1. History taking Part 1 Asst professor ,Internal Medicine
Khalil M Alsoutary ,MD
Asst professor ,Internal Medicine
American Board in Medicine and Endocrinology
Balqa Applied University, June 2019

2. 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

3. 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

4. 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

5. 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

6. 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

8. 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?

9. 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.

10. Engaging your patient
Make sure your patient is involved in each decision, make suggestions,and encourage them to contribute their thoughts

11. 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

13. 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

14. 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 languageلغة الاشارة
Involve someone who is used to communicate with the patient

15. 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

16. Terms used by patients that should be clarified
Allergy Eczyma
Angina Fits
Arthritis Heart attack
Diarrhea migraine
Dizziness Vertigo
Pleurisy

17. Pain threshold Decreased Increased Sleep deprivation Exercise
Depression
Analgesia
Financial and personal worries
Positive mental attitude
Anxiety and fear
Personality
Past experience

18. The effects of chronic pain questions
Money
Have you had lost money
because of illness
Leisure Relationships
Have 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

31. Thyroid Function Tests interpretation
Khalil Alsoutary,MD,FACE
Endocrinologist
May 2019

32. Thyroid Function chemistry & pathophysiology
causes of hyper-& hypothyroidism
thyroiditis
tests of thyroid function
test strategies
case studies

38. Chemistry & Pathophysiology
T ug/d produced by the thyroid gland
T ug/d; 80% by peripheral action of 5’ deiodinase
T % bound & T3 99.0% bound to TBG, albumin & pre-albumin
FT4 & FT3 exert negative feedback on TSH
Hypothalamic TRH modulates feedback setpoint

39. Thyroid Binding Proteins
INCREASES
estrogen/pregnancy
methadone & heroin
acute & chronic active hepatitis
hereditary
DECREASES
glucocorticoids
androgens
L-asparaginase
nephrosis
hereditary

40. Causes of Hyperthyroidism
Graves Disease
Functioning Thyroid Nodule (Plummer’s)
Toxic Multinodular Goiter
Thyroiditis
Factitious Hyperthyroidism
Drug Induced: iodine, amiodarone, lithium
Pituitary-Hypothalamic origin

41. Causes of Hypothyroidism
Chronic Thyroiditis (Hashimoto’s)
After radioiodine,surgery or antithyroid drug therapy
Drugs: amiodarone, lithium,
Congenital - 1in 4000 births:

42. Thyroid hormone tests in various disorders
Free T3
Free T4
TSH
condition
high
V.high
undetectable
Primary hyperthyroid
v.high
normal
T3 toxicosis
increased
Secondary hyperthyroidism N
low
Subclinical hyperthyroidism

43. Free T3
Free T4
TSH
condition
Increased
Increases
Increased or N
Thyroid H Resistance
Decreased or N
decreased
Prim hypothyroidism
Decrease
Secondary hypothyroidism

44. Risk of Overt Hypothyroidism in a 60-Year-Old Woman
Ab neg
Ab pos
Hypothyroidism (%) 2 5
10
TSH
Vanderpump Met al: 2003

45. Thyroiditis Acute suppurative Subacute: granulomatous
Subacute: lymphocytic % postpartum (silent) hamburger toxicosis
Chronic Thyroiditis (Hashimoto’s)

46. Subacute Thyroiditis Granulomatous post viral painful thyroid
systemic symptoms
high sed rates
Lymphocytic
painless
simulates Graves
normal or slightly elevated sed rates

47. 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

48. TSH
Immunometric Assays - Analytical Sensitivity (CV </= 20%) st generation: 1.0 uU/mL sd generation: 0.1 uU/mL rd generation: 0.01uU/mL

49. TSH DECREASES INCREASES hyperthyroidism hypothyroidism
L-dopa, dopamine, steroids
excessive T4 Rx
2sdry hypothyroidism
nonthyroidal illness
INCREASES
hypothyroidism
inadequate T4 Rx
lithium, iodine, antithyroid drugs
nonthyroidal illness

50. Causes of Hypothyroidism
Primary:
Principal Cause and Largely Autoimmune
Central
Secondary + Tertiary
More recently recognized etiologies
Chemotherapeutic Agents
Ipilimumab, Bexarotene, Sunitinib (tyrosine kinase inhibitors)
Consumptive hypothyroidism

51. 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

52. 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

53. Severity of Primary Hypothyroidism by Thyroid Levels
TSH rises first and abruptly
TSH FIRST and abrupt (compare rate of ascent of TSH to onset and rate of decline of T4 and T3, with T3 being slow and late
Decline of T4 and T3 slower and later

55. Approach to SC Hypothyroidism
Serum TSH
5-10 mIU/L
>10 mIU/L
Repeat TSH, FT4, TPOAb
Begin T4 Rx
Normal tests
TSH & TPOAb+
T4 Rx if...
Goiter
Hyperlipidemia
Infertility
Young pt
Follow
Follow

56. Rising TSH By Age in Cross-
sectional Studies

57. • The MEAN rises with age • The upper limit of normal
NHANES III
Normal Range ( Centile) by Decade
lower TSH limit stay
relatively constant with age
MEAN
rises with age
with age? (survival
Benefit?)
Is there a progression to
atrophic hypothyroidism
with age that is included in
normal
the normal range in 8 7 6 5 4 3 2 1
• The MEAN rises with age
• The upper limit of normal
• A “natural” rise of TSH •
• Should Be USED a BMD for
20-29
30-39
AGE
60-69
70-79
80+

59. Thyroid Function: References
Klee, G & Hay, I: Biochemical Thyroid Function Testing. Mayo Clin Proc 1994;69:469-70
Lazarus, JH: Hyperthyroidism. Lancet 1997;349:
Lindsay, RS, Toft, AD: Hypothyroidism. Lancet 1997; 349:413-17
Smith, SA: Commonly asked questions about Thyroid Function Mayo Clin Proc 1995; 70:
Dayan, C: Interpretation of Thyroid Function Tests Lancet 2001; 357:
Fatourechi, V: Subclinical Thyroid Disease Mayo Clin Proc 2001;76: