Lesson 1, Topic 1
In Progress

Closing Comments

April 11, 2024

Patient Coaching
The medical assistant can coach the patient on proper foot care. It is important for patients to check their feet daily and also to care for their feet daily. The following points should be reinforced with patients who have neuropathy:
            • Check your shoes for damaged areas or stones before putting them on. Wear good-fitting shoes at all times to protect your feet.
            • Check your feet when taking off your shoes. Look at all sides of your feet and between the toes. Check for redness, blisters, swelling, sores, and so forth.
            • Keep your toenails trimmed to a proper length.
            • Wash your feet every day with lukewarm water and soap. Dry well with a soft towel. Use lotion, lanolin, or oil on dry skin, but do not put it between the toes because this could cause an infection.
            • Seek medical care immediately for foot sores.
            • Avoid putting pressure on areas with nerve damage for long periods.
            • Use an elbow instead of the toes or hands to check the bathwater temperature.


Legal and Ethical Issues
Pathophysiology of the endocrine system can have far-reaching effects on the body’s ability to function. Patient education interventions should be documented completely to establish legal proof of the information shared with the patient. Never just assume that the patient understands the disease process and treatment recommendations. The following suggestions can help ensure the patient’s welfare and promote risk management.
            • Advise patients that a MedicAlert bracelet with their diagnosis and medication information is an important safeguard.
            • Patients must take medication as prescribed, following the directions for dosage, route of administration, and storage; they also must be alert for possible side effects.
            • Patients newly diagnosed with diabetes should not drive until glycemic control has stabilized. These patients also should be warned about possible visual impairment from the disease.
            • Remember that you are always representing your profession and employer, and respond to each situation accordingly.
            • Ask for assistance or further information if you feel unprepared to perform a procedure or give accurate information.


Patient-Centered Care
Providing patients and families with information, education, and emotional support is part of providing patient-centered care. When working with patients with endocrinology disorders, especially diabetes mellitus, the medical assistant has an important role in connecting patients with additional resources. These can include local support groups, medication discount programs, and websites, including the following:
            • American Diabetes Association: www.diabetes.org
            • Centers for Disease Control and Prevention: www.cdc.gov
            • National Institutes of Health: Genetic and Rare Diseases Information Center: https://rarediseases.info.nih.gov
            • US National Library of Medicine: MedlinePlus: https://medlineplus.gov


Professional Behaviors
An important part of becoming a professional medical assistant is a commitment to lifelong learning. This chapter focused on the details of diabetes mellitus because it is the most common endocrine system disease and also one of the most serious. Regardless of where you work as a medical assistant, you will end up caring for patients with diabetes and interacting with their families on some level. Diabetes researchers are constantly discovering more information about the disease: how it is diagnosed, the best treatment methods, and the pathophysiology of possible complications. You must commit to continual learning about diabetes so that you are best prepared to care for patients with this life-threatening disorder.


Summary of Scenario

Cecilia enjoyed working with the endocrinology team and patients. She was able to observe the diabetic nurse educator work with a newly diagnosed patient. The amount of information newly diagnosed diabetic patients need to learn to manage their disease is incredible. All of the information was not given to the patient during the first visit. The nurse educator explained that over the coming weeks, the patient would get the information. During the first visit, the patient needed to learn how to administer insulin, test blood glucose levels, and learn about hypoglycemia and hyperglycemia. These topics were most critical at this stage.
Later in the day, Cecilia observed the dietitian working with a patient with type 2 DM. The patient stated he enjoyed his beer, snack foods, and sweets and really did not want to give them up. Cecilia was impressed by how the dietitian worked with the patient so that eventually, the patient was willing to cut back on some of his “not-so-healthy” habits. Cecilia’s experiences reinforced her belief that she had made the right decision by volunteering to work with the endocrinology team.
Summary of Learning Objectives

1. Examine the connection between the endocrine and nervous systems.

The endocrine system is composed of ductless glands throughout the body. The hypothalamus, located in the middle of the brain, is the major connection between the nervous and endocrine systems and controls the endocrine system. When it detects rising levels of a target organ’s hormones, it sends a signal to the pituitary gland to release or prevent pituitary hormone production.

2. Differentiate between the hormones of the anterior lobe and those of the posterior lobe of the pituitary gland.

The pituitary gland is connected to the hypothalamus and is composed of two lobes that act as separate glands, the anterior lobe and the posterior lobe. Hormones from the anterior lobe include adrenocorticotropic hormone, follicle-stimulating hormone, growth hormone, luteinizing hormone, prolactin, and thyroid-stimulating hormone. Hormones from the posterior lobe of the pituitary gland include antidiuretic hormone and oxytocin.

