Hypothyroidism: Texts

Text A
Third-generation thyroid-stimulating hormone (TSH) assays are generally the
most sensitive screening tool for primary hypothyroidism. If TSH levels are
above the reference range, the next step is to measure free thyroxine (T4) or
the free thyroxine index (FTI), which serves as a surrogate of the free
hormone level. Routine measurement of triiodothyronine (T3) is not
recommended.

Results in patients with hypothyroidism are as follows:

• Elevated TSH with decreased T4 or FTI
• Elevated TSH (usually 4.5-10.0 mIU/L) with normal free T4 or FTI is
considered subclinical hypothyroidism

Abnormalities in the complete blood count and metabolic profile that may
be found in patients with hypothyroidism include the following:
• Anaemia
• Dilutional hyponatremia
• Hyperlipidemia
• Reversible increases in creatinine
• Elevations in transaminases and creatinine kinase

No universal screening recommendations exist for thyroid disease for adults.

The American Thyroid Association recommends screening at age 35 years
and every 5 years thereafter, with closer attention to patients who are at
high risk, such as the following:
• Pregnant women
• Women older than 60 years
• Patients with type 1 diabetes or other autoimmune disease
• Patients with a history of neck irradiation
Text B
Pediatric Dosage - Congenital or Acquired Hypothyroidism
Start Levothyroxine sodium tablets at the full daily dose in most pediatric
patients. Use a lower starting dose in newborns (0-3 months) at risk for
cardiac failure and in children at risk for hyperactivity. Monitor for clinical
and laboratory response.
Levothyroxine Sodium Tablets Dosing Guidelines for Pediatric
Hypothyroidism
AGE Dally Dose per kg Body Weight*
0-3 months 10-15 mcg/kg/day
3-6 months 8-10 mcg/kg/day
6-12 months 6-8 mcg/kg/day
1-5 years 5-6 mcg/kg/day
6-12 years 4-5 mcg/kg/day
Greater than 12 years but growth 2-3 mcg/kg/day
and puberty incomplete
Growth and puberty complete 1.6 mcg/kg/day

Text C
Important Safety Issues with Consideration to Related Drugs

Over-or Under-Replacement with Thyroid Hormone

Because of their narrow therapeutic index, over-or under-treatment with
thyroid hormones such as levothyroxine may have a number of adverse
effects.
Cardiac Adverse Reactions
Overtreatment with thyroid hormone may cause increase in heart rate,
cardiac wall thickness and cardiac contractility, and may precipitate angina or
arrhythmias, particularly in elderly patients and those with underlying
cardiovascular disease.
Worsening of Diabetic Control
Initiation of thyroid hormone therapy may worsen diabetic control and cause
hyperglycemia in patients with diabetes mellitus.

Decreased Bone Mineral Density Associated with Thyroid Hormone Over-

Replacement
Over-replacement with thyroid hormones may cause increased bone
resorption and decreased bone mineral density, particularly in post-
menopausal women.
Myxedema Coma
Myxedema coma may result in unpredictable absorption of levothyroxine
from the gastrointestinal tract. Use of oral thyroid hormone drug products is
not recommended in patients with myxedema coma. Health care
practitioners should use thyroid hormone products formulated for
intravenous administration to treat myxedema coma.
Adverse Reactions in Children
Pseudotumor cerebri and slipped capital femora epiphysis are associated
with initiation of levothyroxine therapy in children. Over-replacement in
children may result in craniosynostosis in infants and premature closure of
the epiphyses in children with resultant compromised adult height.
Hypersensitivity Reactions
Patients treated with thyroid hormone products have experienced
hypersensitivity reactions to inactive ingredients, including urticaria, pruritus,
skin rash, flushing, angioedema, gastrointestinal symptoms, fever, arthralgia,
serum sickness and wheezing.

