Download Thyroid gland diseases

CENTRE FOR MEDICAL EDUCATION
Tashkent Medical Academy
"Approved"
Prorector for
Academic
Affairs
Prof. Teshaev OR
«_____»_________________ 2012
Department:
Faculty and hospital surgery.
Subject:
Faculty Surgery
SUBJECT:
Thyroid gland diseases
Educational-methodical development
(for teachers and medical students)
Tashkent-2012
SUBJECT:
Thyroid gland diseases
1. Place of the lessons, equipment
- Chair of faculty and hospital surgery, training room, dressing
- Posters, tables, schemes of classification of disease, treatment regimen, radiographs, videos.
2. The duration of the study subjects
Number of hours - 4.9.
3. Session Purpose
Justification showing the importance of topics for the training of students. Introducingstudents with thyroid disease,
the causes of their development, especially styami-clinical course, differential diagnosis, optimal treatment options, postoperative care, rehabilitation patients.
Tasks
The student should know:
- Diagnosis and differential diagnosis and complications;
- Interpretation of the results of instrumental diagnostic investigations for substantiationof the diagnosis and management of treatment choice;
- Preoperative characteristics of this category of patients;
- Determine the nature of surgery and conservative treatment, to know theircharacteristics;
- To prevent complications during and after surgery;
- To acquire some practical skills in the examination of patients with thyroid disease;
- To learn a special survey methods.
The student should be able to:
- Perform practical skills - to acquire some practical skills in the follow-on patients with thyroid disease, to perform special techniques of repetition, of these patients to determine indications and contraindications
for surgical intervene.
4.Motivation
Instilling students with the need for timely development of adequatу operations before to severe complications, and in their development - meeting the most informative and modern methods of diagnosis,surgical treatment, meeting with potential complications of surgeryand operating out of a period of,
prevention. Development of clinical thinking of students. The development of the modern view of the
problem issues from the perspective of world medicine and general practice doctor.
5. Interdisciplinary communication and Intersubject
Teaching this topic is based on the knowledge bases of students of anatomy, normal and pathological physiology of circulation. Acquired during the course knowledge will be used during the
passage of gastroenterology, internal medicine and other clinical disciplines.
6. The content of lessons
6.1. Theoretical part
Although Uzbekistan as a focus of endemic goitre has been known since the last century, the study of diseasemaking thyroid gland, treatment and prevention, as well as the development of goiter surgery, there were implementation-schestvleny only in the mid-twentieth century. In this important contribution was made Patrioticgovernmental scientists: SA Masumov, RK Islombekov, E. X. Turakulov, etc. In particular, they have organized
many expeditions in the area of endemic goiter focus in Uzbekistan carried out scientific and research work on the
skie their study, but also developed a number of important therapeutic and preventive measures to prevent them.
Despite this, today in our country there are more than 15 endemic foci in the crop and more than 10-20% of the
population revealed an increase in thyroid gland of different sizes. First of all, this is due to a lack of iodine in the
environment, which plays a major role in the hyperplasia of the thyroid gland and the occurrence of endemic goiter.
Zob - limited or diffuse thyroid enlargement, which has based hyper-perplasticheskie or degenerative changes. By
origin are two types of goiter: endemic and sporadic.
Endemic goitre - a disease that affects people in geographic areas (End-mission - the defeat of the population of a
certain geographic area), the biosphere of which is poor in iodine. Insufficient intake of iodine in the body leads to a
decrease in production of thyroid-GOVERNMENTAL hormone that is inevitably accompanied by compensatory
hyperplasia of the thyroid gland and leads to the formation of goiter. Such hyperplasia initially compensates for the
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deficiency of thyroid mountains, Mons.
Endemic goiter are subject in most cases, people living in mountainous areas and endemic goiter is characterized
by almost equal incidence between men and women.
Sporadic goitre - occurs in people living outside areas of endemic goiter (isolated, accidental or non-specific for
certain geographic areas). The basis of the origin of a strong leader, took the excitement of the nervous system the
patient - the neuro-psychological stress. In particular, the majority of patients the disease is associated with loss of
loved ones (accidents, disasters, etc.) or some other shock, after which observed the development of the disease. Sporadic goiter occurs in women 8-10 times more often than men.
The existing classification of thyroid disease can be summarized as follows:
• Malformation of the thyroid gland (congenital)
• Damage to the thyroid gland,
• Inflammatory diseases of the thyroid gland:
- Thyroiditis (Hashimoto's struma)
- Strumity (Riedel struma).
