Modul Practicum Guidelines Laboratory Skills Guidelines

BLOCKS OF ENDOCRINE

FACULTY OF MEDICINE
MUHAMMADIYAH UNIVERSITY OF YOGYAKARTA 2010

MODULE
BLOCK OF ENDOCRINE

Editor dr. Sri Sundari M.Kes dr. Agus Widyatmoko, MKes, SpPD dr. Alfaina Wahyuni, MKes Person In Charge: dr. Sri Sundari, MKes

Departments Involved: Internal Medicine Physiology Obstetry and gynaecology Anatomy Anatomical Pathology Clinical Pathology Surgery Pharmacology Center for Islamic Medicine Studies (PSKI) Center for Family Medicine Studies (PSKK)

FACULTY OF MEDICINE MUHAMMADIYAH UNIVERSITY OF YOGYAKARTA 2008

OVERVIEW BLOCK OF ENDOCRINE Block of endocrine is the fourteenth block of 24 blocks of medical curriculum in preclinical stage. The topics of this block range from preclinical, clinical, community and family medicine in which the integration of EBM and family medicine. In this block there are some learning activities consists of small group discussion or tutorial, lecture, clinical skills and practical in laboratory. Generally, this block consist of disease or disorder of endocrine system, patophysiology, diagnosis, and management Finishing this module, students are expected to be able to understand the basic concept of the process on how endocrine diseases and disorders occur and students are also expected to understand the management .

TOPIC TREE BLOCK OF ENDOCRINE

COMPETENCE AREA BLOCK OF ENDOCRINE Competence area of Competence Standard for Medical Doctor (SKD) that will be achieved on this block i.e: 1. Area 1 : Efffective comunication 2. Area 2 : Clinical skills 3. Area 3 : Basic Science of medicine 4. Area 4 : Management of Health disorder 5. Area 5 : Management of information

TEACHING LEARNING PLAN BLOCK COMPETENCIES

At the end of this block students are expected to be able to understand the basic

concept of the process on how endocrine diseases and disorders occur and students are also

A. Characteristic of the students The students attending the block of Endocrine are those who have learned 13 blocks, it means that they sitting in semester 5 or in year 3. They are supposed to have been familiar with the basics of medical science and been introduced to clinical science. The students are expected to develop clinical thinking and clinical reasoning as well as maintaining their independent and in depth learnig process, particularly when they deal with the endocrine. B. Learning outcome At the end of this Endocrine block, the students will be able to: 1. Utilize well developed communication skills to facilitate effective patient care and productive collaboration with patients and their families and communities who have endocrine disorder (Area 1) 2. Will be able to collect and record accurate and important information about the patient and his/her family and also can conduct endocrine disorder (Area 2) 3. Apply the concepts and principles of biomedical, clinical, and behavioural science, and public health about the endocrine disorder, appropriate to the delivery of primary health care, can summarize an appropriate interpretation of the history and endocrine examination of endocrine disorder and then evaluate the effectiveness of patient management.(Area 3) 4. After the student can make diagnosis endocrine disorder, they can manage the patients disorder and problem in the context of the whole person, as a part of a

family and a community, conduct prevention and health education of endocrine disorder in order to promote health and to prevent endocrine disorder and also use a family medicine approach to manage cases of endocrine disorder (Area 4) 5. Use the information of technology and communication to diagnose, therapy, prevention and promotion, and control of the state of patient who have endocrine disease or disorder. (Area 5)

C.Learning of Competence

Level of expected ability

D. Topics Strategy Lecture, Practical, Clinical Skills, Tutorial

Competence Area

Core Competency (SKD)

Topics

AREA 1

Able to explore and exchange information verbally and non verbally with patients of any age, family Clinical skills members, communities, collegues and other professionals. Conduct clinical procedures based on the patients problem and Lecture needs, and the doctors accreditation Practical Clinical skills

Patient education of DM Diit DM dan exercise (leg exercise)

AREA 2

Tutorial AREA 3 Identify, explain and plan a scientific approach to health problem solving, based Lecture on current medical and health science to get an optimal result.

Pathology of Thyroid and other glands Pathology of thyroid, parathyroid, hipofisis and adrenal Pathology of thyroid, parathyroid, hipofisis and adrenal Thyroid examination Technique in giving Insulin, examination of blood glucose Conduct clinical procedure (Scenario 1 4) Endocrine system Physiology Endocrine Reproduction Hormone Biochemical Endocrine System feminine reproduction System Womens and mens Infertility Demography and Family Planning

Endocrine diseases and complications DM Juvenile disease, Thyroid Menstrustion disorder Bormone biochemical Sexualities Azoosperm Tutorial AREA 4 Manage health problems in a person, family or community comprehensively, holistically, sustainably, coordinatedly, and collaboratively in the context of a primary health care service. Physiology and pathophysiology of the disease (scenario 1 4) Pharmacotherapy disorders or Hormonal diseases ACTH Management of endocrine disease and treatment Treatment of hormone disorder diseases Tutorial AREA 5
Acces, care, critical analize of the information to solve the problem or desicion making in the context of a primary health care service.

Lecture

Tutorial

Management of endcocrine disease and disorder (scenario 1 4) Evidence Based Medicine of Doagnose, Managemen and therapy of endocrine disease and disorder.

E. Pre-assessment Block of endocrine is the 14th block in UMY curriculum which give the students to the basic concept of the process on how endocrine diseases and disorders occur and students are also expected to understand the management Learning activities must be followed by the students as the requirements to do final examination. Minimal attendance of the learning activity : 1. Lecture : 75% 2. Tutorial : 75% 3. Clinical Skill : 100% 4. Practical in laboratory: 100%

F. Teaching strategy and learning experience Week 1 Topics Endocrine system Physiology Endocrine System Endocrine System Endocrine disease 1 Pathology of Thyroid and other glands Scenario 1 Thyroid examination Week 2 Topics Hormone Biochemical Pathology of Thyroid and other glands Pathology of thyroid, parathyroid, hipofisis and adrenal Endocrine disease 2 Treatment of hormone disorder diseases Scenario 2 Pathology of thyroid, parathyroid, hipofisis and adrenal Technique in giving Insulin , examination of blood glucose, treatment of hypoglycemic. Week 3 Topics Endocrine disease 3 and 4 DM Juvenile disease, Thyroid Pharmacotherapy disorders or Hormonal diseases Scenario 3 Diit DM dan exercise (leg exercise) Week 4 Strategy Lecture Lecture Lecture Tutorial Clinical skills Department Internal Medicine Duration 4 2 2 2x2 2 Strategy Lecture Lecture Lecture Lecture Lecture Tutorial Practical Clinical skills Department Duration 3 2 3 2 2 2x2 2,5 2 Strategy Lecture Lecture Lecture Lecture Lecture Tutorial Clinical skills Department Duration 5 1 1 2 2 2x2 2

Internal Medicine

Topics Endocrine Reproduction Endocrine disease 5 ACTH Feminine reproduction System Womens and mens Infertility Demography and Family Planning Menstruation Disorders Sexualities Azoosperm Scenario 4 Patient education of DM

Strategy Lecture Lecture Lecture Lecture Lecture Lecture Lecture Lecture Lecture Tutorial Clinical skills

Department Internal Medicine

Duration 2 2 1 2 4 2 3 2 2 2x2

Week 5 Topics Endocrine disease 6 Menstruation and the disorder of menstruation Human behavior: Emotion and self-control Scenario 5 (in English) Plenary Discussion Practical Exam Clinical Skills Exam Strategy Lecture Lecture Lecture Tutorial Department Internal Medicine Duration 2 1 1 2 2-3 2x4

Week 6 Topics Strategy Department Duration

Block Exam
G. Facilities Medical faculty of UMY has some facilities to support teaching learning activities. The facilities consists of : a. 3 Amphitheatre for lecturing completed with computer/notebook & LCD projector, audio recorder, internet b. 15 tutorial room for small group discussion with capacity 12-15 sudents/room completed with TV, DVD media player, CCTV, internet c. d. e. f. 2 clinical skills laboratory rooms 6 laboratoties for practical work 1 Facultys Library 1 Laboratory of Information Technology

g.

hot-spot area H. Evaluation Assessment is conducted using formative and summative assessment. Formative assessment by assessing daily activities using check list, written report, kuiz, etc. summative assessment using written examination (MCQ) and OSCE. The final score of block will be determined by 50% of MCQ 30 % of Tutorial 20 % of OSCE and Practical in laboratory. The students pass Learning skills block if fulfill all of these criteria below : the minimum score of MCQ is 60 the minimum score of OSCE is 60 the minimum of the final score is 60

I. Learning Resources a. Text Book 1. Ganong W.P., 1995. Review Medical Physiology. 17th ed, Prentice Hall International, Englewood, New Jersey. 2. Gilman, A.G., rall, T.W., Nies, A.S., and Taylor, P., 1990. Goodman and Gilmans the Pharmacological Basis of Therapeutics, 8 th ed, Pergamonn Press, New York. 3. Granner, D.K., Mayer, D.A., Rodwell V.W., Harpers Biochemistry, Lange Medical Book , 18th ed. 4. Guyton, A.C., & Hall, J.E., 1996. Textbook of Medical Physiology. W.B Saunders Company, USA. 5. Harrisons, Principles of Internal Medicine (Wilson et al). 6. Kanagasuntheram, R., Sivanandasingham, P, Krisnamurti, A., 1987. Anatomy Regional, Functional & Clinical. P&G Publishing. Singapore. 7. Katzung, B.G (editor). 1998. Basic and Clinical Pharmacology. 7th ed. Appleton & Lange, Conneticut. 8. Lynchs. 1993. Medical Laboratory Technology. 4th ed. 9. Markum. 1991. Buku ajar Ilmu Kesehatan Anak FK UI, Jakarta. 10. Nelsons. 1996. Textbook of Pediatric, 16th ed, 11. Omar Hasan Kasule. 2000. Lectures Islamic Medicine, International Islamic University Malaysia. 12. Robbin, Pathologic Basic disease. 13. Sabiston , Texbook of Surgery. 14. Sarwono, Ilmu Kebidanan. 15. Shahid Athar. 2000. Islamic Medicine. Indiana Univ. School of Medicine, Inidianapolis, Indiana. 16. Staf Pengajar IKA_UI. 1986. Buku Kuliah Ilmu Kesehatan Anak, Jakarta. 17. Widmanns. 1991. Clinical Interpretation of laboratory Test. 10th ed, 18. Williams, P.I., 1995. Grays Anatomy The Anatomical Basics of Medicine and Surgery. ELBS with Churchil Livingstone, great Briatin. 19. Spheroff L & Fitz M.A. 2005. Clinical Gynecology Endocrinology and Infertility,7th ed. Lippincot Williams & Wilkins a. Journal

