internal medicine residency program

PRINCE GEORGE’S HOSPITAL CENTER

INTERNAL MEDICINE RESIDENCY PROGRAM

SECTION 9: ENDOCRINOLOGY, DIABETES AND METABOLISM

This section has been reviewed and approved by the Chief, Division of Emergency Medicine as well as the Program Director, Internal Med icine Residency Program at Prince George’s

Hospital Center.

________________________

Chief, Division Of Endocrinology

______________________________

Program Director, Residency Program

I. Overview

Endocrinology is the diagnosis and care of disorders of the endocrine system. The principal endocrine problems handled by the general internist include goiter, thyroid nodules, thyroid dysfunction, diabetes mellitus, hyper- and hypocalcemia, adrenal cortex hyper- and hypofunction, endocrine hypertension, gonadal disorders, hyper- and hyponatremia, certain manifestations of pituitary tumors, disorders of mineral metabolism, and hyperlipidemias. Obesity is not strictly an endocrine disorder but is considered part of the spectrum of endocrinology because it frequently enters into the differential diagnosis of endocrine disease and is a major element in the management of non-insulin-dependent diabetes. Preventive efforts focus on complications of hyper lipidemias, obesity, thyroid dysfunction, osteoporosis and diabetes mellitus, and on endocrinologic side effects of pharmacologic glucocorticoids and other medications.

The general internist must be able to evaluate and manage common endocrine disorders and refer appropriately. He/she must also be able to evaluate and identify the endocrinologic implications of abnormal serum electrolytes, hypertension, fatigue, and other nonspecific presentations. The general internist plays a key role in managing endocrine emergencies, particularly those encountered in the intensive care unit, including diabetic ketoacidosis and hyperosmolar nonketotic stupor, sever hyper- and hypocalcemia, and addisonian crisis.

During the rotation residents will be expected to perform a history and physical examination on their patients. Responsibility for formulating diagnostic evaluations and treatment plans will be emphasized. Patients will include hospitalized service with a variety of endocrine, metabolic, electrolyte and bone and mineral disorders. The rotation will help residents to evaluate and develop a diagnostic and therapeutic approach to patients with diabetes, thyroid, lipid and osteoporotic disorders. The residents also become familiar with screening guidelines for osteoporosis, diabetes, hypercholesterolemia, subclinical hypo and hyper thyroidism, and asymptomatic primary hyperthyroidism. Residents are also encouraged to attend the attending’s outpatient clinic once a week to broaden the outpatient experience in the subspecialty. Resident responsibilities for the subspecialty rotations are detailed under Section I of the Resident

Handbook.

II. Principle Teaching Methods

It consists of frequent encounters with the attending physician regarding patient care.

The resident will discuss all patients with the attending physician and interpret clinical data to formulate a differential. The attending will assign reading topics on a regular basis and review the material with the residents. This will include accepted national guidelines used in the diagnosis and treatment of various endocrine, metabolic and bone and mineral diseases. The faculty will also critique the residents consult notes, examination and management plan. Rounds will include short 15-30 minute discussions on current topics driven by patient encounters and initiated by resident and completed by the attending physician on most days. Latest information dealing with the topic as provided by literature search and pertinent articles should be discussed.

Residents will also receive outpatient experience in endocrinology by shadowing Dr

Sotoudeh one halfday a week (Thursday morning at 7:30 am). Residents must turn in a signed attendance sheet (attached at the end of this section) for the month to the program coordinator at the end of the month.

The residents are also required to manage/ interpret results of common endocrine issues. These requirements are delineated in the form of a logsheet at the end of this section. During their rotation residents must make a double sided copy of the logsheet and complete the stated requirements by the end of the month. To receive a satisfactory for the month the residents must turn in a completed logsheet to the program coordinator.

III. Strengths and Limitations

The residents will be exposed to a broad range of clinical problems typical of a community-based practice with emphasis on inpatient illness and care. The teaching faculty for the rotation is committed to teaching and patient care with strong role model presentation. For patients with exceptionally unusual clinical problems, the care may require transfer to a tertiary referral center. Outpatient experience in the subspecialty is be obtained by shadowing the attending physician in their private office. Patients in the

IV. Goals and Objectives continuity clinic at Glenridge Medical Center also offer learning opportunities.

During the course of the year, residents will receive lectures on the following topics.