• Endemic goiter:
- Diffuse
- Junction,
- Mixed.
• Sporadic goiter:
- Diffuse
- Junction,
- Mixed.
• Diffuse-toxic goiter (Basedow's disease, thyrotoxicosis)
• Toxic adenoma (nodular toxic goiter)
• Tumors of the thyroid gland:
- Benign,
- Malignant.
On the degree of thyroid enlargement distinguish six degrees:
On stage - the iron is not visible and not palpable;
Grade I - the iron is not visible, but the neck can be felt and seen in swallowing;
Grade II - during swallowing is visible and well-palpable thyroid gland, but the shape of the neck is not changed;
III degree of iron visible to the eye when viewed, alters the contour of the neck, giving it the appearance of a "thick
neck";
IV degree - pronounced goiter, which violates the configuration of the neck;
V degree - increased iron is enormous, often accompanied by compression of the esophagus, trachea with violation Niemi swallowing and breathing.
On the functional state of goiter can be:
a) hyperthyroid - increased thyroid function;
b) euthyroid - thyroid function is not compromised;
c) hypothyroid - thyroid function is reduced.
Clinic and Diagnostics
The leading symptom of the endemic and sporadic goiter is an increase in thyroid cancer-tion. Inspection and palpation can determine the degree of thyroid enlargement.Localization distinguishes the cervical, retrosternal, retrosternal part, goiter and goiter of the tongue.
Most patients with thyroid function is not, however, people living in places severe endemic goiter, the disease
sometimes occurs with symptoms of hypothyroidism. In these patients, slowed reaction to external stimuli, reduced
mental and physical performance. Patients report fatigue, chilliness. In the study revealed, decreased reflexes. Congenital hypothyroidism is accompanied by the development of cretinism, which is characterized by severe
backlog of physical and mental development.
Symptoms: The most frequently sick note "embarrassment" in the neck while driving, doing up the collar, dry
cough, hoarseness, shortness of breath. The latter may be associated with traheomalyatsiey - thinning of the tracheal wall due to the constant pressure of crop-tion in violation of the neural regulation of the trachea and larynx
during their shift at hand, well. Respiratory failure - the most common symptom of retrosternal goiter. Often (especially in the retrosternal goiter) patients complain about the state of heaviness in the head when bending the
body. With OS-Motrya these patients can be identified neck veins, a characteristic pattern of "head jellyfish" in the
upper part of the chest wall. Respiratory failure causes the development of the changes that are characterized as
"thymus heart." Compression of the sympathetic trunk causes Horner syndrome (ptosis, miosis, enophthalmos),
changes in sweating half of the body on the side of compression. With sublingual goiter due to the marginalization
of the epiglottis is disturbed breathing. With goiter, which is located behind the esophagus, there is difficulty swallowing, especially in the collar of the head. X-ray study to delay the barium at the level of aberrant goiter, displacement of the esophagus anteriorly or laterally.
Aberrant goiter - abnormally enlarged thyroid gland surplus often is exposed malignant.Often take for aberrant goiter thyroid cancer metastases in lymph nodes in the neck.
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Treatment: with small diffuse zobah appoint tireoidin. With a large diffuse goitre causing compression of the trachea and blood vessels, shows resection of the thyroid. In all forms of nodular goiter, given the possibility of malignancy nodes need surgical intervention-parameter - resection of the thyroid gland, followed by urgent histological
examination, which decides the tactics. Prevention of endemic goiter in-cluded in the use of iodized salt, a complex
of sanitary-hygienic measures.
Diffuse toxic goiter
Diffuse toxic goiter (Basedow's disease, hyperthyroidism, goiter tireotok-classical) - en dokrinnoe disease that is
caused by increased secretion of thyroid ¬ Noah hormone-tion and is accompanied by severe disturbances in various organs and systems.
Mild form of hyperthyroidism - is not pronounced effects nevraste-state (feeling tired, STI, irritability, tearfulness,
and resentment). Against the background of a slight increase in schito-prominent cancer, labile pulse - from 80 to
100 per minute, a weak hand tremor. There may be a slight weight loss. Reduced ability to work in the afternoon.Basal metabolism does not exceed 30%.
Thyrotoxicosis moderate - marked impairment of function of the central nerve-dimensional system (mild anxiety,
irritability, tearfulness). The pulse rate of 100-120 per minute, increased pulse pressure, increased heart with heart
failure, I grade on Lang. A significant reduction in body weight against the background of relatively high nutritionalof, reducing the ability to work during the day. Basal metabolism increased to 60%.