1. BMJ 2. NEJM 3. PubMed b. Expert 1. Prof. Dr. Sri Kadarsih Soejono, MSc, PhD 2. dr. Luthfan Budi Nugroho, SpPD 3. dr. Zain Alkaf, SpOG

LECTURE TOPICS (ENDOCRINE MODULE) NO 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 TOPICS Endocrine system Physiology Endocrine Reproduction Hormone Biochemical Endocrine System Endocrine System Pathology of Thyroid and other glands Pathology of thyroid, parathyroid, hipofisis and adrenal feminine reproduction System Womens and mens Infertility Demography and Family Planning Menstruation Disorders Sexualities Endocrine diseases, complications and treatments DM Juvenile disease, Thyroid Pharmacotherapy disorders or Hormonal diseases ACTH Treatment of hormone disorder diseases Azoosperm Human behavior: Emotion and selfcontrol DEPARTMENT Physiology Biochemistry Histology Anatomy Clinical Pathology Pathology Anatomy Obsgyn LENGTH (HOURS) 5 hours 2 hours 3 hours 1 hours 1 hours 4 hours 3 hours 2 hours 4 hours 2 hours 3 hours 2 hours 12 hours 2 hours 2 hours 1 hours 2 hours 2 hours 1 hours

IPD IKA Pharmacology Surgery science PSKI

PRACTICUM TOPICS (ENDOCRINE MODULE) NO 1 TOPICS Pathology of thyroid, parathyroid, hipofisis and adrenal DEPARTMENT Pathology Anatomy LENGTH (HOURS) 2,5 jam

SKILLS LAB TOPICS/FIELD (ENDOCRINE MODULE) NO TOPIK DEPARTEMEN DURASI (JAM)

1 2 3 4

Thyroid examination. Technique in giving Insulin , examination of blood glucose, treatment of hypoglycemic. Patient education of DM Diit DM dan exercise (leg exercise)

2 jam 2 jam Skills Lab. 2,5 jam

SUPPLEMENTS OF
BLOCK OF ENDOCRINE

GUIDANCE OF TUTORIAL
BLOCK OF ENDOCRINE

TECHNICAL GUIDELINES OF TUTORIAL SEVEN JUMPS Tutorial process in problem based learning (PBL) will use seven jumps as guidance for tutor and students to discus problem from scenario. There are seven steps in Seven jumps i.e. : 1. 2. 3. 4. 5. 6. 7. Clarifying unfamiliar terms Problem definitions Brainstorm Analyzing the problem Formulating learning issues Self study Reporting

1. Clarifying unfamiliar terms Unclear terms and concepts in a problem description are clarified, so that every group member understands the information that is given 2. Problem definitions The problem is defined in the form of one or more questions. The group has to agree upon the phenomena that need to be explained 3. Brainstorm The preexisting knowledge of group members is activated and determined. This process entails the generation of as many explanations and hypotheses as possible. The ideas of all the group members are collected, without critical analysis 4. Analyzing the problem Explanations and hypotheses of the group members are discussed in depth and are systematically analyzed. Ideas from the brainstorm are ordered and related to each other

5. Formulating learning issues Based on obscurities and contradictions from the problem analysis, questions are formulated that form the foundation for the study activities of the group members. In short, it is determined what knowledge the group lacks and learning issues are formulated on these topics 6. Self study Group members search relevant literature that can answer the questions in their learning issues. After studying this literature the group members prepare themselves for reporting that they have found to the tutorial group

7. Reporting After reporting what sources group members have used in their self study activities, a discussion of the learning issues takes place based on the studied literature. Group members try to synthesize what they have found in different sources Step 1 to 5 will be conduct in the first meeting, after that the students will conduct self study to search the explanation to answer the learning issues. The 7 step will be conduct in the second meeting.

Overview of student skills in PBL

Preliminary discussion Step 1. Description Clarifying unfamiliar terms Chair Invites group members to read the problem Checks if everyone has read the Unfamiliar terms in the problem problem text are clarified Checks if there are unfamiliar terms in the problem Concludes and proceeds to the next phase Problem definition Ask the group for possible problem definitions The tutorial group defines Paraphrases contributions of group the problem in a set of members questions Checks if everyone is satisfied with the problem definitions Concludes and proceeds to the next phase Brainstorm Allows all group members to contribute one by one Preexisting knowledge is Summarizes contributions of group activated and determined, members hypotheses are generated Stimulates all group members to contribute Summarizes at the end of the brainstorm Makes sure that a critical analysis of all contributions is postponed until step four Analyzing the problem Makes sure that all points from the brainstorm are discussed Explanation and Summarizes contributions of group hypotheses are discussed in members depth and are Asks questions, promotes depth in the systematically analyzed discussion and related to each other Makes sure the group does not stray from the subject Stimulates group members to find relations between topics Scribe Divides the blackboard into three parts Notes down the unfamiliar terms

2.

Notes down the problem definitions

3.

Makes brief and clear summaries of contributions Distinguishes between main points and side issues

4.

Makes brief and clear summaries of contributions Indicates relations between topics, makes schemata

5.

Formulating learning issues It is determined what knowledge the group lacks, and learning issues are formulated on these topics

Stimulates all group members to contribute Asks for possible learning issues Paraphrases contributions of group members Checks if everyone is satisfied with the learning issues Checks if all obscurities and contradictions from the problem analysis have been converted into learning issues

Notes down the learning issues

Reporting phase Step 7. Description Reporting Chair Prepares the structure of the reporting phase Findings from the literature Makes an inventory of what sources are reported and answers to have been used the learning issues are Repeats every learning issue and asks discussed what has been found Summarizes contributions of group members Asks questions, promotes depth in the discussion Stimulates group members to find relations between topics Stimulates all group members to contribute Concludes the discussion of each learning issue with a summary Scribe Makes brief and clear summaries of contributions Indicates relations between topics, makes schemata Distinguishes between main points and side issues

CHECKLIST ON ASSESMENT TUTORIAL Tutorial contributes 30% to the final score of the block, consisting of 15% average score of mini quiz and another 15 % of activities score of each tutorial meeting. The components to score in each tutorial are as follow: Students name Students number BLOCK No 1 2 3 4 5 6 7 8 9 Criteria
DEALING WITH WORK Preparation of task Completeness in performing task Brainstorming task Active participation in a group Report back DEALING WITH OTHERS Working in a team Listening to others Performance as a chair of a group Summarizing discussion DEALING WITH ONE SELF Dealing with feedback Giving feedback The ability to reflect Dealing with appointment Being in time

: : : Unsatisfactory Score (meeting ) Satisfactory Good No judgment

10 11 12 13 14

Unsatisfactory

: below the expected average level of the tutorial group. Item for improvement are clear and easy to mention. (score: <60) Satisfactory : on the expected level of the tutorial group. Some issues for improvement rest. (score: 60-69,9) Good : students perform better than expected average of the group (score: 70-80) No Judgment : because student was absent to frequently. (score: 0)

ENDOCRINE MODULE SCENARIOS SCENARIO 1 A 53-year old woman who lives in the area of Merbabu Mountain feels anxious because of the bump in the front part of her neck. She has been feeling it for few months. Whenever she does her activity, she feels her heart beats rapidly. She also feels that her hands are shaking and her legs are swollen. The woman has two shildren. She looking for wood everyday after her husband passed away 1 years ago. Because of anxious about her signs, the woman goes to Primary Health care.

Discuss the case above using seven jumps!

SCENARIO 2 A Primary Health Care doctor found a 24 year old woman has a 120 cm hight and low IQ when he had a job in Primary Health Care at Menoreh Mountain. The doctor got a part of communities have a cretinism after he had got an epidemiology survey. A part of communities who have a cretinism, they have thyroid enlargement grade III to. The doctor looking for the cause of this disease, because the couple who has cretinism so they have a cretinism child to. Discuss the case above using seven jumps!

SCENARIO 3 References: 1. Dods, R.R., 1996. Diabetes Mellitus, in Clinical Chemistry Theory, Analysis, Correlation. Eds. Kapaln L.A, Pesce , J. eds. Mosby Inc, USA: 613-640 2. Sacks, D.B., 2001. Carbohydrats, In Tietz Fundamentals of Clinical Chemistry, eds. Burtis, C.A., Ashwood, E.R., 5th eds, W.B. Saunders Company, USA, 427-461 3. Foster, D.W., 2007. Diabetes Mellitus. In Harrison,s Principles of Internal Medicine, Eds, Fauci, Barunwald, Isselbacher et al, 14th ed, Mc. Graw Hill Companies, USA, 623-75 4. Hendromartono, 1998. Consensus on the Management of Diabetes Mellitus (Perkeni). In Surabaya Diabetes Update VI , Eds Tjokro[rawiro, A., Hendromartono, Sutjahjo, A., Tandra, H., Pranoto, A, 1-14 5. Kaplan, L.A., 1987. Laboratory Approaches. In Methods in Clinical Chemistry, Eds Amadeo J., Kapaln, L.A., 94-96

SCENARIO 4 A married couple who has been married for 2 years goes to a family doctor because the wife is not pregnant yet. The wife is anxious because since she was a young girl, her period is irregular; sometimes she got her period once in three months. Her parents to push aside her to take a baby as soon as. They dont have brother or sister. A Family doctor gives counseling for them.

Discuss the case above using seven jumps.

SCENARIO IN ENGLISH A 35-year old woman presents to he physician for the first time at 10 weeks gestational age. She is well and reports no problem. Her first child was delivered vaginally without complications and weighted 4500 g. Discuss the case above using seven jumps.

GUIDANCE OF SKILLS LABORATORY BLOCK OF ENDOCRINE

Contributrs dr. Tri Wahyuliati, MKes, SpS dr. Denny Prakoso dr. Agus Widyatmoko, MKes, SpPD dr. Sri Sundari, MKes

PRACTICAL SIDES OF MANAGEMENT OF DIABETES MELLITUS IN A FAMILY General Objective: Students understand the practical sides of Management of DM in a family covering DM diet, leg treatment of DM sufferers, independent examination of blood glucose and, injection techniques of insulin pen. Specific Objectives: 1. Students are able to count calories needs of DM patients. 2. Students are able to write down need substitutes on DM leaflet. 3. Students are able to provide education on material substitutes with leaflet and meals models. 4. Students are able to provide diet education in relation with the condition of normal body organs. 5. Students are able to demonstrate legs exercise on DM sufferers. 6. Students are able to show any types of insulin and insulin injection tools. 7. Students are able to conduct and provide education on how to inject insulin pen. 8. Students are able to conduct and provide education on the importance, objectives and ways of blood glucose examination. DIABETES MELLITUS DIET Objective: adjust the meals with body ability to use them, so that the sufferers reach normal organs condition and are able to do daily activities like usual. Requirements: 1. The amount of calories is determined by age, sex, body height and weight, activities, body temperature, metabolic abnormality. 2. The amount of carbohydrates is in line with body ability to use it while pure sugar is not permitted. 3. Proteins, minerals and vitamins are sufficient in food. 4. Food giving is in accordance with types of medicine given. if tablets or injection RI 3x a day are given, meals are given 3x a day; if given PZI, meals are given 4 x a day in relatively same amount. Snacks at 10.00 and 21.00 oclock are taken from the portions of morning and afternoon meals.