3. Differentiate between the hormones of the thyroid and those of the parathyroid glands.

The thyroid gland is a butterfly-shaped gland in the neck above the collarbone. Thyroid gland hormones include triiodothyronine, thyroxine, and calcitonin. The parathyroid glands are four pea-sized glands located on the thyroid gland. The parathyroid hormone comes from the parathyroid gland.

4. Differentiate between the hormones of the adrenal cortex and those of the adrenal medulla.

The adrenal glands are located on the top of each kidney. The outer part of the gland is the adrenal cortex; the inner part is called the adrenal medulla. Adrenal cortex hormones include mineralocorticoids, glucocorticoids, and gonadocorticoids. Adrenal medulla hormones include epinephrine and norepinephrine.

5. Differentiate among the hormones of the pancreas, thymus gland, gonads, and pineal gland.

The pancreas is located inferior and posterior to the stomach. The pancreas hormones are glucagon, insulin, somatostatin, and ghrelin. The thymus gland is in the mediastinum behind the sternum (breastbone) and secretes thymosin and thymopoietin hormones. The male gonads are the testes and secrete testosterone. The female gonads are the ovaries, which secrete estrogen and progesterone. The pineal gland is located deep within the brain and secretes melatonin.

6. Examine the physiology of the endocrine system.

The goal of hormone regulation is to maintain homeostasis. Nervous system stimulation, endocrine control, and feedback systems regulate hormone secretion. Each hormone released into the bloodstream has specific target cells for action. The target cells have receptors that attract only certain hormones. The cell membrane only lets selected hormones pass into the cell and affect cellular action.

There are two categories of hormones, nonsteroid hormones and steroid hormones. Nonsteroid hormones attach to a target cell membrane. Another molecule takes the message from the nonsteroid hormone and carries it to the target cell nucleus or organelle, which then puts the message into action in the cell. Steroid hormones attach to a target cell membrane, then pass directly into the target cell, and bind to receptor sites. This complex communicates its message with DNA in the nucleus, and the DNA tells the cell how to put the hormone’s message into action.

Prostaglandins are produced in tissues and diffuse only a short distance to affect cells in their local area. They help regulate processes such as respiration, blood pressure, digestive system secretions, and reproductive functions.

7. Examine pituitary gland diseases and disorders, including the signs, symptoms, etiology, diagnostic procedures, and treatments.

Anterior pituitary gland disorders include the following:

• Acromegaly and gigantism, which are caused by hypersecretion of growth hormone.

• Dwarfism, which is caused by the hyposecretion of growth hormone.

• Prolactinoma, which is caused by hypersecretion of prolactin.

• Panhypopituitarism, which is caused by the hyposecretion of all the anterior pituitary hormones.

Posterior pituitary gland hypersecretion of antidiuretic hormone (ADH) causes a syndrome of inappropriate antidiuretic hormone (SIADH), and hyposecretion causes diabetes insipidus.

8. Examine thyroid gland and parathyroid gland diseases and disorders, including the signs, symptoms, etiology, diagnostic procedures, and treatments.

Hyperthyroidism occurs when too much thyroid hormone is produced. Hypothyroidism occurs when too little thyroid hormone is produced. Hyperparathyroidism occurs when there is hypersecretion of parathyroid hormone, and hypoparathyroidism occurs when there is hyposecretion of the hormone.

9. Examine adrenal gland diseases and disorders, including the signs, symptoms, etiology, diagnostic procedures, and treatments.

Hyposecretion of cortisol from the adrenal gland causes Addison disease. Hypersecretion of cortisol causes Cushing syndrome.

10. Examine pancreatic diseases and disorders, including the signs, symptoms, etiology, diagnostic procedures, and treatments.

Diabetes mellitus (DM) is the most common pancreatic disease. DM is a group of metabolic disorders characterized by an inadequate production of insulin, a resistance to insulin, or a combination of both. Types of DM include type 1, type 2, latent autoimmune diabetes in adults, and gestational diabetes.

Diabetic ketoacidosis (DKA) is a life-threatening hyperglycemic condition that is more commonly seen with type 1 DM and latent autoimmune diabetes in adults (LADA). Hypoglycemia means low blood glucose (below 70 mg/dL). Hypoglycemia is commonly seen with DM but also can be seen with other conditions.