Severe form of hyperthyroidism - along with disorders of the nervous system, characterized by Etireotoksicheskoza to moderate severity, develop sudden muscle weakness, and heavy-zhelye dysfunction of the
cardiovascular system, degenerative disorders parenhimatous organs. Tachycardia can be up to 120-140 beats
per minute, often accompanied by atrial fibrillation, Xia, heart failure, II-III degree of Lang. The main exchange of
60% or more, with significantly increased feeding, body weight is significantly reduced. Able to work, NOSTA lost.
Treatment: There are three main types of treatment diffuse toxic goiter: medicament therapy, treatment with radioactive iodine and surgery.
To reduce the thyroid hormone is necessary to use preparations of iodine in combination with drugs tireostaticheskim (merkazolil), which is prescribed in doses of 40-60 mg / day, with remission establish the maintenance dose of
prep-rata 5-10 mg / day. When preoperative or thyrotoxic crisis at the moment, with adrenal insufficiency using corticosteroids, which block the effect of thyroxine and delay its excretion.
Merkazolil antitireoiD is a synthetic agent. The drug speeds up the exported cultural-assertion of the thyroid iodide
inhibits the activity of enzyme systems involved in the oxidationing and transformation of iodide to iodine, which
inhibits the iodination of thyroglobulin and delaying the conversion of diiodotyrosine in thyroxine. Small doses of
iodine have an inhibitory effect on the formation of TSH in the anterior pituitary.
Reserpine reduces neuro-vegetative disorders, causes slowing of the pulse.
Reduced therapy used in treatment of diffuse toxic goiter, and preparation for surgery or treatment with radioactive
iodine.
Exposure J131 influenced beta particles leads to cell death of follicular epithelium of thyroid gland and their replacement by connective tissue. Indications for radioisotope le cheniyu J131: hyperthyroidism, which takes place
from mental excitement, is extremely heavy (Kahekili-cal) form of the disease, hyperthyroidism in older people with
heart failure and cardiosclerosis, with irreversible changes in the kidneys and liver forms of diffuse toxic goiter
in absence of goiter. After receiving large doses of J131 may develop thyrotoxic wild reactions were fatal, the
emergence of a permanent, severe myxedema, difficult to treat, the development of malignant thyroid tumors, a
change in the function of sexual glands, increase in exophthalmos.
Indications for surgery: diffuse toxic goiter and medium heavy forms, nodular toxic goiter (thyrotoxic adenoma),
large goiter, compressing organs of the neck, regardless of the severity of diffuse toxic goiter. Before surgery, be
sure to bring the thyroid to the euthyroid state.
Contraindications to surgical intervention: mild forms of diffuse toxic goiter, the old depleted patients due to the high
operative risk in patients with irreversible changes in the liver, kidney, cardiovascular and mental health in-illness.
Diffuse and multinodular toxic goiter produce bilateral subtotal resection of the thyroid gland subfascial on
OV Nikolaev, and toxic adenoma - ¬ ing resection of the corresponding share of cancer.
Postoperative complications. Intraoperative complications: bleeding, by air embolism, nerve damage return, removal or damage to the parathyroid glands, with subsequent development of hypoparathyroidism. If the damage is
both recurrent nerves in the patient begins acute asphyxia, and only immediate intubation or tracheostomy may
save the patient.
In patients with thyrotoxicosis in the postoperative period the most dangerous complication - the development of
thyrotoxic crisis. The first sign of thyrotoxic crisis - a rapid highertion of body temperature to 40 ° C, accompanied
by a rising tachycardia.Blood pres-sure at first increases and then decreases, there are psychological disorders. In
the development of a crisis plays a major role insufficiency of the adrenal cortex, due to operational stressNaja. Stroke Treatment must be directed against adrenal insufficiency howl, cardiovascular disorders, hyperthermia
and oxygen-ciently retarded.
Traheomalyatsiya. With a Long-goiter, especially in the retrosternal, posture, and ditrahealnom pozadipischevodnom its location, due to the constant pressure on the traheyu occur degenerative changes in the tracheal
rings and thinning - traheomalya-tion.After removal of the crop immediately after extubation of the trachea or in the
immediate postoperative period, Mr. inflection can occur in its area of softening or convergence of the walls and
narrowing of the lumen. Comes acute asphyxia, which can lead to death of a patient, if not satisfied, the thread of
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an emergency tracheostomy.