Diet Types and Giving Indication As a guideline, 8 diets of DM are applied: Diet Type I II III IV V VI VII VIII Calorie 1100 1300 1500 1700 1900 2100 2300 2500 Protein g 50 55 60 65 70 75 80 85 Fat g 30 35 40 45 50 55 60 65 Carbohydrate g 160 195 225 260 300 325 350 390

Diet I to III are given to too fat sufferers. Diet IV to V are given to the sufferers with normal body weight. Diet VI to VIII are given to thin sufferers, juvenile diabetes) or diabetes with complications. KNOWING YOUR OWN CALORIE NEED NAME : _______________________________________ DATA Height : cm Ideal Body Weight = 90% (Height 100) Kg = Kg (a) (Women Height < 150 cm, Man Height < 160 cm = Ideal Body Weight = (Height (cm) 100) Kg = . Kg Actual Body Weight = Kg Overweight / Underweight / normal weight Sex Man / Woman Basal Calorie = Calorie (Man 30 cal/kg, Woman 25 cal/kg) (b) Activity Sedentary / Mild Age = year CALORIE COUNTING Basal Calorie = a x b = .. x = Calorie (c) Correction Age > 40 year -5 % x (c) = -5 % x . = .. Calorie Activity = Sedentary = + 20 % x (c) = + 20 % x . = + Calorie Mild = + 30% x (c) = + 30 % x . = + ... Calorie

 Body Weight = - Overweight = - 20 % x (c) = - 20 % x . = - ... Calorie - Underweight = + 20% x (c) = + 20 % x = + ... Calorie Total Requirement = . .Calorie Diet DM = .. Calorie

DIABETES DIET STANDARD (in Food Exchange) ENERGY Time Breakfast Rice Meat Tempe Vegetable A B Fruit Fat 10,00 Fruit Milk Lunch Rice Fish Tempe Vegetable -A B Fruit Fat 16,00 Fruit Dinner Rice Fish Tempe Vegetables A B Fruit Fat 1 1 1 1 1 1 1 1/2 2 1 1 1 1 2 1 1 2 1/2 3 1 1 1 1 3 1/2 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

1100 1300 1500 1700 1900 2100 2300 2500 Exchanges 1/2 1 1/2 1 1 1 1/2 1 1 1/2 1 1/2 1 1/2 1 1/2 2 1 1 1 1 1/2 1 1 1

As you like 1 1 1 1 1 1

1 1 1

1 1 1

1 1 1

1 1 1

1 1 1

1 1 1

1 1 1

1 1/2 2 1 1 1 1

2 1 1

2 1/2 3 1 1 1 1

3 1 1

3 1 2

As you like 1 1 1 1 1 1

1 1 1

1 1 1

1 1 2

1 1 3

1 1 3

1 1 3

As you like 1 1 1 1 1 2

1 1 2

1 1 2

1 1 3

1 1 3

1 1 3

1 1 3

EXCHANGE LISTS For Meal Planning Dietary Department And Diabetes and Lipid Center Dr. Cipto Mangunkusumo Hospital Jakarta What are exchange lists? The 8 exchange lists help make your meal plan work. Foods are grouped together on a list because every food on a list has about the same amount of carbohydrate, protein, fat, and calories. In the amounts given, all the food on a list can be exchanged or traded for any other foods on the same list. Using the exchange lists and following your meal plan will provide you with a great variety of food choices and will control the distribution of calories, carbohydrate, protein and fat throughout the day. Measurement of the food. 1 Tablespoon (Tbs.) = 10 ml 1 Teaspoon (Tsp.) = 3 ml 1 Glass (Glass) = 240 ml 1 Cup (C) = 240 ml *) HHM : House Hold Measurement List 1 : STARCH / RICE Each item in this list contains approximately 40 grams of carbohydrate, 4 grams protein, a trace offat, and 175 calories. FOOD Biscuit Bread (white) Cassava Cassava (flour) Corn flour Crackers Elephant ear Oat meal Mung bean starch HHM*) 4 3 slices 1 medium 8 Tbs. 10 Tbs. 5 1 medium 5 Tbs. 10 Tbs. Gram 40 70 120 50 50 50 125 45 50

Macaroni Noodle (dry) Noodle (cooked) Potato Rice (cooked) Rice Noodle Rice Grueal Rice flour Sago Sweet Potato Wheat flour

glass 1 glass 2 glasses 2 medium glass cup 2 glasses 8 Tbs. 8 Tbs. 1 medium 5 Tbs.

50 50 200 210 100 50 400 50 50 135 50

List 2 : MEAT EXCHANGE

1. Low Fat Each item in this list contains approximately 7 gram of protein, 2 grams of fat, and 50 calories.

FOOD Blood cake Buffalo no fat Chicken no skin Fish Salted fish Small fish Tripe

HHM*) 1 piece 1 piece 1 piece 1 medium 1 small 1 Tbs. 1 piece

Gram 35 35 40 40 15 20 40

1. Medium Fat Each item in this list contains approximately 7 grams of protein, 5 grams of fat and 75 calories.

FOOD Beef Beef liver Brain Egg Chicken livers Duck egg Intes Goat meat Meat balls Shrimp 1. High Fat

HHM*) 1 piece 1 piece 1 piece 1 medium 1 piece 1 medium 1 piece 1 piece 10 medium 5 medium

Gram 35 35 65 55 30 55 50 40 170 35

Each item in this list contains approximately 7 grams of protein, 13 grams of fat and 150 calories.

FOOD Chicken with skin Egg yolk Corned beef Duck meat Pork Sausage

HHM*) 1 medium 4 medium 3 Tbs. 1 piece 1 piece 2 small pieces

Gram 55 45 45 45 50 50

list 3 : BEAN & NUTS

Each item in this list contains approximately 7 grams of carbohydrate, 5 grams of protein, 3 grams of fat and 75 calories. FOOD Cow peas Mung bean Fermented peanut cake Peanuts Peanut butter Red Kidney beans Soya bean Soybean curd Soy milk powder Tempeh HHM*) 2 Tbs. 2 Tbs. 2 small pieces 2 Tbs. 1 Tbs. 2 Tbs. 2 Tbs. 1 piece 2 Tbs. 2 pieces Gram 20 20 40 15 15 20 25 110 185 50

List IV : VEGETABLES 1. Vegetables A exchanges Negligible Carbohydrate Protein, Fat and calories. Calabash Chinese radish Cucumber Lettuce Mushroom 1. Vegetables B exchanges One exchange (1 cup cooked, drained) equal 5 grams of carbohydrate, 1 gram of protein and 25 calories. Bamboo shoot Beef Bitter ground Broccoli Goa bean Mung bean sprouts Inflorescence of banana Yard long beans Ridge gourd Tomatoes Water crush Wax gourd

Cabbages Caisin Carrot Cauliflower Chajola Corn baby Eggplant 1. Vegetables C exchanges

Mustard greens Papaya baby Squash pumpkin Swamp cabbages Spinach String beans

One exchange (1 cup cooked, drained) equals 10 grams of carbohydrate, 3 grams of protein and 50 calories. Belinjo Belinjo leaves Bread fruit Cassava leaves Elephants ear leaves Garden peas Papaya leaves Red spinach Soybean sprout Young jack fruit

List V : FRUITS & SUGAR Each item in this list contains approximately 12 grams of carbohydrate and 50 calories.

FOOD Apple Banana Carambola Grapes Guava Honey Jack fruit Dates Lanzon

HHM*) 1 medium 1 1 big 20 1 big 1 Tbs. 3 3 16

Gram 85 50 140 165 100 15 45 15 80

Lychee Malay rose apple Mango Rock Melon Papaya Peach Pineapple Rambootan Soursop Sapodillas Spanish plum Sweet orange Sugar Watermelon Watery rose apple

10 1 small 1 piece 1 piece 1 small 8 glass 1 2 2 1 Tbs. 1 2 big

75 110 90 190 110 115 95 75 60 55 120 110 10 180 110

List VI : M I L K Non-Fat Milk Each item in this list contains about 10 grams of carbohydrate, 7 grams of protein and 75 calories.

FOOD Skim milk (powder) Skim milk Yogurt non fat 1. Low fat milk

HHM*) 4 Tbs. 1 cup 2/3 cup

Gram 20 200 120

Each item in this list contains about 10 grams of carbohydrate, 6 grams of fat, 7 grams of protein, and 125 calories.

FOOD

HHM*)

Gram

Cheese Goat milk Cows milk Unsweetened evaporated milk Yogurt non fat

1 small cup 1 cup cup 1 cup

35 165 200 100 200

1. High milk Each item in this list contains about 10 grams of carbohydrate, 10 grams of fat, 7 grams of protein and 150 calories.

FOOD Buffalo milk Whole milk List VII : F A T S

HHM*) cup 6 Tbs.

Gram 100 30

Each item in this list contains 5 grams of fat and 50 calories.

1. Unsaturated fat

FOOD Almond Avocado Corn margarine Corn oil Peanuts oil Soy bean oil Sun flower oil Olive oil 2. Saturated fat

HHM*) 7 big 1 Tsp. 1 Tsp. 1 Tsp. 1 Tsp. 1 Tsp. 1 Tsp.

Gram 25 60 5 5 5 5 5 5

FOOD Butter

HHM*) 1 Tbs.

Gram 15

Coconut Coconut milk Coconut oil Coconut shredded Palm oil Bacon

1 1/3 cup 1 Tsp. 2 Tbs. 1 Tsp. 1 Slice

15 40 5 15 5 5

List VIII : NEGLIGIBLE CALORIE FOOD Alternative sugar: aspartame, saccharin Bouillon (Without fat) Coffee / Tea Gelatin Mineral water Soybean sauce Vinegar spices

SCENARIO 1 A 50 year-old man with body weight of 80 kg and body height of 160 cm working as a high school teacher went to ICU due to feeling weak. The man has been diagnosed as suffering from DM since 5 years ago and conduct irregular control. Since month ago, there has been a wet wound on his leg. Medication has been given in Community Health Center (puskesmas) but it has not been recovered yet. SCENARIO 2 An 18-year-old swimming athlete weighed 50 kg, height 160 cm has been diagnosed as suffering from DM since 1 year ago. The athlete has to plan a good diet to support his carrier. Due to ASEAN championship, the athlete actively rehearses twice a day, morning and afternoon. Each exercise takes 2 hours. Plan a well-arranged diet for the athlete correctly.