11. Examine the medical assistant’s role in examinations, diagnostic procedures, and treatments for endocrine diseases and disorders.

During an endocrinology examination, a medical assistant may be required to ask specific screening questions. When completing the medication section of the medical history, the medical assistant must verify the medication name, dose amount, and number of doses taken daily.

During the physical exam, the medical assistant should assist the patient in removing shoes and socks as needed. Many providers have medical assistants perform peripheral neuropathy screening by doing a monofilament foot exam.

Tables 24.3 and 24.4 provide information on the common diagnostic procedures and medical laboratory tests done for endocrine conditions. Some endocrine disorders are surgically treated (see TABLE 24.5). Many endocrine disorders are treated with medications (see TABLE 24.6).

 

Procedure 24.1  Perform a Monofilament Foot Exam
Tasks
Perform a monofilament foot exam to screen for peripheral neuropathy. Provide health maintenance coaching by giving the patient foot care instructions. Document test results in the patient’s health record.
Equipment and Supplies
            • 10 g monofilament tool
            • Gloves
            • Paper towel
            • Provider’s order or standing order
            • Patient’s health record
Procedural Steps
1. Wash hands or use hand sanitizer.

PURPOSE: Hand sanitization is an important step for infection control.

2. Read the provider’s order. Assemble the equipment.

PURPOSE: It is important to know the provider’s order before starting the procedure.

3. Greet the patient. Identify yourself. Verify the patient’s identity with full name and date of birth. Explain the procedure to be performed in a manner that the patient understands. Answer any questions the patient may have about the procedure.

PURPOSE: It is important to identify the patient in two different ways to ensure that you have the correct patient. Explaining the procedure can make the patient feel more comfortable and reduces anxiety.

4. Ask the patient to remove socks and shoes and rest the feet on the paper towel. The paper towel should be placed under the person’s feet, either on the floor or on the exam table step.

PURPOSE: This prepares the patient for the test.

5. Using your hand, demonstrate that the monofilament is flexible and not sharp. Also, demonstrate the monofilament on the patient’s hand. Put gloves on.

PURPOSE: This alleviates the patient’s anxiety. Demonstrating on the patient’s hand allows the patient to know how it feels.

6. Instruct patients to close their eyes. Tell patients to say “yes” when they feel the monofilament on the foot.

PURPOSE: The patient’s eyes must be closed for this test to be accurate.

7. Start with the great toe and place the monofilament perpendicular to the skin. Press the monofilament until it bends, hold for 1 second, and release (Figure 1). Pause to give the patient an opportunity to confirm it was felt. A confirmation is a positive or normal response. The test result is abnormal if the patient cannot feel in one area.

PURPOSE: It is important to hold the monofilament for 1 second for accurate results.

8. Do not cue the patient if no confirmation is given. Just move to the next location. Randomly test 9 to 12 locations on the anterior and posterior side of each foot or as the provider indicates (Figure 2). If a patient does not feel the site, check it three times randomly. Make sure to space out testing times (e.g., the time between each check).

PURPOSE: If the test is done in a rhythmic way, the patient may confirm the feeling without really feeling the test.

9. Discard supplies in the waste container. Remove gloves and wash hands.

PURPOSE: Washing hands is important for infection control.

10. Coach the patient on proper foot care to prevent sores. Include when to check the feet, what to look for, and how to care for the feet daily. Suspicious areas need to be watched carefully and reported to the provider if they do not return to normal.

PURPOSE: Careful monitoring can help prevent serious foot sores.

11. Document the test results in the patient’s health record. Include the provider’s name, the order, and the results of the test. For the test, the first number indicates the total number of sites felt, and the last number indicates the total times done. Indicate all sites where the patient did not feel the test. If the provider indicates specific areas to test, documentation should reflect these areas. Include any teaching done.

PURPOSE: It is important to document the patient education in the health record to show it was done.

Documentation Example07/19/20XX 1625 Per Dr. Kahn’s order, performed a monofilament exam on both feet. Right foot 9/12 and left foot 12/12. Right posterior great toe 0/3. Pt coached on foot care. Stressed daily foot care and inspections. Pt listed the daily foot care required. Pt indicated what and where on his feet he needs to examine daily. All the pt’s questions were answered. The “Feet Guide for Neuropathy” brochure was given to the patient. ___________________ _______________________________ Cecilia Cukier, CMA (AAMA)