Purpose of assessment: how to understand and plan your answer in an interactive session. Thyroiditis and Celiac Disease.

Part of an assessment aka clinical examination in a postgraduate setting, is a series of scenarios or clinical material which a candidate is asked to read and assess, What is the purpose of this form of assessment?

About the scenario: do you understand the information that is given you? Can you make a working diagnosis? Can you try to prove your diagnosis? Can you make the patient comfortable, recognize and treat complications and life threatening situations, can you restore normal or near normal functions, and follow up the patient’s functions? Obviously in the short time allotted you will be asked some of these questions but these are the questions you should prepare.

Sample 1. A 32 year old man from the Northern Areas of Pakistan. He had been unwell for 2 months. The 2 main problems were irregular low grade fever and pain in the front of the neck radiating to the jaw and temporal regions. His local caregiver has given him 3 courses of different antibiotics with the intention of treating a sore throat/pharyngitis but he has not improved. His fever is 101 degree F, with a regular pulse of 110/min, he has fine tremors in both hands and feels nervous and jittery. his appetite is good but he has lost 3 kg of weight. His ENT examination is unremarkable and the front of the neck is tender, and there is a firm palpable non-cystic small mass.

What will the examiner ask you?

  • What is the likely diagnosis or problem?
  • What disease is he suffering from?
  • Why have you reached this conclusion?
  • What is the relevant information in this scenario?
  • What is the organ or system involved?

All these are designed to see if you understood the information in the scenario and interpreted it intelligently. Answers given were as below;

  • Temporal arteritis. Wrong. You have been told that the pain begins in the front of the neck and then radiates. In temporal arteritis or giant cell arteritis temporal headaches are pretty severe and the tenderness is in the temporal regions. It is also known as Horton’s disease, and major manifestations on the basis of which it is diagnosed are new headaches, abrupt onset of visual disturbances, especially transient monocular visual loss, jaw claudication, unexplained fever, anemia, or other constitutional symptoms and signs. Labs will show high erythrocyte sedimentation rate (ESR) and/or high serum C-reactive protein (CRP). None of these are mentioned in the scenario.
  • Thyroiditis: subacute is the right answer. What else is tender other than the thyroid? It is painful and tender and there is fever hence it is inflamed so it is thyroiditis as the gland is inflamed, it has been there for 2 months so not acute and not yet quite chronic and the symptoms are muted too. There is no hint of jaw claudication in the scenario and no evidence of AF. Subacute thyroiditis is fundamentally a clinical diagnosis. In most patients, clinical manifestations (the presence of neck pain, often radiating upward to the jaw; marked thyroid tenderness; and a diffuse goiter) are sufficient to establish the diagnosis. Symptoms and signs of hyperthyroidism may or may not be present, but the serum TSH is usually suppressed (typically <0.1 mU/L) and free T4 and T3 concentrations elevated, particularly in the early stages of the illness.
  • You will be asked what specific tests you will do to further your diagnosis: prove absence of bacteria, blood culture, throat swab culture etc; C-reactive protein and ESR to prove ongoing active inflammation: check the thyroid status usually mild hyperthyroidism with low TSH. antithyroid antibodies will be absent, radioiodine uptake will be low. Thyroid crisis is unlikely to occur. Doppler ultrasound of the neck will show reduced thyroid blood flow.
  • How will you treat or manage this case and what is the objective of your management?The objective is to make the patient comfortable, reduce the inflammation and monitor thyroid function and restore it to normal. The disease is self limiting and will subside in a few weeks to months. No antibiotics are required, a full standard dose of aspirin is effective or ibuprofen or naproxen will relieve the pain and fever; no need to treat the tremors as they will settle by themselves. If the patient does not respond in a few days use an adequate dose of steroids.
  • Differential diagnosis: rarely, fine-needle aspiration biopsy, typically under ultrasound guidance, is necessary to distinguish infection (eg, abscess), hemorrhage, thyroid cancer, or lymphoma from subacute thyroiditis. However, considering the possibility of the presence of a thyroid abscess is important in all cases of subacute thyroiditis. Occasional patients with either chronic autoimmune thyroiditis (Hashimoto’s thyroiditis) or Graves’ hyperthyroidism have neck pain and tenderness. However, the pain in both conditions is much less severe than in subacute thyroiditis, while thyroid dysfunction should be much more severe. In Graves’ hyperthyroidism, radioactive iodine uptake is high, not low. Painless (silent) and postpartum thyroiditis may cause similar changes in thyroid function and are associated with low radioiodine uptake, but thyroid gland or neck tenderness is not present.
  • Thyroid status usually returns to normal i.e euthyroid and therapy for hypothyroidism is not needed because symptoms, are not pronounced but if the hypothyroidism is more pronounced (TSH >10 mU/L) or associated with more than mild symptoms, the patient should be treated with 50 to 100 mcg of T4 (levothyroxine) for six to eight weeks (with a goal TSH in the normal range). The T4 should then be discontinued, and the patient reevaluated in four to six weeks to be sure that the hypothyroidism is not permanent.

