Goals and Objectives
The material provided in this handout is not meant to limit your study and knowledge in the field of the endocrine system. Throughout your training in medicine you will be exposed to a vast amount of material that will complement these learning objectives. Additional material and clinical skills obtain through courseware, PBL, PSD, clinical and research electives should be integrated in your conceptualization of the endocrine system and doctor-patient interaction. Through this integration we believe that you will be able to have a clear conceptualization of hormones and it's diseases.
Review From Previous Blocks
In your first year you have already learned many things that are directly related to endocrinology and metabolism. We suggest you review the following:
- Development and Hemostasis block
- GI anatomy
- physiological basis of stress
- nutrition and metabolism
- Cardiovascular block
- pathology of atherosclerosis
- electrical consequences of acute MI and ischemia
- hypertension
- exercise physiology
- potassium homeostasis
- Renal block
- metabolic acidosis
- proteinuria, nephrotic syndrome
- renal failure
- mineralocorticoid excess
- hypertension
Specific Learning Objectives for Endocrine Block
These objectives are organized by the week. They include objectives that will be included in PBL, lectures, small groups. They are intentionally very specific so that they will help you focus your learning.
Lipid Metabolism and Disorders
Knowledge - Basic Science
- Define the terms lipoprotein, lipid, cholesterol, triglyceride, phospholipid, fatty acid, apoprotein and lipoprotein receptor.
- Name 5 classes of lipoproteins and 5 apoproteins.
- State the location and one major function of apoproteins A1, B-100,B-48, CII, CIII, E, apo(a).
- State the location and function of 3 enzymes: lipoprotein lipase, hepatic lipase, lecithin cholesterol acyl transferase.
- Draw the three major pathways in lipoprotein metabolism labelling the lipoproteins, receptors, apoproteins and enzymes involved in each step
Lipid Disorders
- Enumerate lifestyle factors affecting serum lipid levels.
- Identify the main mechanisms involved in secondary hyperlipidaemia seen in hypothyroidism, diabetes mellitus, nephrotic syndrome, chronic renal failure, cirrhosis, cholestasis.
- Define the following genetic conditions:
- familial hypercholesterolemia
- familial combined hyperlipidaemia
- familial LPL deficiency
- Apo CII deficiency
- familial dysbetalipoproteinemia
- hypercholesterolemia
- List the genetic and secondary causes of:
- hypercholesterolemia alone
- hypertriglyceridemia alone
- hypercholesterolemia and hypertriglyceridema
- hypoalphalipoproteinemia (low HDL-C)
Management of Lipid Disorders
- Outline how to test someone for lipid disorder ie what lab tests to order
- Outline diet changes that may be helpful to reduce lipid levels
- Name 5 classes of drugs used in the treatment of lipid disorders.
- Identify the main mechanism of action of these drugs.
- Describe the effect of each class of drug on serum lipid/lipoprotein levels.
Epidemiology
- Define primary and secondary prevention
- Describe how risk factors are used to assess treatment targets in people with hyperlipidemia.
Skills
- Obtain a history relevant to lipoprotein metabolism.
- Recognize the following physical signs:
- Xanthomas - tendinous, eruptive, planar, tuberous, palmar and xanthelesmas
- Xanthochromia striata palmaris
- Corneal arcus
- Lipemia retinalis
- Interpret results of plasma cholesterol, Tg and HDL-C and translate the results in terms of lipoproteins. Ie. calculate LDL-chol, VLDL-chol
- Name other factors which influence the need for treatment of the lipid disorder.
Attitude
- Recognize the important role played by allied health care staff in the overall management of patients with lipid disorders.
- Recognize the importance of health promotion and disease prevention.
- Recognize the need to teach patients about the role of lipids in coronary artery disease.
Hypothalamus and Pituitary Gland
Knowledge Anterior Pituitary - Basic Science
- Diagram the anatomy of the normal hypothalamus and pituitary and surrounding structures including their blood supply
- Explain briefly the embryological development (derivation) of the anterior and posterior pituitary.
- Relate the different cell types to hormone production.
- Name the hypothalamic factors which control the release of each of the pituitary hormones
- Describe the other factors which control the release of the six anterior pituitary hormones.
- Describe the principal effects of the six anterior pituitary hormones on their respective target organs, including the direct and indirect effects of growth hormone, i.e. somatomedins.
- List the hormones of the proopiomelanocortin (POMC) family.
- List the hormones which belong to the somatomammotropin family of pituitary hormones.
