diagnosis and treatment of DKA
    21. How do you diagnose and treat diabetic hyperosmolar coma
    22. How do you recognize gastrointestinal complications of diabetes
    23. How do you diagnose diabetic nephropathy
  2. Thyroid diseases
    1. Understand the concept underlying thyroid function tests
    2. Know the place of thyroid scan and thyroid uptake tests in diagnosing thyroid disease etiologies
    3. Know the limitations of thyroid scan and uptake tests
    4. Know the approach to a thyroid nodule >1 cm found on palpation vs <1 cm found incidentally on imaging
    5. Know the limitations of thyroid function tests eg abnormal tests in euthyroid patients
    6. Be able to discriminate the etiologies of hyperthyroidism
    7. What are the preferred therapies for each etiology of hyperthyroidism
    8. Know the types of thyroiditis and their individual therapies
    9. Know the concepts of subclinical hyperthyroidism and subclinical hypothyroidism, their natural histories, and therapy of each
    10. How to diagnose and treat hypothyroidism
    11. What concept underlies L-thyroxine therapy of thyroid nodules and recurrence of thyroid cancer? What end-point do you aim for?
    12. How do you diagnose secondary hypothyroidism
    13. How do you diagnose the commonest cause of primary hypothyroidism
    14. What might suggest your patient has thyroid storm? How would you treat it?
    15. If weight loss occurs without decreased food intake, what conditions might be responsible?
    16. What are 5 causes of relative tachycardia?
  3. Adrenal diseases
    1. What makes you think of pheochromocytoma and what is the best test to diagnose it
    2. What makes you think of Cushing's syndrome in an adult and what is the first best test to diagnose it
    3. What is the first best test to diagnose Addison's disease
    4. What makes you think of Cushings syndrome in the adolescent and how do you diagnose it
    5. What is your approach to a 2 cm adrenal incidentaloma vs a 7 cm mass?
    6. What in the history makes you think of secondary causes of hypertension and how would you screen for Conn's syndrome
    7. If you think your patient might have late onset congenital adrenal hyperplasia, what tests would you do
    8. When doing any 24 hr urine testing for hormones, you must order what test on the urine to insure a valid collection?
    9. What is the commonest cause of "spells"--tachycardia, perspiration, palpations
    10. Your patient has a history of spells with facial flushing What is almost certainly not the etiology? What might it be?
    11. What is the commonest cause of adrenal crisis? How do you diagnose and treat it?
    12. You think your patient has subarachnoid hemorrhage (or bacterial meningitis) but CSF is negative and CT scan of the brain is negative and there is progressive worsening neurologically What test and what diagnosis?
    13. The Cortrosyn stimulation test evaluates what function of the hypothalamic-pituitary-adrenal axis?
    14. The best test for Addison's disease? The best hormone test for chronic secondary hypoadrenalism (measure what)? The best test for acute secondary hypoadrenalism?
    15. What clinically might make you think your patient has Cushings syndrome? What is the best screening test? Suppose it is positive, what is the next test and why? Suppose it is negative, then what test?
    16. You are confident your patient has Cushing disease but the MRI of the pituitary gland is negative for the tumor Now what's the diagnosis and how to test it?
  4. Calcium and bone
    1. Your patient has hypocalcemia, how do you test for primary hyperparathyroidism
    2. Before sending your patient with "primary hyperparathyroidism" to the surgeon, what conditions must you be certain he does not have and how do you test for them?
    3. If your patient truly has primary hyperparathyroidism, what are the other conditions that may be found in your patient
    4. In a patient with hypercalcemia, what makes you think the etiology is not due to parathyroid disease
    5. What is the one best test for Vitamin D deficiency
    6. How might you differentiate primary hyperparathyroidism vs secondary hyperparathyroidism due to chronic renal disease?
    7. What laboratory finding might suggest Pagets disease of bone
    8. What might make you think your patient has osteomalacia and which one test would you order?
    9. Under what circumstances might you order a serum calcitonin level
    10. Your patient has a second episode of nephrolithiasis, what screening tests might you order
    11. What blood levels of metabolites are abnormal in osteoporosis
    12. All osteoporosis is osteopenia, but not all osteopenia is osteoporosis What might suggest the osteopenia is not due to osteoporosis? Name some causes (other than osteoporosis) of osteopenia
    13. Your patient has low serum calcium, positive Chvostek's sign and inappropriately low PTH What is the diagnosis? What associated diseases might be present or occur in the future?
    14. Suppose there is low calcium but high PTH, what are 3 possible diagnoses?
    15. The commonest cause of hypercalcemia (with low or normal serum albumen) is sporadic primary hyperparathyroidism What are alternative etiologies?
    16. Suppose your patient has serum calcium of 18 without symptoms (and normal QT interval), why might iv pamidronate cause tetany and what condition might your patient have?
    17. Commonest cause of recurrent nephrolithiasis is primary hyperparathyroidism What blood and urine findings are consistent with this diagnosis? Diagnosis and treatment if only hypercalciuria is found?
  5. Pituitary
    1. What clinically might make you think of acromegaly and what screening test would you order? What confirmatory test?
    2. What is the clinical picture and TFT results of a TSH-oma? How might these results differ from thyroid hormone resistance (generalized)?
    3. What might make you think a patient has hypopituitarism?
    4. You are confident your patient has Cushing's syndrome You get a pituitary MRI and there is a 2 mm tumor, what do you do next? If instead the MRI is negative, what do you do?
    5. What is the commonest cause of incidentaloma of the pituitary and how to diagnose it?
    6. Your patient is acutely ill and hypernatremic Differentiate a central diabetes insipidus from dehydration
    7. What are the 2 commonest causes of secondary amenorrhea and what tests must you do to diagnose them?
    8. A 28 y/o woman has secondary amenorrhea with very high FSH What is the diagnosis and what other diseases might she get in the future?
    9. Unless a prolactin level (mildly elevated, say 90) is due to medications or hypothyroidism, and normalizes on therapy (stop medication, start L-T4 etc), why must you get an MRI on all other patients before starting bromocriptine?
  6. Sex hormones
    1. What is the best test for perimenopause?
    2. What is the initial workup for hirsutism?
    3. What is the first test for dysfunctional uterine bleeding?
    4. What is the initial workup for secondary amenorrhea?
    5. What endocrine diseases occur in the "fourth trimester of pregnancy"?
    6. In pregnancy, how would you differentiate Graves disease from hyperemesis gravidarum?
    7. What clinical picture suggests polycystic ovary (PCOS) syndrome? Suppose you get a negative ultrasound of the ovaries?
    8. What 2 diseases must you always exclude from PCOS and how?
    9. Your patient has secondary amenorrhea (or if male, impotence) and you get a serum prolactin of Can you just treat with bromocriptine or is another test needed?
    10. Your patient has erectile dysfunction and decreased libido What might you expect to find on physical exam and lab tests?
    11. The commonest cause of increased hair growth in a young woman is idiopathic hirsutism What historical finding is necessary to this diagnosis?
    12. Your patient is 18 y/o with small testes? How do you differentiate Klinefelter's, syndrome, Kallmann's syndrome, and hypopituitarism?
    13. What are typical lab findings in an obese, infertile woman that are consistent with PCOS?
  7. Hypoglycemia
    1. Your patient is not diabetic, what symptoms might suggest to you hypoglycemia is responsible? What approach (tests) would you do to prove hypoglycemia is present and to determine its etiology?
    2. What test results might suggest surreptitious sulfonylureas?
    3. How do you diagnose postprandial (reactive) hypoglycemia and what is the treatment?
    4. True hypoglycemia is defined by 2 criteria If hypoglycemia is present you must admit the patient to the hospital to evaluate for insulinoma What is the procedure and what is a positive test?
    5. What blood findings would suggest factitious insulin injections causing hypoglycemia?
    6. In the patient with insulinoma, what other conditions is he prone to get?
  8. Lipid disorders
    1. Your diabetic patient has an HbA1c of 10 (upper normal 1) and fasted triglyceride of 500 mg/dL, what is the treatment for the hypertriglyceridemia?
    2. Which hyperlipidemic condition is responsible for the greatest incidence of premature CAD? What are typical values of each lipid entity in this condition?
    3. What are some advantages to using non-HDL-cholesterol in diagnosis and therapy of hyperlipidemias rather than the usual panel?