Postoperative hypothyroidism - impairment of thyroid function, conditioned complete or almost complete removal of
this during surgery occurs in 9-10% of patients with operator-centered. Hypothyroidism is characterized by general
weakness, a constant sense of mouth-cavity, lethargy, drowsiness, lethargy total patients. The skin becomes dry,
wrinkled, swollen. Hair begins to fall, there are pains in the limbs, sexual function weakens.
Treatment: tireoidin appoint other thyroid medications. With the development of micro-technology and rohirurgicheskoy successes of immunology began to perform allotransplantation schito, a prominent cancer using graft to
the vascular pedicle.Applied and free grafting pieces of gland tissue under the skin into the muscle, but these operations are usually given a temporary effect, so in practice is mainly used in replacement therapy.
Used in this lesson, new teaching technologies, "Black-box ny", "Web."
USE OF THE 'BLACK BOX'
The method provides for joint activities and active participation in the classroom each student, the teacher works with the entire group.
Each student takes out a "black box" issue. (A variant of the adjective-are.) Students are required to detail the reasons for his answer.
To think about each answer the student is given 3 minutes. Then, the answers are discussed, is given in
addition etiopathogenesis, clinical course. At the end of the method of teachers commented on the correct answer, the validity, the activity level of students.
This methodology promotes student speech, forming the foundations of the critical thinking, as In this
case, the student learns to assert his view, analyze responses Rowan band members - participants of
the contest.
Option summary:
In the acute toxic dilatation of the colon for ulcerative colitis is not typical.
USING "WEB"
Steps:
1. Previously students are given time to prepare questions on the passed for Enactment.
2. Participants sit in a circle.
3. One of the participants is given skein of thread, and he sets his prepared question (for which he must
know the full answer), hold the end of the filament coil and transferring to any student.
4. A student who receives skein, answers the question (in this party, who asked him, commented on a
response) and passes the baton on the issue. Participants continue to provide, questions and answer
them until everything will be in the web.
5. Once students have completed all the questions, a student holding a roll of WHO-rotates his party,
from whom he received the issue, while asking his question, and so on, until the "unwinding" of the coil.
Note: To prevent the students, which should be attentive to each answer, because they do not know who
to throw skein.
6.2. analytical part
Situational problem:
In the clinic turned 18 years old patient complaining of enlargement of the thyroid gland.On examination, the thyroid gland detected node 5x5 see signs of hyperthyroidism arenot. The patient initially drawn to the doctor.
I. Your diagnosis:
A nodular euthyroid goiter *
B. nodular toxic goiter
B. toxic goiter
G. illness Hoshimoto
II. Your tactics:
A. surgery *
B. outpatient treatment.
B. Conservative treatment of Endocrinology Department
G. Treatment with radioactive iodine
D. direction in oncology clinic
6.3. Practical part
The task of practical skills (interview a patient, physical examination and inspection of body parts, to jus5
tify the differential diagnosis and final diagnosis, assign the appropriate diet and regular treatment).
1. HOLD DIFFERENTIAL DIAGNOSIS and justify the final diagnosis.
Purpose: To educate and carry out a differential diagnosis to justify a definitive diagnosis.
List
the disease,
clinical
symptoms, which are similar to the disease
Make a differential diagnosis of major clinical syndromes
On the basis of complaints, medical history, objective data andresults of laboratory
and instrumental examinations, as well
asdifferential diagnosis to put a definitive
diagnosis
0
Fully implemented
correctly
25
0
35
0
40
Only
0
100
№
1
2
3
Activity
Not fulfilled
3. APPOINT appropriate diet and planned treatment.
Purpose: The treatment of the disease and to achieve remission
№
1
2
3
4
5
6
Activity
0
Fully implemented
correctly
10
0
10
0
0
20
20
0
20
0
0
20
100
Not fulfilled
The study of the characteristics of medical tables on Pevsner
The right choice
of dietary table in accordance with the diagnosis
Assessment of usefulness of the diet
In accordance with the diagnosis, disease
severity and stage of the appointment
of primary therapy
In accordance with the diagnosis, disease
severity and stage of the appointment of
symptomatic therapy
prophylactic measures
Only
7. Forms of control knowledge, skills and abilities
- Interpreting;
- Writing;
- the decision of case problems;
- Demonstration of skills mastered.