LEG TREATMENT Things to know: Diabetic leg problems All tool types of leg treatment. Ways of cleaning legs Ways of cutting toenails Choosing footwear Things endangering legs that should be avoided Legs exercise Ways of choosing shoes / requirements of good shoes for DM sufferers

Example of Leg Exercise Initial Position: Sit down straight up on a bench and do not lean

1st exercise (10 times) 1. Move the toes from both legs like pawing 2. Straighten them back

2nd exercise (10 times) 1. Lift the toe tips, heels remain on floor 2. Put down the toe tips, then lift the heels and then put down back again.

3rd exercise (10 times) 1. Lift toe tips of your both feet. 2. Spin your ankle sideways. 3. Put them down on the floor and move to the central side.

4th exercise (10 times) 1. Lift your both heels. 2. Spin your heels sideways. 3. Put them down again on the floor and move to the central side.

5th exercise (each leg 10 times) 1. Lift one of the knees 2. Straighten your legs. 3. Move your toes forwards. 4. Put your leg down again, left and right legs take turns. 6th exercise (each leg 10 times) 1. Straighten one of your legs on the floor. 2. Lift the leg. 3. Move the toe tips towards your face. Put down back the hell on the floor

7th exercise (10 times) Like the prior exercise (exercise 6) but this time, with both legs at the same time.

8th exercise (10 times) 1. Lift your both legs, straighten and hold on the position. 2. Move your ankles forwards and backwards.

9th exercise (each leg 10 times) 1. Straighten one of your legs and lift it. 2. Spin the ankle. 3. Write on the air number 0 10 using your leg.

10th exercise (once) 1. A piece of newspaper folded in the form of a ball using feet. Then make it as before folded using both feet and afterwards, tear it up. 2. Collect the torn pieces with both feet and put on other piece of newspaper. Finally, wrap all in the form of a ball with your both feet.

WORK PAGE
I. II. scenarios: Students conduct practice of leg exercise for DM sufferers. Students conduct counseling for DM diet through the following

CHECK LIST EDUCATION ON DM DIET ACTIVITIES 0 1 2 Explain the diet objectives in DM management. Count calorie needs of DM client diet: A. Count the ideal body weight B. Determine clients normal/under/over weight C. Count the calorie basal total relating to sex. D. Count the basal calorie correction (regarding the age, activity, and body weight) Implement the result of calorie counting (no. 2d) A. Into the table of diabetic standard diet (in food exchange) B. To arrange menu example relating to food exchange 4 table (exchange list) relating to the result of 3a. Explain about the needs of pair/family support towards SCORE 1 2

the success of DM diet. TOTAL SCORE

EXAMINATION OF BLOOD GLUCOSE Various blood glucose examination tools (in line with those available in exercise place) : Accutrend (common, mini, GC)

Adbantage Glucometer 4 Glucometer Gx One touch basic One touch II Surestep

Tools/ materials: Autoclix/vaccinostyle Alcohol 70% Cotton Blood glucose examination tools and strip test ( test carik)

How to take the blood: 1. Clean patients ring finger using cotton that has been give alcohol 70%, dry it. 2. Prick the ring finger tip using vaccinostyle vertically, fast and not deep. 3. after blood comes out from the finger, sweep it with dry sterililzed cotton. 4. Push the fingertip outward. 5. Turn the hand up side down. Allow the blood drop alittle. 6. Drop the blood on the strip test. 7. Conduct the examination procedure in line with the instruction of each testing tools. How to use glucometer 1. If the strip test picture appears, put the strip test in 2. Touch the blood drop until filling the central test area. 3. Read the blood glucose that appears. 1. A piece of newspaper folded in the form of a ball using feet. Then make it as before folded using both feet and afterwards, tear it up. 2. Collect the torn pieces with both feet and put on other piece of newspaper. Finally, wrap all in the form of a ball with your both feet.

INSULIN AND WAYS TO USE IT Things students should know: Introduction to any types of insulin Introduction to insulin injection tools: various injection tools with various scale (injection tool BD, Terumo 1 cc and CC) Novo pen II (novo Nordisk) Novo pen III (Novo Nordisk) medijector BD pen (Becton Dickinson) Preparation: Injection location Preparing insulin in accordance with the dosage, ways of mixing insulin. Sterilize location and tools. Cleaning the tools. Storing insulin and the tools. Self-performed injection Complication of insulin injection

Injection techniques for people with diabetes Tools required: Insulin Injection tools with the needle Disinfectants Cotton Hand-washing container

Patients preparation: Fasting begins at night, at least 8 hours, last meal at 20.00 22.00 pm If thirsty in the morning, patients are allowed to drink fresh water or tea with no sugar, do not take any medicine in the morning. After finishing taking fasting blood, medicine-taking or insulin injection may take place two hours post pandrial. Patients eat some diets usually taken. After exactly 2 hours, blood is taken for examination.

(Gloves are used when injecting others. Gloves are useful as self-protection against other peoples body liquid, so that sterilization is not required. As a result, it can be used repeatedly). Injection procedures:

1.Prepare equipments

injection and avoid

2.

If

using

insulin the

3. Take some air into the injection tube with the same volume as the insulin amount to be injected.

suspension,

move

touching the needle.

bottle up side down so that the suspension will mix perfectly and also sterilize the rubber cap with disinfectant.

Slowly stick the needle into the vial insulin with vertical position parallel with eyes.

Insulin goes into injection equipment, knock slowly on the injection equipment so that the appearing air bubbles are gone.

Store

back

the

exceeding insulin into vial insulin so that the sucked away. air is also

Ways of injecting: needles position may be at 45 degrees or vertical.

Inject it slowly, then push with finger on the area took where place injection after the

To avoid injury on the skin tissues due to the repeated injection in one area, it is advised that each injection moves on different areas.

needle was drawn away.

WORK PAGE
I. II. Students conduct blood glucose examination. Students conduct insulin injection. CHECK LIST EDUCATION ON HOW TO INJECT INSULIN PEN ACTIVITIES 0 1 2 3 4 5 6 7 Explain how to put insulin tube on pen. Explain how to put on pen needle. Explain how to arrange dosage/unit required by the equipment. Explain how to conduct disinfectanization on the injection area. Explain how to conduct injection. Explain the locations that injection may take place. Explain how to recognize the symptoms of complication SCORE 1

due to injection (signs of infections and hypoglycemia) TOTAL SCORE

ANAMNESIS OF THE BLOCK GENERAL OBJECTIVES:

Students are able to conduct anamnesis on cases of endocrine diseases.

SPECIFIC OBJECTIVES:
1. Students are able to conduct anamnesis of main complaints and explore well and properly on cases of endocrine diseases. 2. Students are able to conduct anamnesis about recent diseases history and explore well and properly on cases of endocrine diseases. 3. Students are able to conduct anamnesis about past diseases history and explore well and properly on cases of endocrine diseases. 4. Students are able to conduct anamnesis about family and socio culture history and explore well and properly on cases of endocrine diseases. 5. Students are able to summarize well and properly the problems faced by patients 6. Students are able to determine properly the possibility of comparing diagnosis on the problems faced by patients.

ASSIGNMENT:
Each big group is divided into small groups of 2-3 people. One person plays the role of a doctor, one plays as a patient and the other one is the observer. This assignment is done exchangeably. Conduct the anamnesis for cases like the following:

SCENARIO 1
A 52-year-old woman who live in Merbabu mountain area feels upset due to the emergence of a bump on the front area of her neck since last few months. Each time she wants to do her activity, she also feels harder heart beats. She also feels that her hands are trembling and she has swollen legs.

SCENARIO 2
A 32-year-old woman, who was just married, conducts a complete laboratory examination for general check-up. She really wants to have a baby because she feels that she is now turning quite old. Her body weight is 65 kg and with body weight of 155 cm. Lately she has been complaining of feeling sleepy easily and often urinate. There are members of her family who have suffered from the same complaint.

SCENARIO 3

A married couple that has been married for 6 months sees a doctor because the wife is not pregnant yet. The wife feels upset due to her irregular menstruation since she was young, even, he has not had the menstruation in three months long.

SCENARIO 4
A 48-year-old woman, experiencing premenaupause is interested to conduct hormone replacement therapy (HRT) to prevent osteoporosis. She feels hot on her face and sick with intermittent sharp pain on her back. She has been a smoker since 20 years ago and has a family history of breast cancer and heart disease.

CHECK LIST FOR ANAMNESIS NO I ASPECTS TO BE SCORED Maintaining courtesy 1. Say salaam at the beginning of interview, ask to sit down 2. Ask the identity 3. Ask about the main complaints II Nice, sympathetic and friendly appearance Able to collect needed information: 4. Use understandable language to the respondents. a. Interview is not impressed as investigating or interrogating b. Exploring the main complaints Ask about RPS a. Ask about patients other complaints b. Explore patients other complaints c. Ask about RPD d. Ask about personal history e. Ask RPK III IV f. Conduct cross-checking to ensure patients answers g. Be neutral with patients h. Able to take note clearly Possess interviewing appearance properly i. Work consistency and discipline V j. Polite and sympathetic Able to summarize patients problems well and properly a. Able to draw conclusion about recent condition. b. Able to determine the opportunity of comparing diagnosis on diseases suffered. 0 SCORE 1 2 3

Note: 0 1 2 3 : not done : done but less properly : done properly : done properly and perfectly

Patient education of Diabetes Mellitus

Role Play:
Conduct a role-play in running skill of patient educating about Diabetes Mellitus (DM) completely with your friend. Make a couple of 2 persons by turns to play role as:

Doctor who will conduct patient educating Patient DM sufferer The student who is acting as a patient is also act as the observer to evaluate the doctor by using List of Anamnesis Observation hereunder. Good Luck!

The Patients Guidance:

You act as a patient who has been diagnosed as DM Evaluate your friend who is acting as the doctor in conducting patient educating about DM based on the observation list.

The Doctors Guidance:

Educate about DM comprehensively to the patient; if necessary, you may use leaflet and poster about DM. Do not forget to pay attention the verbal and non-verbal communiation
Observation List of Patient Educating about Diabetes Mellitus
No 1. Assessed Aspect To create communication by greeting the patient and introducing himself, and also make a comfortable environment for the patient. To check the patient identity Parameter
0

Score
1 2 3

Assalamualaikum,

Mr. Ali, Im Budi, school of medicine student/ young doctor.. Im a part of medical team who will treat you.

2.

Recite it naturally and do not make a formal impression

Name Age Address Work Marital status Use open-ended questions What do you know about your disease, sir? Use daily communication, not medical one

3. 4. 4. 5. 6.