When you are preparing for the exam this is the information you need about subacute thyroiditis. Organise it in your own mind. Remember that diagnosis depends on some or one salient point, this may be clinical or a lab investigation or a series of lab investigations. Understand and remember these. In the examination it is often obvious that the candidate is thinking of these points for the first time. This is fatal. Treatment consists of reducing distress, pain and discomfort. This is very important and not just an adjunct to the curative treatment. The curative or corrective treatment is an attempt to restore function. You may need to supply the missing hormone, electrolyte, vitamin or enzyme etc or if it is in excess then to block it with drugs or other therapy. You have to anticipate and recognize complications and then rehabilitate the patient.

Remember to read up these points. Finally read up research and controversies, recent advances and remember the name of a current or recently published trial.

If a scenario was being written about Adult Coeliac Disease what would the assessor include?

  • For acute disease: some form of diarrhoea (not bloody or with mucus), recent onset but with a history of recurrence over months, weight loss, may not always be related to intake of wheat as adult will have been on wheat all their lives, evidence of malabsorption such as anemia (iron deficiency, folate and vitamin B 12 deficiency, vitamin D deficiency). What tests you will be expected to do to prove that it is coeliac disease: intestinal biopsy for villous atrophy and some tests for gluten enteropathy such as autoantibodies; anti-endomysial antibody (EMA-IgA), anti-tissue transglutaminase antibodies (tTG) (tTG-IgA, tTG-IgG), or antibodies targeting gliadin, antibody to native gliadin: anti-gliadin antibody (AGA-IgA, AGA-IgG), antibodies against synthetic deamidated gliadin peptides: Deamidated gliadin peptide (DGP)-IgA, DGP-IgG. Anti-gliadin antibodies are unreliable as there are too many false positives. Undetectable IgA levels but not partial immunoglobulin A deficiency (low but detectable serum IgA) decreases the sensitivity of TTG-IgA.
  • Points in the scenario may give probability of disease: low probability; absence of suggestive signs or symptoms of malabsorption such as significant chronic diarrhea/steatorrhea or weight loss,, absence of family history of celiac disease, Chinese, Japanese, or Sub-Saharan African descent. High probability is likely if there are symptoms suggestive of intestinal coeliac disease or evidence of extra-intestinal diseases; malabsorption or nutrient deficiency plus risk factors such as first and second degree relative with confirmed celiac disease Type 1 diabetes, autoimmune thyroiditis, Down and Turner syndromes, pulmonary hemosiderosis (moderate risk).
  • What is the value of doing HLA testing? Only a 12% negative value if the usual HLA typing is absent. If HLA DQ2/DQ8 is negative, celiac disease is excluded.
  • These need to be excluded: irritable bowel syndrome, small intestinal bacterial overgrowth, lactose intolerance, chronic pancreatitis, microscopic colitis, and inflammatory bowel disease. Celiac disease can be differentiated from these by serologic evaluation and small bowel biopsy.
  • Why follow up coeliac disease? To correct the nutrient deficiency and look out for malignancy.

Whenever you are revising for an interactive assessment pick out the salient points and not just remember them but understand them.

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I am a Professor of Medicine and a Nephrologist. Having served in the Army Medical College, Pakistan Army for 27 years I eventually became the Dean and Principal of the Bahria University Medical and Dental College Karachi from where I retired in 2016. My passion is teaching and mentoring young doctors. I am associated with the College of Physicians and Surgeons Pakistan as a Fellow and an examiner. I find that many young doctors make mistakes because they do not understand how they should answer questions; basically they do not understand why a question is being asked. My aim is to help them process the information they acquire as part of their education to answer questions, pass examinations and to best take care of patients without supervision of a consultant. Read my blog, interact and ask questions so that I can help you more.

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