8. Criteria for evaluating the current control я
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№ Progress in%
evaluation
1
Perfectly
96-100%
“5”
2
91-95%
Perfectly
“5”
3
86- 90%
Perfectly “5”
4
81-85%
well “4”
5
76-80%
Well “4”
6
71-75%
well “4”
7
66-70%
satisfactorily “3”
8
61-65%
Satisfactorily “3”
The level of student knowledge
Complete the correct answer to the questions. Summarizes andmakes decisions, creative thinking, selfanalyzing. Solve situational problems correctly, with
a creative approach, with full justification forthe answer.
Actively and creatively participate in interactive
games, the right to make informed decisions and
summarize, analyze.
Complete the correct answer to the questions. Creative thinking, selfanalyzing. Solve situational problems correctly, with
a creative approach, the rationale for the answer.
Actively and creatively participate in interactive
games, the rightdecision makers.
The questions covered completely, but there
are inaccuracies in the answer 01.02. Independently analyzed. Inaccuracies in
solvingsituational problems, but with the right approach.
Actively involved in interactive games, make the
right decisions.
The questions covered in full, but there is
a 03/02 inaccuracies, errors. Into practice, understand
the essence of the issue, saysconfidently, is a faithful
representation. Case solved the problemcorrectly, but
the rationale for not fully answer.
Actively involved in interactive games, make decisions correctly.
Correct, but incomplete coverage of the issue. Understands theissue, says confidently, is a
faithful representation. Actively involvedin interactive games. On case studies gives a partial solution.
Correct, but incomplete coverage of the issue. Understands theissue, says confidently, is a
faithful representation. On case studiesgives
a partial solution.
The correct answer to half the questions. Understands
the issue, saysconfidently, is accurate representations only on individual issuestopics. Case solved the
problem correctly, but there is
no justificationresponse.
The correct answer to half the questions. Says uncertainly is accurate representations only on individual issues topics. Mistakes in
solvingsituational problems.
7
55-60%
satisfactorily “3”
10
50-54%
unsatisfactorily
“2”
11
46-49%
unsatisfactorily
“2”
12
41-45%
unsatisfactorily
“2”
13
36-40%
unsatisfactorily
“2”
14
31-35%
unsatisfactorily
“2”
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Reply with errors on half of the questions. Says uncertainly, is partialview on the subject. Case solved the problem incorrectly.
The correct answer to the third set of questions. Situational problemssolved correctly if the
wrong approach.
The correct answer to the fourth set of questions. Situational problems solved correctly if the
wrong approach.
Lighting fifth of the questions correctly. Gives incomplete and partiallyincorre
ct answers to questions.
Lighting 1 / 10 of questions at the wrong approach.
To the questions are not answers.
9. Chronological map of lessons
№
1
2
3
4
5
6
7
Stages of lessons
forms lessons
Introductory word teacher (study subjects)
Discussion topics practical lessons, assessment
of baseline knowledge of students with
new educational technologies (small groups, case
studies, business games, slides, videos, etc.)
Summing up the discussion
The survey, an
explanation
Providing students with visual aids
and giving explanations to them
Self-study students in mastering skills
Clarification
of the
extent
to Oral interview, writte
which lessons objectives on the basis of devel- n
survey,
testoped theoretical knowledge and practical experi- ing, checking the reence on the results and taking into account sults of
practical
this evaluation activities of the group.
work,
discussion debate.
Conclusion of the teacher
Information, questions
on this lesson. Assessment of the students on a
for self-study
100 point system and its publication. Cottage set onthe next
class (a set of questions)
10. Quiz Questions
1. Definition of goiter frequency etiopatoganez, clinic, diagnosis and treatment.
2. Principles of conservative therapy
3. To teach the diagnosis of goiter, preoperative
4. Indications for surgical treatment of diseases of the thyroid gland.
11. Recommended Reading
8
duration in m
inutes. 90
5
25
5
10
15
25
5
1. SH.I. Karimov - "Surgical Diseases" Tashkent 2005.
2. MI Kuzin, "Surgical Diseases." Medicine 1986
3. S. Karimov, "Hirurgik kasalliklar." Medicine 1994
4. Littman I. "Operative Surgery" 1982.
5. Agzamhozhaev SM "Hirurgik kasalliklar" 1991.
6. BV Peter "Guide to Surgery" 7 tons Medicine 1970.
7. Tutorial on the subject.
Internet addresses on the subject of activity:
http://www.tma.tmn.ru/Vestnik
http://medi.ru/doc/83.htm
http://www.rmj.net/index.htm
http://www.consilium-medicum.com/media/refer
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