Text D
Nutritional advice for patients with hypothyroidism
People with hypothyroidism should base their diet around vegetables, fruit
and lean meats. They are low in calories and very filling, which may help
prevent weight gain. It should be emphasised to patients that this is not a
restrictive diet, and that there are plenty of food options available to them,
including:
• eggs - whole eggs are best, as much of the iodine and selenium
beneficial for patients is found in the yolk, while the whites are full of
protein
• meat
• fish
• vegetables - all vegetables are fine to eat, though cruciferous
vegetables (e.g. broccoli, kale, spinach, cabbage) should be eaten
cooked, in moderate amounts
• fruits - apart from peaches, pears and strawberries
• gluten-free grains and seeds - e.g. rice, buckwheat, quinoa, chia seeds
and flaxseed
• dairy - all dairy products including milk, cheese, yogurt, etc.
• beverages - preferably water and other beverages that are not
caffeinated.
 Part A

Questions 1-7
For each question, 1-7, decide which text (A, B, C or D) the information comes
from. You may use any letter more than once.
In which text can you find information about
1. Reassurance for patients regarding the impact of their condition?
_________________

2. How younger patients can be treated for hypothyroidism?

__________________

3. Possible negative responses to treatment for hypothyroidism?

__________________

4. Instances when the initial amount of a drug given should be reduced?

__________________

5. Who is more likely to suffer from hypothyroidism?

__________________

6. Avoiding a particular form of a drug?

__________________

7. What patients with hypothyroidism should eat?

__________________

Questions 8-15
Answer each of the questions, 8-15, with a word or short phrase from one of
the texts. Each answer may include words, numbers or both.
8. From what age are women considered to be more likely to develop
thyroid problems?
________________________________________________________
 9. In suspected cases of hypothyroidism, what can be checked instead of the
free hormone level?
_________________________________________________________

10. Which thyroid hormone needn’t normally be measured?

_________________________________________________________

11. What characteristic of thyroid hormones means that over-treatment or

under-treatment can be harmful?
_________________________________________________________

12. What is sometimes reduced in post-menopausal women if they are

prescribed too high a dose of thyroid hormone?
_________________________________________________________

13. What type of drinks should hypothyroid patients avoid?

_________________________________________________________

14. What minimum daily dose of levothyroxine sodium should be given to a

four-month old patient with hypothyroidism?
__________________________________________________________

15. What dose of levothyroxine sodium should be given to a three-year old

with hypothyroidism?
__________________________________________________________
Questions 16-20
Complete each of the sentences, 16-20, with a word or short phrase from one of
the texts. Each answer may include words, numbers or both.
16. The recommended diet for patients with hypothyroidism helps them
maintain a healthy _____________________
17. Egg yolks contain_________________ , which is good for patients.
18. Diabetic patients treated with thyroid hormone may experience
_______________
19. Too much thyroid hormone can provoke heart problems for older people
and patients already suffering from _______________
20. A TSH level of 7.5 mIU/L combined with free T4 that is normal is regarded
as hypothyroidism.
 Part B

In this part of the test, there are six short extracts relating to the work of
health professionals. For questions 1-6, choose the answer (A, B or C) which
you think fits best according to the text.
1. The memo reminds staff about
A) The importance of explaining to patients what happens if they
decline help.
B) A situation where there is a requirement to override the protocol.
C) Guidelines which are available to provide additional support.

Memo
To :All staff
Subject: Reminder about guidance for safeguarding adults in suspected cases
of domestic abuse
If you suspect a patient is the victim of domestic abuse, explain to them that
you’re concerned and give your reasons. Point out that this is a routine
procedure where we think patients may be experiencing domestic abuse.
Tell them that there are specialists on site who they can talk to in confidence
if they wish. If this offer isn’t taken up, document your concerns and pass the
information onto the Independent Domestic Violence Advocate (IDVA), who
will keep the information confidential. Remember that IDVAs will not make
direct contact with the patient without their consent unless there is
significant threat to life. However, where you think the patient’s own life
may be in imminent danger, disregard matters of confidentiality and contact
the police.