Interpersonal/communication skills:

Residents are observed for interpersonal and communication skills, and appropriately guided to better techniques as appropriate.

Professionalism:

The components of a profession are learning, organization, and altruism. These qualities are fostered in each resident's journey toward becoming a professional. Namely, membership in the professional associations (The Endocrine Society, American Association of Clinical Endocrinology, The American Medical Association, others as appropriate); life-long learning as a component of practice, through organized CME and continual self-study; and a spirit of altruism is fostered in the example of faculty and verbal reinforcement at every step, that all practice is done in the interest of the patient first.

Practice-based learning and improvement:

Deficiencies and strengths of the resident's performance e.g. physical exam are identified and discussed with the resident daily as they occur. On the other hand, life-long education can only be a life-long process. This process in each resident is encouraged by identifying the important endocrine literature that a general internist needs to be aware of the rest of his professional career, including at a minimum (at this writing): Diabetes Care; Journal of Clinical Endocrinology and Metabolism; Endocrine Practice; and Endocrine Clinics of North America. These journals have the up-to-date original research publications, reviews, and guidelines for practice.

Systems-based practice:

Text/references to be consulted:

The major references are the periodicals noted above. The best endocrine book for clinicians today probably is Becker's Principles and Practice of Endocrinology and Metabolism and probably the best for diabetes mellitus is Joslin's "Diabetes Mellitus" by Kahn and Weir. These are often consulted, as well as the current literature in journals as identified above.

Methods of evaluation:

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