Residents are advised to pick up cases during the rotation pertaining to one of the following topics after discussion with the chief resident and endocrinology attending. This is to ensure that all of the following topics get covered. Some topics may require more than one scheduled lecture. The topics are:



Diabetic Ketoacidosis



Management of diabetes and new diabetic medications



Thyroid disorders



Parathyroid disorders and calcium metabolism



Electrolyte abnormalities (related to sodium, potassium)



Metabolic bone disease



Adrenal disorders



Pituitary disorders



Sex hormone disorders

Legend of Learning Activities

Learning Venues:

1. Direct Patient Care/Consultation

2. Attending Rounds

3. Core Lecture Series

4. Self Study

Evaluation Methods:

A. Attending Evaluation

B. Direct Observation

C. Nurses’ Evaluation

D. In-training Examination

Competency: Patient Care

Interview patients skillfully, gathers accurate and essential information with emphasis on endocrine disorders

Examine patients more skillfully with competent and complete observation of normal and abnormal signs with emphasis on endocrine disorders

Defi ne and prioritize patient’s medical problems

Generate and prioritize differential diagnoses with appropriate testing and therapeusis in a broad range of multisystem disorders as illustrated by endocrine illness

Develop rational, evidence-based management strategies

Demonstrate ability to generate differential diagnosis, diagnostic strategy, and to define appropriate therapeutic plan and modifications to ongoing therapy in patient with diabetes, diabetic ketoacidosis, or hyperglycemic, non-ketotic coma, fluid balance, adrenal and pituitary disorders, and thyroid disorders

Competency: Medical Knowledge

Expand clinically applicable knowledge base of the basic and clinical sciences underlying the care of patients.

Access and critically evaluate current medical information and scientific evidence relevant to patient care

Articulate the pathophysiology, evaluation, and management of disorders of the

Learning Venues Evaluation Methods

ALL A, B, D

1, 2

1, 2

ALL

ALL

1,2,3,4,

ALL

1, 2, 4

1,2,,4,

A, B, D

A, B

A, B

A, B, D

A, B, D

A, B, D

A, B, D

A, B, D

endocrine organs

Competency: Interpersonal and

Communication Skills

Interact in an effective way with physicians and nurses participating in the care of patients requiring endocrine consultation or care (including physicians requesting consultation, attendings, medical students, and other personnel)

Show understanding of differing patient preferences in diagnostic evaluation and management of endocrine disorders

Competency: Professionalism

1,2

1,2

A, B, C

A, B, C

Treat team members, primary care-givers, and patients with respect

Actively participate in consultations and rounds

1,2

1,2

Attend and present in scheduled conference 3,

A, B, C

Competency: Practice-Based Learning

Identify limitations of medical knowledge in evaluation and management of patients with endocrine disorders and use medical literature to address these gaps in medical knowledge

Competency: Systems-Based Practice

Understand barriers to optimal care of patients with diabetes, obesity, and chronic endocrine problems

1,2,4,

1,2,3,4 A

Understand how financing of diabetes care and care for chronic medical/endocrine conditions can influence patient care

Understand need for effective communication between multiple caregivers and sites (e.g., endocrinologists, primary care physicians, diabetes nurse educators, nutritionists, surgeons, interventional radiologists, social workers, hospitals, in- and out-patient units) in delivering optimal care to patients with diabetes and other chronic endocrine problems

1,2,3,4

1,2,3,4

V. Educational Content

A. Pituitary gland

1) Understand the causes and presentation of patients with:



Pituitary adenomas

A

A

A, B, C

A, sign in on attendance sheet

A



Prolactinomas



Panhypopituitarism

2) Interpretation of results of:



Pituitatary and target organ hormones



Serum prolactin concentration



Imaging studies of the sella turcica



Relationship between prolactin, gonadotropin, TSH and medications

B. Thyroid disorders

1) Understand the causes, presentation, pathophysiology, and management of:



Enlarged thyroid (goiter, nodule)



Hyperthyroidism, thyrotoxicosis, thyroid storm, thyroiditis



Hypothyroidism, myxedema coma



Sick euthyroid



Thyroid cancers

2) Order appropriate tests and interpret results of:



Serum thyroid function tests



Thyroid scanning and ultrasound

C. Parathyroid disorders




Hypercalcemia



Hypocalcemia



Hyperparathyroidism (primary and secondary)



Vitamin D metabolism




Urinary calcium, phosphate, uric acid excretion



Serum phosphate concentration

D. Adrenal disorders

1) Recognition and management of:



Primary and secondary adrenal insufficiency, steroid dependency



Hypercortisolism



Hypoadrenocortisolism, acute



Hypoadrenocortisolism, chronic



Incidentalomas, Adenomas

2) Understand the pathophysiogy and interpretation of:



Dexamethasone suppression test (overnight)



Home blood glucose monitoring



ACTH stimulation test



Urinary sodium, potassium excretion



Urine metanephrine, VMA (vanillylmandelic acid), and total catecholamine levels

E. Pancreas

1) Know the pathophysiology, complications and updated management guidelines for diabetes as well as treat patients with:



Diabetic ketoacidosis



Type 1



Type 2



Gestational diabetes



Exocrine and endocrine functions of pancreas: including the standards of care for DM- cardiovascular risk reduction, BP and lipid control, lifestyle changes