2. What does the extract say about original copies of informed-consent

A) They must always be kept in the patient's medical record.
B) It is acceptable for them to be placed in the research records.
C) Researchers should make them available to hospital staff on request.
Medical Research: Storage of informed-consent documents
Informed-consent documents must be readily accessible to all medical staff.
Therefore, where research is pertinent to clinical care by hospital physicians
and nurses, researchers must place either the original document, or a copy
of it, in the patient’s medical record, as well as a copy in the research
records. Should commercial sponsors require the original informed-consent
document to be filed within a research binder, the hospital's Medical
Records Department will accept a copy of the patient’s signed informed
consent in lieu of the original. In order to determine the manner of storage,
it is important to understand sponsor requirements prior to initiating a
research study. As an original consent document could go astray, and
therefore not make its way to the medical record, a researcher may always
choose to store the original document in the research binder.

3. The guidelines state that clinical staff must

A) Obtain permission to order new devices.
B) Record all instances of devices going missing.
C) Assess whether devices are functioning properly

Extract from guidelines - Medical devices and equipment

Procurement
Any member of staff wishing to procure an item that is defined as a ‘medical
device or piece of equipment used for patient care’ should seek advice from
the Health and Safety Manager, who will then ensure that the device is being
purchased from an approved supplier.
Device deployment
When equipment is allocated to a department, clinical staff have primary
responsibility for the way they treat the equipment and the state in which it
is left. These responsibilities also include performance checks before use and
routine maintenance, such as charging batteries. Any problems with any
device/equipment should be reported to the manager without delay and the
device/equipment should not be used until it is fully tested as safe. If a piece
of equipment or device is removed from service, then an incident form
should be completed and sent to the Health and Safety Manager.
 4. This notice about the management and reporting of accidents is aimed
at
A) All managers and staff of the hospital.
B) External contractors working in the hospital.
C) Any hospital employee regardless of location.

Management and Reporting of Accidents and Incidents

Every member of staff has a responsibility to maintain safe systems of work,
to take care of their own safety and that of colleagues and all other persons
who may be affected by their acts or omissions. Any incident or near miss
should be reported to the person in charge, supervisor or senior manager as
soon as possible. That person is the person with responsibility for the area
concerned at the time that the incident or near miss takes place. An incident
report should be completed as soon as possible after the event.

In the event of a member of staff suffering an incident or near miss whilst in

the course of their duties on the premises of another organisation, the
reporting procedures for that organisation should be followed in addition to
our own.

5. The extract from the policy document stresses that in the event of a
fire,
A) The required number of staff will always be on duty.
B) All staff are competent to move patients out of danger.
C) Patients must never leave the building unaccompanied.

Extract from Hospital Fire Safety policy

The basic concept governing means of escape from premises is that the
occupants, including patients, assisted as appropriate, should be able to turn
their backs on a fire, wherever it occurs; then travel away from it directly
through circulation spaces and stairways to a relative place of safety, firstly
within the premises and then, if necessary, to one outside the building to a
final place of safety. As far as reasonably practicable, a minimum of two
members of staff will be present at all times (three if there are over thirty
patients). These members of staff will have received training in the methods
of patient evacuation appropriate to the level of dependency of the patients
and will be familiar with the evacuation strategy particular to their place of
work.

6. The extract from the users' manual explains that the device may be
damaged
A) If the collection jar is allowed to overfill.
B) If certain parts are not cleaned regularly.
C) If it is not regularly maintained by qualified staff.

Mains-powered suction units

The AC 20 is a mains-operated suction unit for removing secretions, blood
and body fluids. During all suction procedures, always observe the fill level in
the collection jar (including foam). Rinse suction catheter, suction cannula
and suction hose with clean water after each suction procedure.

CAUTION!
• Make sure that the collection jar is evacuated in time. Generally, it
must be evacuated after each finished suction procedure. When the
jar is full, the overflow safety reacts and the unit stops sucking. In the
event of extensive foam formation, however, liquid may reach the
filter which will then lose its air permeability and need to be replaced.
• When secretion has penetrated the pump the unit has to be
maintained by an authorized service technician.
 Part C