To ask the patient understanding about DM To explain the general description about DM To explain about DM sympthom To ask about the history of family disease (RPK) To ask about history of social personal

member

Childhood disease Disease in his family Death, the cause and age of die time of his family Draw it into FAMILY GENOGRAM * * * * ADULT: Education Work environment Home/family/mariage environment Habit/lifestyle (diet, physical activity, smoking, alcohol, drug, etc) CHILDREN: History of mother pregnancy (ANC, medication, etc) History of mother delivery History of prenatal History of nutrition (ASI, etc) History of immunization History of growth development Skin Head Eye Ear Nose & sinus Throat (mouth& faring) Neck Breast Lungs Heart Digestion Ureter Genital: male / female Vein perifer

7.

* * * * * *

8.

Anamnesis system (review system)

9. 10.

To embrace the gained history of the patient Non-verbal communication aspects

Muscle & bone Psychological Nerve Blood Endocrine To embrace the finding of history of yang retell it to the patient
To give a chance the patient to check the reality Eye contact maintaining Friendly expression, smile Open ended gesture, to face the patient with 45 degree Clear voice articulation & prompt intonation Clean & neat appearance Content reflection Feel reflection

11.

Aspects of emphaty and skill of active hearing

Explanation: 0 = Not conducted

1 = Conducted but improperly

2 = Conducted properly

3 = Conducted properly and perfect

Observation List of Genogram Family Making And Family Life ciclus Identification
No 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Assessed Aspects Made of minimum 3 generations The symbol made for male and female family member and marital status The first birth of each generation is located at the most left and followed by the next birth at the right side. The family name is on the top Name and age are under each symbol The patient is identified with an arrow Writing down the date of diagram making Taking a note about health problems of each family member (into symbols with explanation) Taking a note about important dates in family history: Death, birth (age), marriage, divorce Identifying the family member who live in the same house to identify family type of the patient: nuclear family; extended family, etc Taking a note about name and main role /function of the family member: B = Breadwinner D = Decision maker C = Caregiver PN=Pencari nafkah PK=Pembuat keputusan POS= Pengasuh OS Explanations of all the used symbols Cyclus identification of family life: TOTAL

Parameter
No (0)

Check
Yes (1)

12. 13

EXAMINE OF THE THYROID GLAND GENERAL OBJECTIVES: Students are able to examine the thyroid gland .

SPECIFIC OBJECTIVES: 1. Students are able to examine of the normal thyroid gland. 2. Students are able to examine of the abnormal thyroid gland. 3. Students are able to interpret the result of the examine thyroid gland. EXAMINE PROCEDURE: 1 . Inspect. a. b. Ask the patient to bend the head back a bit. Inspect the region below the cricoid cartilage for the thyroid gland. c. d. Then ask the patient to take a sip from a glass of water, again extend the neck and swallow. Watch the movement of the thyroid gland, nothing its countour and symmetry. An enlarged thyroid gland, and also many normal ones, may be visible even before swallowing. An enlarged thyroid gland is called a goiter

2 Palpate. Palpation is probably best done from behind the patient. Because you cannot see what you are doing, you may initially find this position awkward. Orient yourself first to the

patients cricoid cartilage- the basic landmark for the examination. Feelings any visible thyroid tissue form in front of the patient first may also give you guidance a. from behind, place the fingers of both hands on the patients neck so that the index fingers are just below the cricoid. b. The patients neck should be extended, but not far enough to tighten the muscles c. As the patients swallows the thyroid isthmus should rise under your fingers. d. By rotating your fingers slightly downward and laterally, feel as much of the lateral lobes as possible, including their lower borders. e. During both maneuvers the patient should sip water as necessary to swallow as you repeat your palpation. Note the size, shape, and concistency of the gland and identify any nodules or tenderness. The anterior surface of a lateral lobe is approximately the same size as distal phalax of the thumb, its consistency is somewhat rubbery

3. Auscultate If the thyroid gland is enlarged, listen over the lateral lobes with a stethoscope to detect a bruit ( a sound similar to a cardiac murmur but of noncardiac origin). A localized systolic or continous bruit may be beard in hyperthyroidism. CHECK LIST FOR THYROID EXAMINATION NO I ASPECTS TO BE SCORED Maintaining courtesy a. Say salaam at the beginning of interview, ask the objective of examination II A. Inspect 1. Ajust patients neck for extention 2. Inspect lower os cricoid to examine the glandula SCORE 0 1 2 3

thyroidea and report the result of the examination B. Palpate 1. Examiner stands behind the patients 2.Put his two fingers below os cricoid, patients is asked to swallow 3. Examiner checks thyroid and reports the result of palpate examination. e. When enlargment happens, auscultation is done. Examiner can put stethoscope on lobus lateralis glandula thyroidea and report the bruit. A. Examiner cincludes the result of the examination in general. Note: 0 1 2 3 : not done : done but less properly : done properly : done properly and perfectly

GUIDELINES FOR PRACTICUM BLOCK OF ENDOCRINE

Contributor: dr. Agus Suharto, SpPA

ENDOCRINAL SYSTEM I. ENDOCRINAL SYSTEM GENERAL DESCRIPTION A. Component system Endocrinal system in the body consists of some endocrinal organs, those are: adenohipofisis thyroid gland adrenal gland endocrine tissue in exocrine gland, such as insula pancreatic and some endocrine cells with DNES function in the alimentary canal mucosa

B. Endocrine origin Endocrine gland is a gland that doesnt have exit canal (ductus excretorius), it develops as epithel surface invaginasi, such as oral ectoderm or colon endoderm, which finally released, separated from the main epithel. C. MICROSCOPIC STRUCTURE Endocrine gland is specifically formed by lots of sekretorik cells which are arranged as chorda, gathered or convex follicle which directly connects with blood capillary or sinusoid. D. SECRETION Endocrine cells release their secretion, as hormone specially, into the blood circulation. Other substances are not released into blood circulation but they are released into a canal (ductus) (those substances are enzyme and albumin serum), but they are also considered as hormone secretion. Hormone is a molecule which influences on the special arrangement on target cells, a tissue or organ which is located far away from the glands location. Hormone, even in a small portion, can give dramatic and specific effects and it can also directly or indirectly influence all tissues. There are so many hormones that can keep the environment in balance. Hormone plays important roles in controlling the carbohydrate, protein, and lipid metabolism; mineral and water balance in body liquid; growth; sexual function and body shape differences in terms of sex and behavior, character or temper and emotion. There are two kinds of hormones, those are: 1. Peptide Hormone Protein, glycoprotein, or short chain peptide hormones tie a special receptor in the target cell surface. This kind of hormone sometimes stimulates the second

intracellular messenger production, such as Krebs cyclic (AMP cyclic) in the target cell.

2. Steroid Hormone Hormone that dissolves in lipid can easily go through target plasma cells and then directly influences the cells function. This hormone binds in the special joint protein in cytoplasm and nucleus. E. NEUROENDOCRINE SYSTEM There is a complex connection of function in the cells, tissue and body organ is monitored and coordinated by two interconnected system i.e. nervous and endocrine system. With the increasing of attention on these two systems, it is considered as single system that is neuroendocrine system. One of its glands is called master gland because of its capability in controlling endocrine gland and nervous system. The secretoric activities of these two parts of this hipofisis are neurohipofisis and adenohipofisis, both are controlled by other part of the brain which is located near to each other, that is hypothalamus. The hypothalamus activities are controlled by: 1. Nerves connection with other parts of nervous system, and 2. Negative feedback from hormone that is produced by hipofisis target cells. Diseases occur are related with hipofisis, especially as the result of hipofisis hormones hyper-secretion or hypo-secretion; this hyper or hypo secretion is caused by hipofisis, target organs or hypothalamus damage.

II. GENERAL ORGANIZATION AND HIPOFISIS EMBRYONIC ORIGIN There are two parts of hipofisis those are: Adenohipofisis, and Neurohipofisis, These two parts are difference on their origins, structure and function. A. ADENOHIPOFISIS 1. Origin It is rom evaginasi go up to ectoderm which layers the primitive mouth cavity. This part makes contact and then intact with neurohipofisis that grows down. 2. General structure Adenohipofisis consists of glandular capillary gully which is separated from one another by a big amount of sinusoidal capillary from plexus capillary secundaricus. Adenohipofisis does not directly get nerve from hypothalamic nerves.

3. Subdivision Adenohipofisis is divided in to: Pars distalis (pars anterior), which is the biggest part. Pars tuberalis, which is an expansion toward superior area from pars distalis, forming the hand part which is an infundibulum partial cover (neurohipofisis) Pars intermedia, a ribbon like part of hypofisis slender tissue which borders with neurohipofisis B. NEUROHIPOFISIS 1. Origin Neurohipofisis is appeared as downward growth of ectoderm neural hypothalamus and because of it; it becomes a part of the brain. 2. General structure Neurohipofisis consists of a big amount of axon. The axon comes from nervous cell body especially in supraopticus nucleus and paraventricularis hypothalamus nucleus. 3. Subdivision Neurohipofisis is divided into infundibulum which consists of infundibular stem (neural stalk) and eminentia mediana. This infundibular stem brings axon from hypothalamus to pars nervosa, it also contains capillary from plexus capillaries primaries. Eminentia mediana from tuber cinerium forms hypothalamus floor. Pars nervosa (infundibularis processus) is an expansion of neurohipofisis lobus; this pars nervosa contains axon terminal and some big blood capillaries. III. ADENOHIPOFISIS Every secretor cell in adenohipofisis synthesizes and stores on of the following hormones: follicle-stimulating hormone (FSH) thyrotropin (thyroid stimulating hormone : TSH) luteinizing hormone (LH) adrenocorticotropic hormoe (ACTH) growth hormone (GH), and prolactin The secretion of those hormones, which control the activities of other glands, are regulated or controlled by special releasing or inhibiting hormones which are produced by hypothalamus and carried to adenohipofisis by blood in the hipofisis portal system. A. PARS DISTALIS Consists of two cell groups, those are:

1. Chromophobus This cell does not bind color, so it is in a pale color, looks transparent or white in the tissue microscopic preparatory. There are three kinds of this chromophobus cell, all of the three kinds are 50% epithel in the pars anterior; the cells are: a. Non-secretoric cell which has not been differentiated, it might be a stem cell. b. Cromofilic cell that some of it has been degranulated, which contains small amount of granule, and c. Foliker cell is a cromofob type cell which dominates in making stroma web that supports other cell (cromofil). Its a star-shaped cell (stelat) and can have fagositic function. 2. Chromophylus This hormone producer cromofil binds color tightly because there is a bug amount of granule, where hormone is stacked or stores, in its cytoplasm. There is a specific cell for every hormone. The cromofil cell has bigger size than cromofob cell and it is divided into two classes, those are: a. Acidophil This cell is a simple protein producer, it is strongly painted with eosin and orange G, but it isnt painted with PAS. This cell stays in one group in the edge of the organ; it has smaller size than basophile cell while its sitoplasmic granule is bigger and in a bigger quantity. Acidophil cell consists of two kinds of hormone producer cell; those are samototroys which produces samototropin (growth hormone) and mammotrop cell which produces prolactine. To remember hormones that are produced by acidophil cell, the GPA (Growth hormone, Prolactine, and acidophil) abbreviation is used. b. Basophile Basophile is painted with hematoksilin and other base colors and has PAS positive character. The location of this cell is in the middle of the organ; it is bigger than acidophil cell. This basophile cell consists of 3 kind of cell which produces 4 kinds of hormones, those are: Each cell from the two gonadotrops cells produces different gonadotropin. One of the cells produces follicle stimulating hormone (FSH); while the other cell produces luteinizing hormone (LH; it is also known as interstitial cell-stimulating hormone = ICSH in men) Kortikotrovik produces adrenocortitropin (ACTH). Tipotropi produces thyroid-stimulating hormone (TSH) B. PARS TUBERALIS