- Describe the inhibitory feedback loop regulating pituitary hormone release using thyroid hormone or cortisol as an example.
Pituitary Tumours
- Name the different types of pituitary tumours.
- Name syndromes produced by secretory pituitary tumours.
- Define macroadenoma and microadenoma.
- Name local symptoms of a mass lesion in the pituitary or hypothalamus.
- Name three therapeutic approaches to pituitary tumour.
- Describe laboratory tests/stimulation and suppression tests useful in diagnosis of pituitary tumours.
Hyperprolactinemia
- List the causes of hyperprolactinemia, physiologica, pharmacological, and pathological.
- Describe the clinical presentation of hyperprolactinemia in men and women.
- Outline the causes of hypopituitarism.
- Outline an investigative approach to someone with suspected acromegaly.
- Discuss therapeutic options and risks of not treating hyperprolactinemia.
Acromegaly
- List the clinical features (S&S) of acromegaly in children and adults
- Describe therapeutic options and risks of not treating acromegaly.
Hypopituitarism
- Describe the evaluation of anterior pituitary function.
- Describe the clinical manifestations of hypopituitarism.
- Define empty sella syndrome.
- Define pituitary apoplexy
- Define Sheehan's syndrome.
- Describe the hypothalamo-neurohypophyseal system.
- Explain the production of the two hormones released from the posterior pituitary.
- Describe the control and action of vasopressin
Skills
- Define bitemporal hemianopsia.
- List signs of hypothalamic-pituitary-adrenal dysfunction.
- Outline CT and MRI microadenoma, macroadenoma, craniopharyngioma.
Knowledge - The Adrenal Gland
- Describe the location, blood supply, lymphatic drainage and innervation of the adrenal glands.
- Compare the embryological origin of the adrenal cortex and medulla. Name two common locations of aberrant tissue.
- Describe the cytology of the adrenal cortex and medulla.
Steroids
- Describe the basic structure of steroids
- List which organs produce steroids
- Categorize steroids into major classes and their physiological action
- Describe the circulation and metabolism of steroids
Adrenal Cortex
- Name the 3 groups of hormones synthesized in the adrenal cortex and relate the different cell types to hormone production.
- Recognize that there are multiple steps and enzymes required for the production of steroids. Name the major precursers and enzymes involved in steroidogenesis.
- Discuss how steroids interact with their receptor and cause target tissue responses
- Discuss the principal physiological effects of each group of hormones.
- Describe briefly the transport and catabolism of adrenocortical hormones.
- Describe the regulation of each of the three groups of adrenocortical steroid hormones with particular attention to the difference between mineralocorticoid and glucocorticoid regulation
Adrenal Insufficiency
- Define adrenocortical insufficiency and Addison's disease.
- Distinguish between primary and secondary adrenocortical insufficiency.
- Name causes of primary adrenocortical insufficiency.
- Name symptoms and signs of adrenocortical insufficiency.
- Identify the changes in: serum sodium, potassium, urea, creatinine, acid-base balance, glucose and calcium in adrenocortical insufficiency.
- Discuss the use and interpretation of the following tests: serum cortisol, serum ACTH, ACTH stimulation test (short and prolonged), serum aldosterone, plasma renin activity, serum 17-hydroxy progesterone.
- Outline in brief the treatment of acute and chronic adrenocortical insufficiency.
Adrenocortical Hyperfunction
- Define Cushing's syndrome and Cushing's disease.
- Name the 3 categories of causes of Cushing's syndrome and their frequency.
- Name the symptoms and signs of Cushing's syndrome.
- Describe 2 screening tests for Cushing's syndrome.
- Explain the steps needed to make the diagnosis of Cushing's syndrome and to determine its cause.
- Name the treatment modalities available for each form of Cushing's syndrome.
- Define congenital adrenal hyperplasia. Explain how the biochemical features relate to the clinical findings in 21-hydroxylase deficiency.
- Recognize that use of glucocorticoids in the treatment of various disorders may result in iatrogenic Cushing's syndrome and outline ways to minimize this effect.
- State the clinical and biochemical effects of mineralocorticoid excess.
- Define primary aldosteronism, secondary aldosteronism and Conn's syndrome.
- Describe investigations used in the diagnosis of primary aldosteronism.
Adrenal Medulla - Basic Science
- Identify the catecholamines secreted by the adrenal medulla.
- Explain briefly the major steps in the synthesis and metabolism of catecholamines.