In this part of the test, there are two texts about different aspects of
healthcare. For questions 7-22, choose the answer (A, B, C or D) which you
think fits best according to the text.
Text 1: Psychology and allergy
As a clinical psychologist, I’m very familiar with the concept of ‘Them and Us’,
the idea that in order for me to be okay, to have what I need, I have to keep
others – them – out. It’s not an uncommon belief in society. Interestingly, this
definition also almost perfectly defines allergy. When the body - Us -
mistakenly identifies foreign food proteins - Them - as dangerous, it launches
an excessive, possibly cataclysmic, defence. Of course, that food will usually
become part of Us once eaten and digested, but in cases when the body sees it
as a threat, it is most certainly Them. Them and Us confusion also causes other
immune system diseases such as autoimmune arthritis where the body
mistakes connective tissue for a threat and attacks it, resulting in terrible joint
pain.
You may be wondering why a psychologist would be interested in allergies.
There are actually a few good reasons, but basically, in terms of allergies in
general, during the middle part of the twentieth century, we often viewed the
condition as a psychosomatic illness, a physical manifestation of psychological
problems. In the case of asthma, the asthmogenic, or asthma-producing,
home, often featuring a stereotype smothering, overbearing parent, was often
seen as the cause of childhood asthma, to the extent that so-called
‘parentectomies’ – the separation of the child from its parents – were
suggested as a possible cure.

Also at that time, the relationship between mental illness and food allergy
symptoms was similarly complicated, and controversial. Food allergists and
their critics clashed frequently. On the one hand, many prominent food
allergists stressed that food allergy could trigger mental disturbances, ranging
from depressive and psychotic episodes to hyperactivity in children. The
solution to many a person’s mental illness, they argued, was a thorough
elimination diet to determine the food that was at fault. Food allergy critics
however – and there were many of them – argued the very opposite: the
symptoms of food allergy were nothing more than the physical manifestations
of psychological problems. So-called food allergy sufferers, they argued, would
benefit more from the counsel of a good psychiatrist, rather than an
unscrupulous food allergist, who would merely encourage their delusions.

As in many instances of medical controversy, it now seems likely that neither

the allergists nor their critics were completely right, nor completely wrong.
While food, and especially food chemicals, are most probably the cause of
mental disturbances in some sensitive individuals, and particularly children,
the intensity of an allergic reaction can certainly be exacerbated by heightened
levels of stress. There is most certainly a psychological component not only to
allergy, but also to many other aspects of our immune system.

But after I gave a talk on allergy at another conference recently, it became

clear that there was also another psychological aspect to the subject. As I
stepped down from the podium, a crowd of people quickly assembled in front
of me, asking all manner of, well, fairly personal questions about their, frankly
surprising, range of food allergies. Now, while I always provide the disclaimer
that I am not a medical doctor, I quite enjoy hearing the stories people have to
tell, which are often very poignant. And sometimes I feel I can give a small
amount of advice, if it is only to suggest that a second opinion is sought. In this
particular instance, I could tell that many of the people asking me questions
had not received a great deal of sympathy from their doctors and simply
wanted someone to talk to. It was as if I was the first person with the word
doctor in front of their name who was willing to listen. and I felt the beginnings
of a real connection. But time is not always on the side of the listener. After
about ten minutes, I needed to move aside for the next speaker. On the stairs
outside of the auditorium, however, the fascinating conversations continued
until I had to be hauled away from them because I’d promised to give a media
interview.

What struck me was that there was something missing in the relationship
these people had with their various physicians. Dealing with disturbing,
unexplained symptoms, many food allergy sufferers feel isolated. This is
terribly unfortunate, but it does help to explain why often completely
unqualified food allergists have been so successful in attracting patients,
despite their often eccentric theories. For one thing, they listened to their
patients. Not only that, they also had to rely on their patients’ testimony and
experiences to diagnose their allergies. The relationship between food
allergists and patient was more of a partnership, with each party playing an
essential role. Some psychiatrists might even learn something from this
approach.

7. What does Dr Goody find interesting about the idea of ‘Them and Us’?
A) The parallels between people’s mental and physical processes.
B) The probability that the concept is generally a mistaken one.
C) The fact that it is so widespread in terms of health problems.
D) The wide range of medical conditions it is relevant to.