Pars tuberalis shape is like a ships chimney and is an upward expansion of pars distalis which surrounds infundibular stem. The histological description is similar to the pars distalis, but it mainly contains gonadotrops cells. Pars tuberalis is full of blood capillary from plexus capillaries primaries of hipofiseal portal system. C. PARS INTERMEDIA A pars intermedia looks like ribbon or adenohipofisis belt between pars distalis and pars nervosa. It does not develop in human body. It contains Rathkes cysts. This Rathkes cysts are small rooms with irregular shapes and contain colloid which is covered with cuboids epithel. These cysts are the remains of Rathkes pouch. Pars intermedia also contains groups and basophile cell gullies or melantrops which produce melanocyte-stimulating hormone (BMSH) D. VASCULAR AND HIPOFISIS PORTAL SYSTEM 1. Plexus capillaries primaries This plexus is located in the upper part of infundibular stalk = truncus infundibularis and in the lower part of emenentia medianal widen into pars tuberalis. These plexus capillaries get the blood from hypophysealis anterior and posterior superior (from circulus Willisi) arteries and flow into portalis hypophysealis vena. 2. Portalis hypophysealis vena Small vena or venula is mainly located in the center and lower part of truncus infundibularis and in the pars tuberalis. This portalis vena accepts blood from plexus capillaries and is directly carried to plexus capillaries secundarius in the pars distalis. Blood vessels carry blood directly from a certain plexus capillaries to other plexus capillaries without returning to main circulation that is portal vessel. 3. Secondary Plexus Capillaries Plexus which is rich with full of holes capillaries is located in the whole part of pars distalis; it goes also trough pars tuberalis and pars intermedia. In this plexus, it is also found the connections between these capillaries and the capillary which is located in pars nervosa. Capillaries which are located in gland cell lines in the pars distalis, belong to this plexus, get blood directly from portalis vena and arterial blood from hypophysealis anterior-superior. The blood flows from inferior hypophysealis inferior into the internal jugulars vena. E. RELEASING AND INHIBITING HYPOTHALAMUS HORMONES This peptide hormone with light molecule is synthesized in the neuron (neurosecretoric cell body) with nucleus in hypothalamus and released from its terminal axon into primer capillaries plexus. That hormone flows through

hypophysealis portalis venula into secondary venous plexus. Then, it goes trough the adenohipofisis to stimulate or hamper the release of hormone by acidophil and basophile cells (endocrinocytus acidophilicus dan endocrinocytus basophilicus). 1. Releasing Hormone Hormones that are included in this hormone are: a. Corticotrophin-releasing hormone (CRH) It is a peptide hormone which consists of 41 amifio acids and is synthesized in the paraventricularis nucleus and also spur the Corticotrophic/ Corticotrops cells to produce ACTH. b. Gonadotropin releasing hormone (GnRHI) It consists of 10 kinds of amino acid, synthesized in the preopticus and arcuatus nucleus; it spurs the gonadotropic/gonadotrops cell to stimulate the release of FSH and LH hormones. c. Thyrotrophin-releasing hormone (TRH) It is a peptide hormone which consists of 3 amino acids, stimulates the thyrotrophic/ thyrotrops to release TH (tirotrophin). 2. Inhibiting hormones a. Somatostasin (GHIH = Growth hormone-inhibiting hormone) It is a peptide hormone which consists of 14 amino acids; synthesized in the suprachiasmaticus nucleus which inhibits somatotropic/somatotrops cells which produce somatotropin (GH = Growth Hormone). This somatostatin also inhibits the secretion of glucagons, insulin and other hormones related to the digestive system (gastrointestinal tract) b. Dopamine (Prolactin-inhibiting hormone = PIH) It is a neurotransmitter which is synthesized in the arcuatus nucleus which inhibits the mamotropic/mamotrops to release prolactin. F. SUMMARY OF ADENOHIPOFISIS HORMONES PRODUCTION 1. Neuron in nucleus in hypothalamus synthesizes inhibiting and releasing hormones and packs them in neurosectorial vesicle. 2. Neuron carries this neurosecretoric vesicle downward into the tuberoinfundibularus tractus axon and hypothalamohypophysealis tractus into the axon terminal which surrounds primaries plexus capillaries. 3. Nervous or hormonal reciprocal stimulation from adenohipofisis target organ causes this nerves stimulate the action-potential which releases correct inhibiting and releasing hormones from axon terminal. 4. And then, inhibiting and releasing hormones go into the primaries capillaries plexus and flows through portae vena to the secondary capillaries plexus. 5. In this secondary capillaries plexus, hormones ooze out from capillary lumen through windows or holes (fenestratum) and stimulate or inhibit the releasing

of adenohypofisis hormones which is stored in it from acidophil and basophile cells. 6. Adenohipofiseal hormone goes in through secondary capillaries plexus; and then, leaves adenohipifisis through anterior-inferior hypophysealis vena into the big circulation. G. THE HISTOPHYSIOLOGIES OF ADENOHIPOFISIS HORMONES 1. Somatotropin = GH = growth hormone (STH) Somatrotopin is a protein with a small molecule, consists of 190 amino acids and never has target organ, but it influences the cells in entire body, raises the protein synthesis ratio. Another metabolic influence is raising the fat acid from adipose tissue and lowering the ratio of glucose use. The most prominent influence is the growth ratio of young animals. The absent of this hormone can cause pituitary dwarfism. The excessive amount of this hormone can cause pituitary gigantism. The overproduction of this hormone is caused by a tumor in pars distalis in adulthood which causes acromegali, a typical condition which is marked by disproportional/imbalance bone thickening. 2. Prolactine It is a protein with molecule weighting 25.000 D and consists of 205 amino acids. Its prime role is to stimulate the development of mammary and lactase glands. During the pregnancy, the concentration of this hormone growths rapidly, starting from the fifth week until aterm pregnancy. 3. Thyrotrophin (thyroid stimulating Hormone = TSH) It is a glycoprotein hormone with molecule weighting approximately 2.8000 D. This hormone holds tiroglobulin proteolysis and releases thyroid hormone to blood. This hormone can also cause gland cells become hypertrophy and cause the ratio of thyroid hormone increasing. 4. Gonadotropin: FSH and LH The two hormones are produced by pars hipofisis hormone which is called gonadotropis. FSH is a glycoprotein with molecule weighting about 30.000 D. In women, this hormone undergoes the secretion circulation which goes up and down every month. The increasing of this hormone stimulates the development of some follicles in the ovarium as a preparation to one or two ovulation in the middle of the cycle. For men, FSH plays an important role in the initiation of spermatogenesis during the puberty period. The role of this hormone in adolescence human in not clear but it seems it plays the roles in sertoli cell (endocrinocytus interstitials) in the seminiferus tubules, stimulates the synthesis of androgen hormone which binds protein. LH is a gicoprotein with molecule weighting 26.000 D. In women, the function in the ovarium is to increase estrogen hormone secretion by developing its follicles, and in the middle of the cycle, it increases the LH hormone peak level. After ovulation, this hormone

causes differences in luten cells which creates luteum corpus. In men LH hormone stimulates interstitial in testis, discharges testosterone which is important in keeping the process of spermatogenesis. 5. Adrenokorticotropin = adrenokortikotrop hormone This hormone is included in polypeptide with 39 amino-acid chains, with molecule weighting about 4.500 D. This hormone stimulates cortex of adrenal gland to produce/discharge cortisol kortisol hormone. IV. NEUROHIPOFISIS Neurohipofisis has three structural components, those are; A. NEUROSECRETORIC AXON CELL Neurohypofisis contains lots of nervous fiber (axon) without myelin cover (neurofibra non-myelinata). This axon comes from nervous cell body (corpus neurocyti) which is mainly located in supraopticus nucleus and hypothalamic paraventricularis nucleus. This axon spreads from both nucleuses to the hipofisis nervosa, together forming hypophysealis hypothalamo tractus. This axon contains granule neurosecretoric and show granule with neurosecret in big size, which is called Herring bodies (corpusculum neurosecretorium accunulatum). Neurosecretoric materials which are located in the granule are produced and packed in those nucleuses. 1. Neurohipofisial Hormone Neuron hypothalamus which is terminated in the neurohipofisis releases oxytosin and anti-diuretic hormones, around blood capillaries in that hipofisis part. a. Oxytocin is a peptide with 9 amino acid chains, especially synthesizes by hypothalamic paraventricularis nucleus. This hormone stimulates the breast milk from mammae granule and stimulates the contraction of uterus smooth muscle when copulation and child birth. b. Antidiuretic hormone (ADH = arginine vasopressin) It is a peptide which consists of 9 amino acids and is synthesized mainly by cells in supraopticus nucleus. This hormone stimulates the reabsorbing of water by ductus collectivus renalis. 2. Neurofisin as protein-binding which binds the two neurohipofisis hormones 3. ATP = Adenosin triphospate B. PLEXUS CAPILLARIES FENESTRATUM It surrounds the axon terminal. The blood capillaries accept the secretic products and carried them to the big sirculation. C. PITUICYTUS Pituicytus is a glia cell with branches, and its taju surrounds and supports axon without covering myelin.

