1
Hyperthyroidism Weightloss
22 year Miss Emilia Mills was brought in by her boyfriend because of loss of weight.
Take a detailed history and discuss further investigations with the patient.
TSH 0.2mU/L ( Normal - 0.4 - 4.0mU/l (milliunits perlitre)
T4 - 35pmol/l ( Normal - 9.0 - 25.0 pmol/l (picomolesperlitre) T3
- 6pmol/l (Normal - 3.5-7.8 pmol/l (picomoles perlitre)
D/D
1. Thyrotoxicosis - heat intolerance, palpitation, ↑appetite, anxiety, family history of
thyroid disease or weightloss.
2. TB – cough, night sweats, travel history,contact,
3. Diabetes – Increased thirst and hunger, increased frequency of urination. Family
history ofdiabetes.
4. Cancer – lumps & bumps, change in bowel habit, cough, haemoptysis, Breastlumps,
5. HIV – sexual Hx,drugs.
6. Depressions - ↓mood, early morning awakening, suicidal thoughts. Recentjob,
changes/loss, separation frompartners
7. Anorexia nervosa – intentional, insight (do you think you have lost weight or only
others telling you this), role model. dieting, exercise, laxatives, diuretic, vomiting
(purging)
8. Drugs – metformin, opiates. slimmingagents,
9. Alcohol/smoking
10. Malabsorption- difficult to flush the stool in thetoilet.
11. Malnutrition – how is the diet ( healthy eatinghabits)
12. Addison’s disease – weakness, dizziness. ↑d pigmentation over palmercrease.
13. Coeliac/crohn’s – diarrhoea with blood mucus, painabdomen
, 2
PositveHx - How much, how long - Lost 5 kg in 2months,↑appetite,Palpitation,
Examination
Miss – I need to examine your hands, eyes and yourneck.
( examiner did not give anyfinding’s)
Invt.
TFT - T3 N, T4 ↑, TSH ↓
Isotope scan (swallow radioactive substance in capsule orliquid),Technetium
Rx – thionamides (carbamazole, prophylthiouracil)
Beta blockers
Radio-iodine – shrinks Thyroid – so ↓ hormones
Surgery – if recurrent overactive thyroid.
IV cannula – Talk to FY 1
Your junior colleague (FY1 doctor) Dr Wilson did not insert IV
cannula to Mrs Williams who supposed to receive IV antibiotics. Talk
to your colleague.
You – Hi Wilson I am Peter. How are you
doing? Him- I am fine Peter
You – How’s the workgoingon? Him- it is good notbad.
You – was it verybusytoday? Him – Not so much. I couldmanage.
Him- it is good not bad.
, 3
You – was it verybusytoday? Him – Not so much. I couldmanage.
You – She has put a complaint saying that you didn’t insert a IV
cannula and she is waiting for a long time.
Him – oh really. But there is 2 hours’ time for the next antibiotics. I
don’t understand why she has to complain.
You – What did you tell her about the cannula.
Him – Well I told her that I will be back in about 15 min to insert
cannula but then I saw an interesting X ray, I went to the library to
read about it.
You – It is good to know that you are interested in learning. But I
think since youhad already told her that you will be back in 15 min
to insert the cannula you should had done that first or you could
have told her that you will be back to insert the cannula before the
next dose indue.
Him – Well yes, I think I should have done that.
You - Do you have any problem in prioritising, because when I
started working I too had the problem of prioritising, then I went to a
course, it helped me a lot. May be you too can attend one course like
that if you want to.
Him – ok, I will surely try that.
You – I think you need to talk to Mrs Williams and explain to her and
may be apologise to her if you think so.
Him – Yes, I will.
You - I think you can insert the cannula now and tell her that no
harm has happened also I suggest you to fill up a clinical incident
form.
Him – yes, thank for your suggestion. Will you tell the consultant?
You – I guess he may come to know that from others. It may be
better you that to him yourself rather than he hearing it from others.
Him – yes, thank
you. You – thank
Sometimes the colleague says he forgot to insert the cannula.
You can ask him to maintain a diary so that he will not forget the
jobs.
Sometimes he says he was caught up in doing CPR.
, 4
You can tell him that he could have told you to insert the cannula
or he could have informed the nurses in the ward to tell the
patient that he will be late.
IV cannula – talk to upset
patient
Yourjuniorcolleague(FY1doctor)DrJohnDaviddidnotinsertinsertIVcann
ulatoMrs
WilliamswhosupposedtoreceiveIVantibioticsforinsectbite.TalktoMrsW
Hello Mrs Williams I am doctor… How can I help you.
Pt - Doc your colleague told me that he is going to come back and
inset cannula in my hand and he did not come back since then. I am
due for antibiotics through my veins. I am supposed to go home
now. I have a meeting to attend in the next one hour.
Dr - I am very sorry for what happened, but I will insert the cannula
to you now.
Pt - Thank you for that, but why is that your colleague did not come
back to insert the cannula.
Dr - I am not sure why he did not come to insert the cannula may be
he is caught up in some other emergencies. But as I told you I will
insert the cannula now and I will ask him to come and tell you what
happened. I would like to reassure that nothing serious has
happened to your health now. Is that OK?
Pt: What about him?
DR: I will ask him to come and explain to you about
what happened. Pt: I don’t’ want to see him. Will you
take any action on him.
Dr: We do take all such incidents very seriously. We will all the
measures so that these type of problems will not happen again.
Pt - I don’t want such things to happen to me or anyone else again.
Dr - Yes, sure we will make sure that these things will not happen. I
will inform my seniors about this.
Pt – I want to put a written complaint.
