Anny Xiao Week 4 Endocrinology Day 3 & 4

Yesterday we were with Dr. Lin in the morning and Dr. Tsai in the afternoon as they saw endocrinology patients in the outpatient department. Interestingly, some of the patients did not appear to have any endocrine-related issues, like one patient who mainly had hypertension but had been seeing Dr. Tsai for a few years. Dr. Tsai only recently started working at Taipei Hospital a couple months ago after previously working as an endocrinologist at another branch hospital in a different part of Taipei. However, we saw a handful of patients today who had followed him to this hospital in order to remain his patient and it soon became clear that Dr. Tsai is a respected and well-liked doctor. One thing that stood out to me is that he always encourages his diabetes patients when they have improved their blood glucose control or have lost weight. Almost all of the patients seen in the endocrinology outpatient department were diabetic or had thyroid disease.
One diabetic patient was told she would need to start injecting insulin to supplement his oral diabetes medication and she asked Dr. Tsai if insulin was harmful to the kidney. Apparently, many patients have this notion because they know of or hear of friends who start injecting insulin and then start dialysis soon afterwards. Dr. Tsai explained that insulin is not harmful to the kidney but often when patients have been diabetic for a long time, diabetic nephropathy and decline in pancreatic islet cell function occur concomitantly, resulting in a need for dialysis & insulin therapy around the same time. Additionally, Dr. Tsai said that when patients are prescribed insulin, it is usually because their blood glucose control is inadequate on oral agents. However, it may be that some patients are actually noncompliant with their oral agents and choose to take Chinese herbal medicine instead, which contributes to kidney failure requiring dialysis. It is not only the compounds found in herbs that can potentially damage the kidney but also the fact that patients use them to replace (instead of supplement) the western medications that they are prescribed and damage their kidney further by forgoing those medications.

Another interesting patient had previously come in for an exam and lab tests because he had noticed that there would be ants in his bathroom around the urine in his toilet. This prompted him to think that perhaps his urine was sugary, so he made an appointment to be evaluated for diabetes and was subsequently diagnosed with T2DM. After starting metformin, the patient's fasting blood sugar had improved since his last visit from 223 to 151 and he reported that there were no more ants in his toilet now that his blood sugar was better controlled.

Dr. Tsai had to educate many of his patients on when to take their oral diabetes medications. They were instructed to take them immediately before eating and not before cooking to avoid hypoglycemia. However, if they forgot to take them before the meal, they could also take them immediately after eating. Dr. Tsai also told patients to be aware that hypoglycemia is most likely to occur at 10-11am, 4-5pm, and in the middle of the night.

Today, Dr. Tsai didn't have many patients scheduled for thyroid ultrasound so he showed us how to properly perform a thyroid ultrasound exam. Although we've practiced using ultrasound a few times this year, I hadn't yet had a chance to examine anyone's thyroid so I appreciated this opportunity to learn from Dr. Tsai. To see the right or left thyroid gland in a coronal view, the probe is placed horizontally/transversely to the patient's neck. The strap muscles, trachea and carotid artery can also be seen in this view and the artery is differentiated from the jugular vein by its pulsing and the fact that it does not compress under the ultrasound probe. To see the longitudinal view of the thyroid gland, the probe is rotated to line up with the sternocleidomastoid muscle. The isthmus can also be seen on thyroid ultrasound, and Dr. Tsai explained that while a normal parathyroid gland is not visible on ultrasound, patients with parathyroid lesions will have visible abnormalities on the bottom of the thyroid gland sonogram while in coronal view.

Dr. Tsai preparing to teach me how to perform a thyroid ultrasound scan on student doctor Jonathan Go

Thyroid ultrasound anatomy