- Describe the physiological effects of these hormones on target tissue including which receptors they stimulate.
Phaeochromocytoma
- Define pheochromocytoma
- Specify the relative frequency of adrenal or extra-adrenal phaeochromocytomas and the frequency of multiple phaeochromocytomas.
- Name the 2 conditions associated with phaeochromocytoma in the Multiple Endocrine Neoplasia syndrome Type 2A and 2B.
- Name the symptoms and signs present during a phaeochromocytoma crisis.
Skills
- Recognize clinical manifestations due to increased or decreased adrenal hormone production.
- Choose appropriate laboratory tests for the diagnosis of adrenal disorders.
- Combine clinical and laboratory data to suggest diagnosis.
Attitudes
- Appreciate that chronic organic disease may cause psychological problems (patient and family).
Diabetes Mellitus and Hypoglycemia
Knowledge - Basic Science
- Describe the location, gross anatomy of the pancreas, its blood supply, and its relationship to the liver and small intestines.
- Describe the Islets of Langerhans and its hormone producing cells.
- Discuss the main effects of insulin and glucagon.
- Discuss the normal regulation of insulin and glucagon secretion.
- Define glycolysis, gluconeogenesis, glycogenolysis, and glycogenesis.
- Describe the main factors determining the blood glucose level during fasting and post-prandial state (post-meal)
- Describe the mechanism of insulin action at the cellular level
- Outline the structure of the insulin receptor
- Explain insulin resistance
- Explain the main effects of insulin deficiency on glucose, lipid and protein metabolism.
- Describe the effect of exercise on glucose control
Diabetes Mellitus - Diagnosis and Classification:
- Define diabetes mellitus.
- Describe the diagnostic criteria for diabetes mellitus.
- Describethe different types of diabetes mellitus and their distinguishing characteristics (classification).
- Compare and contrast type 1 and type 2 diabetes with respect to epidemiology, etiology, risk factors, clinical presentation, acute and chronic complications and treatment
Diabetes Type 1
- In the development of type I discuss the role of:
- genetic factors
- the immune system
- precipitating events and factors
- Describe the pathological changes in the pancreas for type I.
- Describe the incidence of type I with respect to age, gender, race and geographical occurrence.
- Discuss the main principles of therapy for type I including diet, exercise, blood glucose monitoring and insulin administration
Diabetes Type 2 (NIDDM):
- In the development of type 2 discuss the role of:
- the beta cell
- obesity
- the liver and the peripheral cell
- genetic factors
- Describe the pathological changes in pancreas for type 2.
- Describe syndrome X (syndrome of insulin resistance) and the conditions associated with type 2 diabetes.
- Describe the incidence of type 2 with respect to age, gender, race, and geographical occurrence.
- Discuss the management principles of type 2 including diet, exercise, home blood glucose monitoring, oral hypoglycemic agents and insulin
- Compare the mechanism of action of the available types of oral hypoglycemic agents.
Diabetic Ketoacidosis (DKA):
- Explain the pathophysiology of diabetic ketoacidosis.
- Describe the major symptoms and signs and laboratory findings in diabetic ketoacidosis.
- Discuss the principles of management for DKA.
Hypoglycemia In Diabetes:
- Define hypoglycemia.
- Identify the main causes of hypoglycemia in diabetic individuals.
- Discuss the role of counterregulatory hormones during hypoglycemia.
- Describe the major symptoms and signs of acute hypoglycemia.
Microvacuslar Disease In Diabetes Mellitus:
- Describe the pathogenesis of microvascular disease in diabetes
- Discuss the importance of glycemic control in preventing microvascular complications
- Outline other risks besides hyperglycemia for the development of microvascular complications.
Diabetic Nephropathy:
- Describe the incidence and prevalence of nephropathy in type 1 and type 2 diabetes
- Describe (pathology, signs, symptoms) the sequential phases in the progression of diabetic nephropathy
- Define microalbumenuria, incipient nephropathy, proteinuria, overt proteinuria, end stage renal disease.
- Outline ways of preventing worsening of diabetic nephropathy.
Diabetic Retinopathy:
- Describe the incidence of diabetic retinopathy in type I and type 2 diabetes
- Describe the different stages of diabetic retinopathy
- Describe the fundoscopy findings in diabetic retinopathy
- Outline ways of preventing worsening diabetic retinopathy.
Diabetic Neuropathy :
- Describe the prevalence of diabetic neuropathy.