8. Dr Goody says that the psychologist ‘s interest in allergies reflects the

fact that they were
A) Linked to some early theories of gender stereotyping.
B) Widely regarded as examples of psychological illness.
C) Considered to be good guides to general mental health.
D) Thought to be curable by treatments based on psychology.

9. According to Dr Goody, critics of food allergists believed that they

A) were guilty of exploiting their patients’ own misguided beliefs.
B) had misunderstood the exact role of allergy in mental health-issues.
C) were deliberately ignoring the benefits of psychiatric help for
patients.
D) had overlooked important psychological research evidence on the
subject.

10.Dr Goody explains that we now know that the food allergists and their
critics had both
A) contributed to current understanding of the immune system.
B) been unaware of the mental health risks from chemicals in food.
C) made a number of incorrect assumptions when discussing allergy.
D) correctly understood different aspects of the consequences of
allergy.
11.What did Dr Goody learn from his recent experience at a conference?
A) A lot of allergy sufferers feel that their GPs have too little time to help
them.
B) Allergy sufferers are often in need of someone to share their
problems with.
C) Only a limited number of allergy sufferers have ever received any
treatment.
D) Many allergy sufferers are unwilling to take their problems to a
psychologist.

12.In the sixth paragraph, Dr Goody uses the expression ‘hauled away’ to
emphasise
A) His reluctance to speak to the media about his work.
B) The extent to which he had enjoyed giving his talk that day.
C) His desire to learn more about the problems faced by his audience.
D) The involvement he felt with the people who had wanted to talk to
him.

13.Dr Goody believes that unqualified food allergists attract patients

because
A) They offer a fresh perspective on their patient’s problems.
B) They have a mutually beneficial relationship with their patients.
C) They are happy to tell their patients what the patients want to hear.
D) They have more time to spend with patients than mainstream
practitioners.

14.In the final paragraph, the word that in the expression not only that
refers to
A) an approach to the care of allergy patients.
B) a particular way of coping with allergy problems.
C) one assumption regarding the origin of certain allergies.
D) the relative importance of doctor and patient in allergy cases.
Extract 2
Text 2: Chronic pain
You sometimes hear it said that physicians in the USA have a rather negative
attitude towards chronic pain. If so, it’s an attitude that is already evident in
medical school. The literature supports the notion that undergraduate medical
students are concerned about treating patients with chronic pain. A qualitative
study found that many viewed chronic pain as the condition it was most
difficult to deal with. The failure to teach undergraduates appropriate bio-
psychosocial chronic-pain management skills is consistent with the finding that
pre-clinical relationship skills curricula aren’t well coordinated. Of this
disconnect, Giordano and Boswell astutely noted, ‘So, while mechanisms of
pain and analgesia are taught during basic neuroscience courses, there is no
direct link to how the complexities of these systems are relevant to the illness
of chronic pain and challenges of chronic-pain management’.

Inadequate training of primary-care providers is certainly not a new

phenomenon. Early in the history of the discipline of pain medicine in 1976,
John Bonica called for increased education about pain in all health-sciences
schools. There was a minimal response to this call. Then, in 2000, the American
Academy of Pain Medicine (AAPM) issued a position statement, calling upon
medical schools to increase required curricular content in chronic pain,
palliative care, and end-of-life care, but this, too, had little influence on
medical school curricula as far as we can determine.

In their 2011 study, Mezei and Murinson found that a number of American
medical schools didn’t report any teaching of pain whatsoever, with many
requiring five or fewer hours of such education. The authors concluded ‘that
pain education for North American medical students is limited, variable, and
often fragmentary’. In 2005, the International Association for the Study of Pain
published its Core Curriculum for Professional Education in Pain. The report of
the First National Pain Summit also called for better education about pain, as
did the Core Competencies for Pain Management report and the Institute of
Medicine (IOM) report. Little happened to medical education in response to
these guidelines and reports. As reported by Briggs and colleagues, ‘... the
amount of hours of pain education in the undergraduate curricula is woefully
inadequate given the burden of pain in the general population’.