Hyperthyroidism Weightloss
22 year Miss Emilia Mills was brought in by her boyfriend because of loss of weight.
Take a detailed history and discuss further investigations with the patient.
TSH 0.2mU/L ( Normal - 0.4 - 4.0mU/l (milliunits perlitre)
T4 - 35pmol/l ( Normal - 9.0 - 25.0 pmol/l (picomolesperlitre) T3
- 6pmol/l (Normal - 3.5-7.8 pmol/l (picomoles perlitre)
D/D
1. Thyrotoxicosis - heat intolerance, palpitation, ↑appetite, anxiety, family history of
thyroid disease or weightloss.
2. TB – cough, night sweats, travel history,contact,
3. Diabetes – Increased thirst and hunger, increased frequency of urination. Family
history ofdiabetes.
4. Cancer – lumps & bumps, change in bowel habit, cough, haemoptysis, Breastlumps,
5. HIV – sexual Hx,drugs.
6. Depressions - ↓mood, early morning awakening, suicidal thoughts. Recentjob,
changes/loss, separation frompartners
7. Anorexia nervosa – intentional, insight (do you think you have lost weight or only
others telling you this), role model. dieting, exercise, laxatives, diuretic, vomiting
(purging)
8. Drugs – metformin, opiates. slimmingagents,
9. Alcohol/smoking
10. Malabsorption- difficult to flush the stool in thetoilet.
11. Malnutrition – how is the diet ( healthy eatinghabits)
12. Addison’s disease – weakness, dizziness. ↑d pigmentation over palmercrease.
13. Coeliac/crohn’s – diarrhoea with blood mucus, painabdomen
, 2
PositveHx - How much, how long - Lost 5 kg in 2months,↑appetite,Palpitation,
Examination
Miss – I need to examine your hands, eyes and yourneck.
( examiner did not give anyfinding’s)
Invt.
TFT - T3 N, T4 ↑, TSH ↓
Isotope scan (swallow radioactive substance in capsule orliquid),Technetium
Rx – thionamides (carbamazole, prophylthiouracil)
Beta blockers
Radio-iodine – shrinks Thyroid – so ↓ hormones
Surgery – if recurrent overactive thyroid.
IV cannula – Talk to FY 1
Your junior colleague (FY1 doctor) Dr Wilson did not insert IV
cannula to Mrs Williams who supposed to receive IV antibiotics. Talk
to your colleague.
You – Hi Wilson I am Peter. How are you
doing? Him- I am fine Peter
You – How’s the workgoingon? Him- it is good notbad.
You – was it verybusytoday? Him – Not so much. I couldmanage.
Him- it is good not bad.
, 3
You – was it verybusytoday? Him – Not so much. I couldmanage.
You – She has put a complaint saying that you didn’t insert a IV
cannula and she is waiting for a long time.
Him – oh really. But there is 2 hours’ time for the next antibiotics. I
don’t understand why she has to complain.
You – What did you tell her about the cannula.
Him – Well I told her that I will be back in about 15 min to insert
cannula but then I saw an interesting X ray, I went to the library to
read about it.
You – It is good to know that you are interested in learning. But I
think since youhad already told her that you will be back in 15 min
to insert the cannula you should had done that first or you could
have told her that you will be back to insert the cannula before the
next dose indue.
Him – Well yes, I think I should have done that.
You - Do you have any problem in prioritising, because when I
started working I too had the problem of prioritising, then I went to a
course, it helped me a lot. May be you too can attend one course like
that if you want to.
Him – ok, I will surely try that.
You – I think you need to talk to Mrs Williams and explain to her and
may be apologise to her if you think so.
Him – Yes, I will.
You - I think you can insert the cannula now and tell her that no
harm has happened also I suggest you to fill up a clinical incident
form.
Him – yes, thank for your suggestion. Will you tell the consultant?
You – I guess he may come to know that from others. It may be
better you that to him yourself rather than he hearing it from others.
Him – yes, thank
you. You – thank
Sometimes the colleague says he forgot to insert the cannula.
You can ask him to maintain a diary so that he will not forget the
jobs.
Sometimes he says he was caught up in doing CPR.
, 4
You can tell him that he could have told you to insert the cannula
or he could have informed the nurses in the ward to tell the
patient that he will be late.
IV cannula – talk to upset
patient
Yourjuniorcolleague(FY1doctor)DrJohnDaviddidnotinsertinsertIVcann
ulatoMrs
WilliamswhosupposedtoreceiveIVantibioticsforinsectbite.TalktoMrsW
Hello Mrs Williams I am doctor… How can I help you.
Pt - Doc your colleague told me that he is going to come back and
inset cannula in my hand and he did not come back since then. I am
due for antibiotics through my veins. I am supposed to go home
now. I have a meeting to attend in the next one hour.
Dr - I am very sorry for what happened, but I will insert the cannula
to you now.
Pt - Thank you for that, but why is that your colleague did not come
back to insert the cannula.
Dr - I am not sure why he did not come to insert the cannula may be
he is caught up in some other emergencies. But as I told you I will
insert the cannula now and I will ask him to come and tell you what
happened. I would like to reassure that nothing serious has
happened to your health now. Is that OK?
Pt: What about him?
DR: I will ask him to come and explain to you about
what happened. Pt: I don’t’ want to see him. Will you
take any action on him.
Dr: We do take all such incidents very seriously. We will all the
measures so that these type of problems will not happen again.
Pt - I don’t want such things to happen to me or anyone else again.
Dr - Yes, sure we will make sure that these things will not happen. I
will inform my seniors about this.
Pt – I want to put a written complaint.