- Describe the main clinical subgroups ("classification") of diabetic neuropathy and the symptoms associated with them
Diabetic Vasculopathy (Macrovascular Disease):
- Describe the prevalence of coronary artery disease and large vessel disease in type 1 and type 2 diabetes
- Discuss pathogenetic factors associated for macrovascular disease in diabetes mellitus.
- Outline ways of preventing macrovascular disease in someone with diabetes
Hypoglycemia Without Diabetes:
- Discuss fasting and postprandial hypoglycemia.
- List causes of hypoglycemia in the non-diabetic population
Skills
- Outline an appropriate history in a patient with diabetes mellitus.
- Outline an appropriate physical examination of a patient with diabetes mellitus including assessment for long-term complications
- Describe capillary blood glucose measurements including barriers to patients be able to do them.
- Outline steps of administration of insulin.
- Interpret results of an oral glucose tolerance test.
Attitudes
- Recognize that diabetes mellitus is a self-management disease for which the affected individual and family have to take the major responsibility.
- Recognize the importance of education about diabetes as an essential component of the management of the disease
- Recognize the importance of a healthy lifestyle and attitude for the continuing management of diabetes and prevention of long-term complications.
- List and recognize the important role of other health professionals and the multidisciplinary team approach to the overall management of diabetes mellitus.
- Recognize that the attitude of health professionals, including physicians, to diabetes mellitus and its many problems, is critical to a successful management of the disease.
- Recognize the impact of diabetes mellitus on personal relationships, social life, family and society in both social and economic terms.
Mineral and Bone Metabolism
Knowledge - Basic Science
- Describe the location, the gross anatomy, the arterial supply and surrounding structures of the parathyroid gland.
- Describe the different cell types of the parathyroid gland.
- Describe the function of the parathyroid hormone (PTH).
- Describe the physiological actions of PTH on bone, kidneys and intestines.
- Describe vitamin D metabolism and action on target tissue.
- Describe the regulation of 1,25(OH) 2D3 .
- Describe the regulation of serum calcium using a diagram.
- Describe the physiological action of Calcitonin.
- Describe the normal bone (re)modelling system.
Hypercalcemia
- List the main causes of hypercalcemia and the mechanism for hypercalcemia.
- Describe presentation of primary hyperparathyroidism.
- Differentiate hypercalcemia of malignancy from primary hyperparathyroidism.
- Define secondary and tertiary hyperparathyroidism.
Hypocalcemia
- List the main causes of hypocalcemia.
- Describe the main clinical manifestations of hypocalcemia.
Osteoporosis
- Define osteoporosis
- Briefly describe the different types of osteoporosis.
- Name common forms of fractures resulting from osteoporosis.
- Outline risks for development of osteoporosis in men and women
- Describe tests that can be done to assess presence of osteoporosis
- Describe investigations that can be done to look for secondary causes of osteoporosis
Metabolic Bone Diseases and Paget's Disease
- Define Osteodystrophy.
- Explain the pathophysiology of Osteodystrophy.
- Define Rickets and Osteomalacia.
- Explain the pathophysiology of Rickets and Osteomalacia.
- Define Paget's disease.
- Explain the pathophysiology of Paget's disease.
Skills
- Correct serum calcium for disturbances in serum proteins.
- Describe ECG changes associated with hypercalcemia and hypocalcemia.
- Outline what questions to ask when assessing someone for osteoporosis.
Attitudes
- Demonstrate understanding and respect for a patient attempting a major lifestyle change such as diet and exercise in prevention of osteoporosis.
Thyroid
Knowledge - Basic Science
- Describe the location, the gross anatomy, the arterial supply and surrounding structures of the thyroid gland.
- Explain the embryological development of the thyroid gland.
- Describe the different cell types of the thyroid gland.
- Describe, with the aid of a diagram, the hypothalamic-pituitary-thyroid feedback axis and regulation.
- Describe, with the aid of a diagram, the steps in the synthesis and release of the thyroid hormones.
- Describe the regulation of thyroid function.
- Describe the state of thyroid hormone in the blood and the metabolism of thyroid hormone.
- Describe the thyroid hormone action at the cellular level.
Hypothyroidism
- Describe important signs and symptoms of hypothyroidism.
- Discuss the use of thyroid function tests in the diagnosis of hypothyroidism.
- Discuss common causes of primary and secondary hypothyroidism.
- Describe the pathophysiology of Hashimoto's thyroiditis.