Most medical schools utilise a biomedical model and focus on knowledge-

based learning, often ignoring students’ emotional development and reflective
capacity, both of which are necessary to deal with pain patients effectively. A
recent study in which board members of the AAPM rank-ordered ideal
objectives of medical student pain education yielded not only examination and
prescribing skills but also compassionate care/empathy and communication as
the top four of twenty-eight topics identified.

Recently, Carr and Bradshaw recommended changing the approach of the

standard pain curriculum from an emphasis on subcellular and cellular
processes to a focus on interpersonal, social processes, thereby shifting the
paradigm from ‘bio-psychosocial’ to ‘socio-psychobiological’. Medical students
and residents, they say, need to be taught the differences between acute and
chronic pain, and the potential for acute pain to progress toward chronicity if
the psychosocial sequelae of pain aren’t treated appropriately.

Altering a medical-school curriculum by internal political processes can be

exceedingly difficult. The reality, of course, is that the number of hours allotted
to a curriculum is fixed; indeed many schools are trying to reduce their
classroom hours. To introduce something new into the curriculum, something
old must be taken out. As most medical schools are strongly departmentally
organised, nobody wants to give up time from their specialty area to allow this
to happen. This is compounded by the fact that pain doesn’t have a clear
departmental home, in contrast to all organ systems. So what department is
likely to fight for pain turf? The problem isn’t the lack of educational materials
but rather the lack of time in the curriculum to teach about the sciences basic
to pain and its clinical management.

It is widely recognised that optimal management for chronic-pain patients

comes from a multi-disciplinary and even multi-professional approach that
makes use of medical, nursing, social work, psychology, physical, and
occupational-therapy skills. Inter-professional education will facilitate chronic-
pain management, but this is a novel educational format in most health-
sciences educational programs. The response to the IOM report should include
a revolution in education regarding chronic pain in American schools of
medicine. We’ve seen little evidence that this is about to occur in spite of the
NIH Pain Consortium Centers of Excellence for Pain Education programs in
twelve health-sciences schools. Chronic pain remains an orphan disease for
undergraduate medical education; yet, it is one of the most common reasons
for seeing a healthcare provider. The time is long overdue for a change in what
we teach medical students and residents about pain, and, most importantly,
how to deal compassionately with chronic-pain patients.

Text 2: Questions 15-22

15.What point is made about chronic pain in the first paragraph?
A) Medical schools should include courses on its causes.
B) Medical students should be better trained to recognise it.
C) There should be a greater focus at medical school on how to treat it.
D) Courses on managing it should no longer be optional for medical
students.

16.What does the word ‘this’ refer to in the second paragraph?

A) A response to John Bonica's call
B) Required curricular content
C) Medical school curricula
D) A position statement

17.In the third paragraph, the writer refers to the guidelines and reports
to
A) qualify a previous statement
B) reinforce an earlier argument
C) question a contradictory claim
D) acknowledge alternative points of view
18.What does the writer say about medical students in the fourth
paragraph?
A) Many dispute the need for further training in crucial subjects.
B) Many are unaware of significant gaps in their medical knowledge.
C) Many have ultimately proved to be unsuited to their chosen career.
D) Many lack guidance in key areas relating to professional competence.

19.Carr and Bradshaw suggest that the pain curriculum should

A) include a wider range of relevant topics.
B) prioritise the study of patients with acute pain.
C) reflect the most recent scientific research findings.
D) cover the consequences of inadequate interventions

20.In the fifth paragraph, what attitude does the writer express towards
medical schools?
A) irritation with the behaviour of their staff
B) frustration at how old-fashioned they are
C) understanding of the challenges they face
D) approval of the way they deal with innovation

21.In the fifth paragraph, the expression ‘fight for pain turf’ tells us that
there is
A) little demand for the study of pain amongst students.
B) a general refusal to recognise the value of the study of pain
C) nobody willing to promote the study of pain at medical school
D) resistance to attempts to include the study of pain in the curriculum

22.In the final paragraph, the writer expresses

A) Optimism about evolutions in chronic pain education
B) Impatience with the rate of improvement in chronic pain
management
C) Confidence in the ability of healthcare workers to address chronic
pain.
D) Concern about the impact of developments on patients with chronic
pain