Islet cell tumors (insulinomas glucagonomas, vipomas)

2) Understand and interpret results of:



Fasting and standardized postprandial serum glucose concentrations



Glycohemoglobin or serum fructosamine concentration Microalbuminuria



Serum and urine ketone concentrations (quantitative or qualitative)



Serum and urine osmolalities

F. Reproductive/sexual disorders




Change in sexual function



Galactorrhea



Gynecomastia – differential diagnosis and management



Hirsutism/virilization



Hypogonadism, female menopause



Hypogonadism, male gonadal failure



Erectile dysfunction



Menstrual disorders, infertility; PCOS and its relation with metabolic syndrome




Serum gonadotropin concentrations (follicle-stimulating hormone, luteinizing hormone)



Estrogen, progesterone



Serum testosterone concentration

G. Bone disorders

1) Recognition and management of:



Osteopenia/osteoporosis

 Paget’s disease of bone

2) Understand the indications and interpretation of:



Bone mineral analysis (densitometry)

 Serum alkaline phosphatase activity (for Paget’s disease of bone)

H. Metabolic disorders

1) Understand the causes, pathophysiology and treatment of:



Hyperosmolar state



Hypoglycemia



Hyponatremia/hypernatremia (incliuding SIADH, Diabetes Insipidus)



Lipid disorders



Obesity and its complications

2) Interpret results of:



Serum and urine osmolalities



Lipid profile



BMI



Serum and urine electrolytes

I. Paraneoplastic syndromes

1) Recognise presentation, diagnose and management of ectopic hormone production from tumors (like PTHrP etc.)

2) Order appropriate tests and interpret results

VI. Recommended Readings

All senior residents are encouraged to read the MKSAP for Endocrinology during their one-month rotation. Questions will help develop analytical thinking. Residents should also consult the following texts during their rotation regarding the key clinical issues in diagnosis, pathophysiology and therapy raised by the patients they evaluate and care for on the consult rotation:

 Harrison’s Principles of Internal Medicine



Principles and Practice of Endocrinology and Metabolism by K.L. Becker



Endocrine Secrets by M.T. McDermott



Williams Textbook of Endocrinology can be accessed through MDConsult

Residents are also encouraged to use MDConsult and Up To Date to read on a case-bycase basis. Other reading resources are as follows:

A. Diabetes

1) ADA practice recommendations for 2006. Diabetes Care29: S4-42

2) Anonymous. Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). UK

Prospective Diabetes Study (UKPDS) Group. Lancet. 1998 Sep

12;352(9131):854-65

3) Wulffele MG. Kooy A. de Zeeuw D. et.al: The effect of metformin on blood pressure, plasma cholesterol and triglycerides in type 2 diabetes mellitus: a systematic review. J Intern Med. 2004 Jul;256(1):1-14

B. Dyslipidemias

1) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive Summary of The Third Report of The National Cholesterol

Education Program (NCEP) Expert Panel on Detection, Evaluation, And

Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). JAMA.

2001 May 16;285(19):2486

2) Maki KC. Dietary factors in the prevention of diabetes mellitus and coronary artery disease associated with the metabolic syndrome. Am J Cardiol. 2004 Jun

3;93(11A):12C-17C

3) LaRosa JC. Gotto AM Jr. Past, present, and future standards for management of dyslipidemia. Am J Med. 2004 Mar 22;116 Suppl 6A:3S-8S

4) Foley KA. Vasey J. Alexander CM. Markson LE. Development and validation of the hyperlipidemia: attitudes and beliefs in treatment (HABIT) survey for physicians. J Gen Intern Med. 2003 Dec;18(12):984-90

5) Lorenzo C. Okoloise M. Williams K. et.al: San Antonio Heart Study. The metabolic syndrome as predictor of type 2 diabetes: the San Antonio heart study.

Diabetes Care. 2003 Nov;26(11):3153-9

C. Thyroid Disorders

1) Baelaurt K, Franklyn JA. Thyroid hormone in health and disease. Journal of endocrinology 2005, Oct 187 (1) 1-15

2) Cooper DS. Ridgway EC. Thoughts on prevention of thyroid disease in the

United States. Thyroid. 2002 Oct;12(10):925-9

3) Vanderpump MP. Tunbridge WM. Epidemiology and prevention of clinical and subclinical hypothyroidism. Thyroid. 2002 Oct;12(10):839-47

4) Biondi B. Palmieri EA. Lombardi G. Fazio S. Subclinical hypothyroidism and cardiac function. Thyroid. 2002 Jun;12(6):505-10

5) Sawin CT. Subclinical hyperthyroidism and atrial fibrillation. Thyroid. 2002

Jun;12(6):501-3

6) Osman F. Gammage MD. Franklyn JA. Hyperthyroidism and cardiovascular morbidity and mortality. Thyroid. 2002 Jun;12(6):483-7