Hyperthyroidism
- Describe the important signs and symptoms of hyperthyroidism.
- Discuss the use of thyroid function tests in the diagnosis of hyperthyroidism.
- Discuss the common causes of hyperthyroidism and how to differentiate between them.
- Describe the pathophysiology of hyperthyroid Graves' disease.
Thyroiditis
- Define and describe acute, subacute and chronic thyroiditis.
- Describe the three phases of subacute thyroiditis.
- Describe the clinical course of postpartum thyroiditis.
Goiters and Thyroid Nodules
- Define the terms goiter and thyroid nodule.
- Discuss the different causes of goiter and thyroid nodules.
- Describe four types of thyroid cancer and their clinical behavior.
Skills
- Obtain an appropriate history from a patient with suspected thyroid disease.
- Describe how to examine the thyroid gland for size, consistency, mobility, tenderness, nodules and bruit.
- Describe the use of the following thyroid function tests in clinical practice:
- Total and free T4, T3 and TSH
- TRH stimulation test
- Thyroid scan
- Thyroid uptake of radioactive iodine
- Thyroid ultrasound
- Fine needle aspiration
Attitudes
- Appreciate the effects of thyroid dysfunction on mood.
- Appreciate the variability in impact of thyroid dysfunction on different individuals.
Week V - Paediatric Endocrinology
Growth - Basic Science
- Describe the hormones and other determinates of (i) prenatal growth and (ii) postnatal growth.
- Describe the control of growth hormone and IGF-1 secretion and their action.
- Describe the normal patterns of growth hormones secretion during childhood and adolescence.
Clinical
- Describe the normal growth patterns during infancy, childhood and adolescence.
- Describe the endocrine and nonendocrine causes of short stature, distinguishing between normal variant and pathologic causes.
- Explain how bone age is determined.
- Describe the relationship between chronological age, height age and bone age for various growth disorders.
- Describe the investigation and management of children with short stature.
- Describe the methods and limitations of testing for growth hormone deficiency.
- List the criteria for growth hormone therapy.
Skills
- Outline an appropriate history and physical examination in a child with short stature.
- Know how to obtain accurate height measurements and plot them correctly on a growth curve.
- Calculate midparental height and expected final adult height based on genetic potential.
- Recognize normal and abnormal growth patterns on a growth chart.
- Choose appropriate investigations for the assessment of a child with short stature.
- Interpret the results of a bone age assessment.
Attitudes
- Understand the psychological effects of short stature on the child and adolescent's emotional development.
- Recognize the financial costs of growth hormone therapy.
Puberty - Basic Science
- Describe the normal secretory patterns of GnRH. LH, FSH and sex steroid secretion in males and females in utero, infancy, childhood and puberty.
- Describe the hypothalamic-pituitary-gonadal axis and the hypothalamic-pituitary-adrenal axis and their involvement in normal pubertal development.
- Describe the postulated mechanism(s) of normal pubertal maturation.
Clinical
- Describe the normal sequence of events during the development of secondary sexual characteristics in boys and girls and the hormones responsible for these changes.
- Describe the variations of normal pubertal development in males and females.
- Define delayed puberty and precocious puberty in boys and girls.
- Describe the causes and clinical manifestations of delayed and precocious puberty in boys and girls; distinguish between normal variants and pathological causes.
- Describe the investigation and management of children with i) delayed puberty, ii) precocious puberty.
- Describe the indications for and interpretations of LHRH stimulation tests.
- Outline the management of a child with delayed or precocious puberty.
Skills
- Outline an appropriate history and physical examination in an adolescent with delayed puberty.
- Outline an appropriate history and physical examination of a child with precocious puberty.
- Determine the stage of puberty (Tanner Stage) in children and adolescents at differing stages of pubertal development.
- Choose appropriate investigations when assessing a child with delayed or precocious puberty.
Attitudes
- Be aware of the psychological changes in normal puberty as well as the effects of delayed or precocious puberty on the child's emotional development.
Congenital Hypothyroidism - Knowledge
- State the epidemiology of congenital hypothyroidism.
- List the causes of congenital hypothyroidism.
- Describe the clinical manifestations of congenital hypothyroidism with and without screening.
- Describe the laboratory findings in congenital hypothyroidism.
- List the causes of a false positive screen for congenital hypothyroidism.
Skills
- Interpret the results of a positive newborn screen for congenital hypothyroidism.
- Recognize the cost effectiveness of screening for congenital hypothyroidism.