D. SUMMARY OF NEUROHIPOFIS HORMONE PRODUCTION 1. Each Neuron in supraopticus nucleus synthesizes ADH and oxytocin hormones 2. Its neuron packs those two hormones with neurofisin and ATP in the neurosecretoric vesicle. 3. The vesicles are transported by neuron with its axon faces downward from tractus hypothalamohypophysealis into axon terminal among the blood capillaries in nervosa pars. 4. In the right stimulation, neurosecretic cells arouse the action potential along its axons, causing exocytose with vesicle in terminal axon. GLANDULE ADRENALIS 1. GENERAL DESCRIPTION OF HORMONAL SECRETORIC CELLS = endocrinocytus: structure-function relation. The knowledge about endocrinocytus structure can give a prediction or presumption about ultra endocrinocytus which produces steroid hormones that contain more reticulum endoplasmicum nongranulosum than reticulum endoplasmicum granulosum; whereas endocrinocytus which produces peptide hormone contains a big amount of reticulum endoplasmicum granulosum. 2. GLANDULE ADRENALIS = GLANDULE SUPRARENALIS It forms a hat on top of renal (kidney). These glands are divided into two main categories according to their origin, structure and function, those are: A. ADRENAL CORTEX 1. Embryonic origin Adrenal cortex comes from mesoderm coelom intermedia 2. Structure of mature glands Gland cell in adrenal cortex has a special structure as a steroid hormone producer. Adrenal cortex is divided into three layers, those are: a. Glomerulosa Zone Glomerulosa Zone is the outer layer of adrenal gland and it is located right under the capsule and occupies 15% of adrenal volume. Its cells cluster looking like archers bow (glomerulus) surrounded by blood capillaries. Endocrinocytus in this zone produces mineralocorticoid. b. Fasciculate zone This middle layer of adrenal cortex occupies approximately 65% of adrenal gland. Its cells are arranged like straight lines forming fascicules which are perpendicular with organ surface. Endocrine-ocytus in this organ produces gukokortikoid and some adrenal androgen hormones. c. Reticularis Zone This zone is the inner layer and occupies about 7% of adrenal volume. Its cells are arranged like cordial or irregular rope which braids anastomosis

(reticulum). Its cells are similar to the fasciculate, but smaller and more asidofil. The cells contain lesser lipid than those cells in fasciculate zone and have more lipofuscin granule. Reticularis and fasciculate zones forms single functional zone with retucolaris zone forming most of the glucocoticoid and adrenal androgen, while fasciculate zone plays role as a reserve zone which is activated by long term stimulation. 3. Normal Function Adrenal cortex produces three kinds of steroid hormones; those are: a. Mineralocorticoid It is mainly consisted of aldosteron which is produced by glomeru-losa zone as its response to stimulus, especially for angiotensin II stimulus, and also by ACTH. Aldosteron organizes the balance of water and electrolyte by stimulating the absorbing of Na by renis distalis tubulus, it also has influence on gastrica mucose and saliva gland. b. Glucocorticoid It is mainly consisted on cortisol and corticosteron. Both hormones are produced by reticularis zone with the stimulus from ACTH and fasciculate zone with the long term stimulus. Glucocorticoid organizes carbohydrate metabolism, especially by stimulating carbohydrate synthesis in hepar (liver). Glucocorticoid has opposite role in other tissue; that is as catabolism (degradation) of carbohydrate to get the carbohydrate base material for hepar. Glucocorticoid also suppresses the responds of body immune by decreasing the amount of lymphocyte and eosinofil circulation. c. Adrenal Androgen Adrenal androgen is mainly consisted of dehidro-epi-androsteron, which is discharged as a responds to ACTH by recticularis and undergoes the long term stimulation, it is also produced by fasciculate zone. The influence of this hormone is its masculinis-asi and anabolic characters which are similar to the testosterone, but it is less patent. 4. Abnormal Function a. Hyper secretion Cushings syndrome is an example of the existence of cortisol hypersecretion and more often androgen. the sympthoms cover trunchus obesity (body), moon face, high blood glucose degree, diabetes mellitus, hirsutism, amenorrhea, acne and unstable emotion. B. Hypersecretion Aldosteron, For instance sindroma conn, causing retention of water and Na, and hypertension. hyposecretion: Hypofunctional chronic of adrenal cortex, such as Addisons desease causing blood glucose degree, Na, Cl, and carbohydrate low and K degree in serum

high. this casues body weaknesses, nausea, losing body weight, and increasing ACTH degree (causing hyperpigmentation). In this case, there is no compensation for androgen from testis, decreasing synthesis androgen adrenal on women can cause the loss of pubes and armpits hair. 5. Cortex Foetalis or Provisional Cortex The thickest adrenal layer before birth is located in between medulla and thin permanent immature cortex. it causes sulfated androgen which is activated by placenta and come into material circulation. after birth, foetalis cortex experiences regression, and permanent cortex develops into three layers such as described above. B. MEDULLA ADRENAL 1. Origin: It originates from crista neuralis. 2. Structure: composed of two primary cells, they are: A. Cromaphin Cell It is also called phoechromocytus. It is a cell type that predominates medulla. This cell is a modification of neuron postganglionic symphatic that loses axon and its dendrite. It has big neculceus. Granula secretoric is solid electron. This granula contains catecholamine (epinefrin or nore-pinefrin). Complexus golgiensis grows well. There are only some reticulum endoplasmicum granulosum, and very many oval mitochondrion are found. The secretoric granula has strong affinity towards cromium color substance. Cromafin cell synthesizes and releases the catecholamine content facilitated by neuron preganglionic sympatic. B. Ganglion Cell Some existing parasimphatic ganglion cells perform morphology of ganglion cell type of specific autonomy. 3. Normal Function The normal function of medulla adrenal covers the production of 2 types of catecholamine, that is, epinephrine and norepinephrine, on the response to stimulation ganglion simpatico (such as stress). The two catecholamine hormones increase blood glucose degree by stimulating glicogenolisis in hepar; this hormone increase the blood circulation to the heart. a. Epinephrine It causes harder heartbeats and blood vessel dilatation, which is required by organs to prepare or avoid sties, such as heart muscles and skeletal muscles. Perform dilatation of bronchioles and perform contraction of blood vessel in organs (such as on skin, digestive system, kidneys) that is not important to react against stress. b. Norepinephrine

It causes blood vessel contraction on unimportant organs. It increases periphery resistance so that it increases blood pressure and blood circulation to the heart, brain and skeletal muscles. 4. Abnormal Function Tumor hypersecretion of chromafin cell (pheocromocytoma) causes the increase of stress respons (mainly hypertension) although without the existence of stress. Tumor cell ganglion (neuroblastoma and ganglion neuroma) often occur, mainly on children but they manifest clinically various. C. ADRENAL VASCULARISATION 1. Artery Three main arteries supply blood to every adrenal gland. they are: A. suprarenalis superior, originating from a. phrenicus inferior. A. suprarenalis medialis from aorta, A. suprarenalis inferior from arterial rhenalis.

The three arteria penetrate capsula separately, and the branches of anastomose create plexus arteria subcapsularis. From this plexus, three groups of arteries emerge: a. arteria in capsule b. arteria in cortex, that has many branches forming cortical capillary that runs in between secretoric cells and flow into medularis capillary; and c. arteria in medulla This arteria runs through cortex without the branches until it reaches medulla, and this artheria forms medullaris capillary. 2. Medullaris Capillary Which accepts double blood, that is, from both artheria in cortex and medulla, meeting to form several medullaris vena. 3. Medularis Vena. These medularis vena meet each other to form one big suprarenalis vena. 4. Suprarenalis Vena Located in the middle of the medulla, and this vena flows into renalis vena or directly comes into vena cava inferior. INSULA PANCREATICA This insulae pancreaticae is a building like endocrine cell nest (endocrinocytus) that spreads all over pancreas. Each insula contains four types of cell producing peptide hormones. A. ALFA CELL = ENDOCRINOCYTUS ALPHA. This cell produces glucagons hormone, playing a role of increasing low blood glucose degree, and this hormone works on the reverse of insulin hormone. B. BETA CELL = ENDOCRINOCYTUS BETA

This cell is found abundant inside insulae pancreatincae and produces insulin. The insulin works at the condition of high blood glucose degree and can decrease the high degree of blood glucose to be normal again. Insulin increases the blood glucose intake by most cells; increasing glycogen synthesis by hepatocytus and grigliserid synthesis by adipocytus. Malfunction of beta cells may cause diabetes mellitus, a condition as a manifestation due to excessive glucose blood degree (hyperglycemia), that is released through urine so that glicosuria takes place. Hyperplasia and neoplasia of bheta cell can cause hiperinsulism syndrome, with the specific symptom of hinoglikemia. C. DELTA CELL = D CELLS = ENDOCRINOCYTUS DELTA Somatostatin that suppresses insulin release, glucagons and growth hormones, is produced by this delta cells. Besides, this cell also produces gastrin that triggers gland secretion in digestive system mucosa. Syndrome zollinger-ellison (gastrinoma) is caused by the excessiveness of acid. Gastric produced by parietal cell on gaster mucosa/gastric, is singed by ulcus pepticum. Somastostatinoma is a tumor that is hardly found and has various effects. D. F CELL = PP CELL This type of cell secretes polypeptide pancreatica that slow pars exocrine pancreas to produce enzyme and bicarbonate. This hormone causes vesica fellea relaxation and reduces bile secretion. GLANDULA THYROIDEA Is located on neck, anterior larynx. This thyroid gland is composed of two lobus connected by isthmus. This gland is composed of follicles in great amounts and in the form of spheres and wrapped by thin capsules penetrating into parenchyma, creating septas. B. THYROID FOLLICLES each follicle is composed of epithelium simplex cuboideum/one-layered cuboids epithel rotating/limiting a lumen containing colloid. These follicles have various sizes, enlarging if there is stimulation. C. THYROID FOLLICLES CELL 1. Structure The thyroid follicles cell that originates from endoderm has its ultra structure that performs specific cell that produces peptide hormone. The cell size is ranging from flat on inactive glands until columnar if there is stimulation. 2. Normal Function Thyroid follicles cell is different from other endocrine gland cells that store halfmade hormone (intermediate) (thyroglobulin) extracellularly inside colloid, but it is not stored inside the granula cytoplasm. Stimulation by TSH that is generally followed by the increase of energy need. Synthesis and secretion increase. a. Synthesis and thyroglobulin storage Required steps to perform this process are:

Synthesis of tirosin-rich protein = tiroglobulin, on reticulum endoplasmicum granulosum. Protein glicosilation in reticulum endoplasmicum and complexus golgiensis. Wrapping in vesicles on complexus golgiensis, and Fusion of vesicles on apex membrane cell, resulting in exsositosis tyroglobulin into colloid on lumen follicles.