7) Fontanilla JC. Schneider AB. Sarne DH. The use of oral radiographic contrast agents in the management of hyperthyroidism. Thyroid. 2001 Jun;11(6):561-7

D. Primary Hyperparathyroidism

1) Bilezikian JP. Potts JT Jr. Fuleihan Gel-H. et.al: Summary statement from a workshop on asymptomatic primary hyperparathyroidism: a perspective for the

21st century. J Clin Endocrinol Metab. 2002 Dec;87(12):5353-61

2) Rao DS. Wallace EA. Antonelli RF. Talpos GB. Ansari MR. Jacobsen G. Divine

GW. Parfitt AM. Forearm bone density in primary hyperparathyroidism: long-term follow-up with and without parathyroidectomy. Clin Endocrinol (Oxf). 2003

Mar;58(3):348-54

3) Rao DS. Agarwal G. Talpos GB. Phillips ER. Bandeira F. Mishra SK. Mithal A.

Role of vitamin D and calcium nutrition in disease expression and parathyroid tumor growth in primary hyperparathyroidism: a global perspective. J Bone Miner

Res. 2002 Nov;17 Suppl 2:N75-80

4) Rao DS. Parathyroidectomy for asymptomatic primary hyperparathyroidism

(PHPT): is it worth the risk? J Endocrinol Invest. 2001 Feb;24(2):131-4

5) Talpos GB. Bone HG 3rd. Kleerekoper M. Phillips ER. Alam M. Honasoge M.

Divine GW. Rao DS. Randomized trial of parathyroidectomy in mild asymptomatic primary hyperparathyroidism: patient description and effects on the SF-36 health survey. Surgery. 2000 Dec;128(6):1013-20;discussion 1020-1,

2000

6) Rao DS. Honasoge M. Divine GW. Phillips ER. Lee MW. Ansari MR. Talpos GB.

Parfitt AM. Effect of vitamin D nutrition on parathyroid adenoma weight: pathogenetic and clinical implications. J Clin Endocrinol Metab. 2000

Mar;85(3):1054-8

E. Osteoporosis

1) Hauselmann HJ. Rizzoli R. A comprehensive review of treatments for postmenopausal osteoporosis. Osteoporos Int. 2003 Jan;14(1):2-12

2) Anonymous. Osteoporosis: review of the evidence for prevention, diagnosis and treatment and cost-effectiveness analysis. Introduction. Osteoporos Int. 1998;8

Suppl 4:S7-80

3) Looker AC. Bauer DC. Chesnut CH 3rd. et.al: Clinical use of biochemical markers of bone remodeling: current status and future directions. Osteoporos Int.

2000;11(6):467-80

4) Anonymous. Who are candidates for prevention and treatment for osteoporosis?

Osteoporos Int. 1997;7(1):1-6

F. Hormone/Estrogen Replacement Therapy

1) Anderson GL. Limacher M. Assaf AR. et.al: The Women's Health Initiative

Steering Committee. Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: the Women's Health Initiative randomized controlled trial. JAMA. 2004 Apr 14;291(14):1701-12



ENDOCRINOLOGY LOGSHEET

RESIDENT NAME______________________________________________

PGY LEVEL_______________ ROTATION MONTH_____________

LABORATORY

DATA

THYROID

FUNCTIONS

DIABETES

MANAGEMENT

ADRENAL

FUNCTION/COSYNTROPIN

STIMULATION

MR#

Interpretation of result by resident

(diagnosis/ management plan)

Comment by supervising attending

(correct/not, missed findings etc)

SIGNATURE of

Supervising attending & DATE

MR#





SIGNATURE of


MR#





SIGNATURE of


CALCIUM*

RESIDENT NAME:

LABORATORY DATA

THYROID

FUNCTIONS

MR#

Interpretation of result by resident (diagnosis/ management plan)



SIGNATURE of


MR#




SIGNATURE of


MR#




SIGNATURE of


MR#




SIGNATURE of


DIABETES

MANAGEMENT

DEXA SCANS SODIUM*



ENDOCRINOLOGY OUTPATIENT ATTENDANCE SHEET

RESIDENT NAME______________________________________________

PGY LEVEL_______________ ROTATION MONTH_____________

DATE COMMENTS (IF ANY) BY ATTENDING

SIGNATURE OF

ATTENDING

Outpatient Visits are to be done at the following office:

Dr. F. Sotoudeh

7525 Greenway Center Drive

Ste 209

Greenbelt, MD 20770

Phone: 301-474-0400

Residents must report at 7:30 am every Thursday morning

internal medicine residency program

PRINCE GEORGE’S HOSPITAL CENTER

INTERNAL MEDICINE RESIDENCY PROGRAM

SECTION 9: ENDOCRINOLOGY, DIABETES AND METABOLISM

PRINCE GEORGE’S HOSPITAL CENTER