b. Absorption and iodide oxidation Molecular pump in plasma membrane of follicle cells move iodide in the circulation into cytoplasm. This iodide is oxidized by peroksidase and then moved to cell apex. Iodide absorption is also triggered by TSH. c. Iodination of tiroglobuline and the formation of tiroid hormone Enzymes that are found on the tips of microvilli plasma membrane penetrate into colloid catalyzing iodination of tirosin residue in tiroglobulin. The reaction is in between bending microvillus surface. One iodide molecule is added with tirosin, creating monoiodotyrosine (MIT). The second iodide molecule is then added into some tyrosine residue, forming diiodotyrosine (DIT). The pair of two tyrosine that has been iodized forms tyronine molecules. The combination of two DIT molecules forms tetra-iodothyronine (thyroxin; T4), while the combination of one MIT and one DIT forms triiodothyronine (T3). Although T4 is the producer of 90% thyroid hormone, this hormone is not strong in general. d. Secretion of thyroid hormone Stimulation by TSH causes follicular cells to perform pinositosis on colloid part, creating vesicles that contains tiroglobulin that has been iodized. These vesicles run fusion with lisosoma containing enzyme that smashes tiroglobulin. T3 and T4 are released, spreading outside from secondary lisosoma. this vesicles penetrate cytoplasm and membrane plasma to reach blood circulation. e. Target and the effect of thyroid hormone T3 and T4 affect whole body cells. it increases basal metabolism ratio (i.e., ratio on the time the cell uses glucose), increases cell growth, increases heartbeat, increases energy-user cells. this hormone also affects on TRHproducing cells on hypothalamus and thyrotrops on adenohipophisis to reduce TSH secretion (negative feedback). 3. abnormal function a. hypothyroidism Excessive production of thyroid hormone is also known as thyrotoxicosis, causing some symptoms such as nervousness, palpitation, fast polls, muscles weaknesses, fatigue. Weight loss with good appetite, drench in sweat, do not

stand sun heat and unstable emotion. Hyperactive follicles thyroid due to additional length of epithelia follicles and the increase of tiroglobulin sediment causes swelling of the thyroid gland and it is called goiter. b. hypothyroidism Hypothyroidism is called cretinism on children and myxedema = mixoedema on adults. Hypothyroidism causes less glucose use. The symptoms appearing among others are: lethargy, unable to stand cold weather, slow inttellctual and motoric skills, storage of glicosamino-glican on dermis (skin) with the consequence that the skin becomes bump and sometimes body weigh increases. Because iodide is needed for normal thyroid function, lack of iodide on food diets reduces the production of functional thyroxin and often cause cretinism and myxedema. Because thyroxin that is not iodized is caused by iodide deficiency does not give negative feedback on TSH production, follicle and goiter enlargement often comes along with this type of hypothyroidism. D. PARAFOLICULAR CELL = CELL C This cell is found on thyroid glands, spreading among between follicular cells or clustering among follicular cells. On human being, the cytoplasm of parafolicular cell is colored pale with standard and specific color substance that look transparent and white. The structure of the ultra cell plays a role to increase Ca (calcium) degree in blood. Calcitonin causes Ca absorption by cell and increase Ca deposition on bones, so that it causes the decrease of Ca degree in blood.

GLANDULA PARATHYROID There are 4 parathyroid glands, located in posterior surface of tiroid glands; coming from endoderm (3rd and 4th pharynx bags). in adults, this gland is composed of two types of primary cells; chief cell = cellula principalis and oxyphil cell = cellula oxyphylus. A. CHIEF CELL = CELLULA PRINCIPALIS is a parenkim cell in large amount. 1. Structure: This cell has small size (proximately 4-8 micron in diameter), polygonal and ultra structure illustrates cell type that produces peptide hormone. This cytoplasm cell that is coloured pale is full of small granula secretoric. 2. Normal function This principal cell secretes paratiroid hormone (PTH = parathyroid hormone) in response to stimulation of low Ca blood degree with 3 targeted areas, they are: a. In bones, PTH increases bones reabsorption. b. In kidneys, it inceases phosphate excretion and Ca reabsorption as well as causes precursor activities of vitamin D. c. In intestine, PTH (may be due to the vitamin D activity causes the increase of Ca absorption from foods by intestinal mucosa. 3. Abnormal function a. Hyperparatiroidism Excessive secretion of PTH increases serum Ca (hyperphosphatemia) and decreases serum phosphate degree (hypophosphatemia). The effect includes Ca urine, abnormal Ca sedimentation in artheria and kidneys, and loses Ca from bones excessively that will cause osteomalacia and osteitis fibrosa cytica. b. Hypoparatiroidism. Insufficiency of PTH secretion distracts neuromuscular function. due to low Ca blood degree, it tends to reveal spontaneous action potency and the flash of action potency is out of control. on the edge nerve, it can cause spontic muscle contraction called tetanus. neutron spontaneous flash on brain may influence behaviors. B. OXIPHYL CELL This cell has bigger size compared with principal cells, but the amount is less than that of principal cells. This cell contains much mitochondrion so that it is so acidophil. The function of this cell is not yet recognized clearly. EPIPHYSIS CEREBRI Is small organs with the size of 3-5 mm X 5- 8 mm, in the form of conus/conical (called epiphysis cerebri as well), clinging on the branch on diencephalons roof near ventriculus tertius cerebri (the posterior aspect). Epiphysis cerebri contains globular building that is basophile and calcifies in groups called brain sand or corpora arena-cea, that increases in amount and sizes and calcification increases as age goes on.

epiphysis cerebri contains two primary cell types: A. PINEALOCYTUS. 1. Structure: This cell has nucleus in big size and has irregular shape and also has nucleolus that can be seen clearly/bumping and the cytoplasm is pale basophile. With silver dyeing method according to Del Rio Hortega, this cell performs ; long cytoplasmic crowns and terminate as bubbles on septa near blood vessels. this inervation epiphysis cerebri (both symphatic and through the branch from commissural posterior) plays unknown roles. 2. Normal Function Pinealocytus secretes melatonin. The cycles of melatonin degree change in blood plasma follow the environment shining changes, but this relationship is not yet known. Melatonin may help determine circadian rhythm and has antigonadotropic influence that flees when sexual maturity appears in puberty. The other pinealocytus product is arginine basotocin and the opportunity of increasing substance that use antigonadoptropic influence through hypothalamo-hypophysealis fuse. 3. Abnormal Function. Glandula damage. This pinealis happens to mostly young men and may cause praecox puberty and decreases sexual maturity. Due to the organ location, pineal tumor may disturb the flow of cerebrospinal fluid through aqueducts sylvii, so that it causes hydrocephalus and the following symptoms. B. ASTROGLIAL CELL This cell is also called interstitial cells. This cell is like glia and has lengthening nucleus heterocromatic and simpthoplasmic crowns containing philamentum intermedium. This cell is commonly found around blood vessels and amongst the groups of pinealocytus.

PRACTICUM OF ANATOMY PATHOLOGY OF ENDOCRINE BLOCK 1. STRUMA COLOIDES MACRO ET MICRO FOLLICULARIS Is the enlargement of thyroid gland mostly observed. This struma occurs due the short of iodine intake, the increasing need of thyroxin (for instance on growth time, lactation, stress), the existence of goitrogenic materials that hamper the production of thyroxin hormone (such as cabbage, cassava, radish), as well as the existence of familial defect on synthesis or thyroxin hormone transportation. Clinic: A 35-year-old woman suffers from an egg-sized bump on neck front area that moves when swallowing saliva. This has been happening in the last 3 years. Macroscopic: Capsulated egg-sized tissue, elastic consistency. Brownish white spongius profile. Microscopic: Weak Enlargement Small and big follicles are seen, all containing red colloid mass. Most of these colloids flee from follicle wall and located in the middle. Big follicles wall consists of flat one-layered epythel. Epythel wall of small follicles is still in the form of one-layered cuboids.

Strong Enlargement

2. STRUMA LIMPHOMATOSA HASHIMOTO (LIMPHOSITIC THYROIDITIS) This occurs mostly in menopause women, although it can also occur in any age. Occurrence on women is 10-20 times more than on men. Struma Hashimoto is tyroiditis autoimmune, with the existence of autoantibody circulation towards thyroglobulin and follicular cell antigen especially thyrotropin (TSH) receptor. Clinic is indicated with the enlargement of thyroid gland, that in the initial phase may be still in the form of eutiroid. in advanced phase, hypotiroid may occur, and in some cases, it is followed by tirotoxicosis symptoms. Sometimes, clinic is difficultly differentiated with carcinoma. Clinic: A 40-year-old man with a lanseh-sized bump in neck front area. it moves when swallowing saliva. Microscopic: Weak and strong enlargement o Thyroid gland Asini is mostly penetrated by lymphoid tissue by forming lymphoid follicles. o Asini becomes small with very narrowing lumens. o Inside the lumens, colloid is sometimes seen. o Asinus lumen is limited by polyhedral-forming cells.

1.

Graves disease Clinic: A 35 year old woman has a duck egg-sized symmetric bump on neck front area and it moves when swallowing saliva. In the last 3 years, the bump enlarges. Besides, the sufferer feels his eyes become bump, often feels hard heartbeats, drenching in sweat and increasing blood pressure that was once only 120/70 and now becomes 170/100. Thyroidektomy is conducted and the result was sent to pathology anatomy laboratory. Macroscopic: Brown and elastic tissue with the diameter of 6 cm, reddish brown profile with the gland that is seemingly composed of translucent mass. Microscopic: Thyroid tissue with small-sized gland follicles with irregular edge and hyperplasia, some papillary grow into the lumen. Papillary epythel cell has the core in basal cell area. Lumen contains sufficient colloid mass. 2. Parathyroid Adenoma Clinic: a 40-year-old woman with a pigeon egg-sized bump on neck front area. it moves when swallowing saliva and it has been 2 years and enlarging. besides, the sufferer conducts blood examination and it is found in the blood that the calcium degree increases. extirpation is conducted and the result is sent to pathology anatomy laboratory. Macroscopic: parathyroid tissue with arranged tubular/granular tumor. small-sized follicle gland. cells with small core with cytoplasm are sufficient and very vacuolar. 3. Phaeochromocytoma Clinic: A 34-year-old man with a bump on his belly on his left upper waist. It is felt to enlarge since the last 6 months. He then met a surgery and operation is suggested. Durante operation: left kidney is identified, macroscopic is good. Capsulated tumor intoto is identified outside the kidney. Glandula suprarenalis is not identified. Macroscopic: tissue with the diameter of 15 cm is capsulated, blackish brown with elastic consistency. Some are fluctuated, on kidney fission, yellow profile with brown part, some are blackish, fragile, some has cavity containing red blackish liquid. Microscopic: Ephytelial tumor tissue is composed solidly, some have band around with blooding area and necrosis is large. atipi and polymorph tumor cells are medium to big, cytoplasm is eosinofil or granular. The core is sometimes vesicular chromatin. Core is irregularly rough. Some of core descendents are obvious. Few big cells with more than one core are found. There are several mitosis.

4. Pituitary adenoma Clinic: A 25-year-old girl complains of her enlarging breast in the last few months. White liquid comes out from the nipples and she has not had menstruation in 3 months. She is reffered by the doctor to RS PKU Muhammadiyah and CT scan is conducted. CT scan suggests the existence of mass in sella tursica with diameter of 2 cm. extirpation is performed by a surgery and the result is sent to pathology anatomy section. Macroscopic: Tissues with diameter of 2 cm, white brownish and elastic, with while brownish profile. Microscopic: Tumor tissues are composed of uniform cells of polygonal shape in groups that is limited by supportive tissues or reticulin. Tumor cells have monomorf cores. Some cytoplasm is reddish or bluefish. Mitosis can be found.