Distance Education in Medicine - Module 3: How To Write

H O W T O W R I T E A
D I S T A N C E E D U C A T I O N L E S S O N
I N M E D I C I N E
(An Off-Campus Study)
Reynaldo O. Joson, MD, MHA, MHPEd
1995
FOREWORD
Dear Learner,
Mabuhay!
Welcome to a learning experience in becoming a health

professional.
This program has been especially designed with you, the

learner, and the principles of effective teaching and learning in
mind.
As you go through this learning program, please bear in mind

the following:
1. I am treating you as an adult learner which
1.1 Assumes you have learning aspirations and

expectations and, therefore, are motivated;
1.2 Gives you the privilege to use other learning

strategies in achieving the objectives in this
program;
1.3 Welcomes you to go beyond the learning package

as you so desire; and
1.4 Expects discipline, honesty, and maturity in

fulfilling your learning activities.
2. We shall define learning as a positive observable

change (for the better or improvement) in human
behavior, disposition, attitude, performance, or
capability which persists over a period of time.
3. Active learning strategies and activities will be

utilized as much as possible.
4. The program will contain learning materials which I

think will be relevant to your being an effective,
efficient, and humane health professional.
5. The ultimate goal of the learning program is to

produce health professionals who will contribute to
the health development in the Philippines.
6. When I made the program, I tried my best to
facilitate your learning. Bear in mind, however, I
am not infallible. Thus, analyze carefully
everything in this program. Don't hesitate to offer
disagreements and constructive criticisms for my own
learning and for the improvement of the program.
Best wishes for a fruitful learning with the help of this

program.
Reynaldo O. Joson, MD, MHPEd

1995
GUIDELINES IN STUDYING THE PROGRAM
Dear Learner,
Mabuhay!
Welcome to an experience in self-instruction.
This program has been designed so that you learn on your

own. You can learn at your own pace - as fast as you can or as
slow as you wish. You can choose to study anywhere and anytime.
For effective learning, however, please follow the following

guidelines in studying the program:
1. You should diligently and chronologically go through

each part. Each part has an important role.
- The Introduction gives you an orientation,

perspective, and tells you the importance of the
subject matter.
- The Prerequisites tells you what you must

possess before you go into the program proper.
- The Objectives tells you what you are expected

to achieve after you have finished the program.
- The Text, of course, is the learning material

proper.
- Within the text are Activities where you will be

actively involved in the learning process.
- The Summary helps you put together all

that you have learned in the text.
- The Summative Evaluation tells you what you

should undertake, for me, your faculty
facilitator, to be able to assess you for
certifying purpose.
- The Student's Assessment of Self-Study Program

will give me a feedback on my efforts to
facilitate your learning.
- The List of Papers to Submit will provide you

with a checklist on what to submit to me.
- The Recommended Follow-up suggests what other
learning activities you should undertake.
2. You must follow all the specific instructions to the

letter.
3. You must complete and submit all the assigned tasks

on the specified date.
4. You need to have the following materials when you

accomplish the activities of the program:
- Ballpen or pencil
- Carbon papers
- Papers
- The self-instructional program written by yours

truly which you have gone through before:
"Distance Education in Medicine. An Off-

Campus Study"
The estimated study time for the program excluding the

summative evaluation activity is 1 to 2 hours.
Best wishes!

1995
Table of Content
Introduction ........................................... 1
Prerequisites .......................................... 1
Learning Objectives .................................... 2
I Embarking on a Task to Write a Distance Education

Lesson in Medicine .................................... 2
Planning 1
Planning 2
Planning 3
II Writing a Draft of the Self-instructional Material ..... 16
Preliminary Drafting
III How to Write a Self-instructional Material ............. 22
Analysis and Comparison of Three Self-instructional

Materials
IV Critiquing and Developmental Testing of a

Self-instructional Material ........................... 26
Checklists and Questionnaires .......................... 27
Summary ................................................ 34
Summative Evaluation Activities ........................ 36
Critiquing a Self-instructional Material in Print

Writing a Distance Education Lesson in Medicine
Developmental Testing of a Self-instructional
Material
Student's Assessment of Self-Study Program ............. 37
List of Papers to Submit ............................... 38
Recommended Follow-up .................................. 39
Attachments:
Checklists and Questionnaires
Clinical Diagnosis of Thyroid Disorders

HOW TO WRITE A DISTANCE EDUCATION LESSON IN MEDICINE
Introduction
Conducting a distance education (DE) program in medicine

will invariably necessitate construction of self-instructional
materials by the medical educators.
Self-instructional materials may either be in the print or

nonprint medium. Whatever medium to be used, the medical
educators constructing the self-instructional materials must
always start with a "writing". The "writing" can end up in self-
instructional materials in print or it can serve as the script
for the self-instructional materials in the nonprint medium.
Writing self-instructional materials for DE use is quite

different from writing materials for use in residential
education. The former takes into strong consideration the
geographic distance between the student and the teacher and its
inherent constraint in face-to-face interaction.
The self-instructional materials are usually constructed in

such a way that the students will learn just by going through
them without the physical presence of the teacher.
The self-instructional materials are usually written in

such a way that they are "interactive", meaning, as the students
go through them, they get the feeling that the teacher is just
nearby interacting with them.
Thus, writing self-instructional materials for DE use

requires a skill and a format different from those use in
residential education.
In this self-study program, you will learn how to write a

self-instructional material in medicine for DE use. In this
program, a DE module, unit, chapter, or lesson will be used
interchangeably, that is, all referring to a self-instructional
material that can be completed in 1 to 2 hours.
Prerequisites
There are four prerequisites that you must possess before

you go into learning how to write a DE lesson in medicine.
First, you must understand fully the concept of DE.
Second, you must be convinced of the usefulness of DE in

medicine.
1
Third, you must have already designed a DE program in
medicine before.
The last prerequisite is that you are motivated and willing

to learn how to write a DE lesson in medicine, no matter what it
takes.
If you don't possess these four prerequisites, you will

surely encounter rough sailing in this program. To have the
first three prerequisites, therefore, I suggest that you first go
through the following two self-study programs written by yours
truly:
1. Distance Education in Medicine. An Off-campus Study.
2. How to Design a Distance Education Program in

Medicine. An Off-Campus Study.
Specific Learning Objectives
When you finish this program, you should be able to:
1. Write a distance education lesson in medicine.
2. Critique a distance education lesson in medicine in the

print medium.
I. Embarking on a Task to Write a Distance Education Lesson in

Medicine
Let us say you, as a medical educator, have decided to

embark on a task to write a distance education lesson in
medicine. This DE lesson is synonymous with a self-instructional
material (SIM) in medicine in the print medium.
This decision carries with it at least four assumptions.

These are:
1. You understood fully the concept of DE in medicine.
2. You had designed a DE program in medicine. You are

about to develop the program by starting to
construct SIM in the print medium. The SIM you are
going to write is part of the DE program you have
designed.
3. You are a content expert of the SIM that you are

going to write.
2
4. The fourth assumption is on knowing how to write the
SIM. You may or may not know it. For the purpose
of this self-study program, let us assume that you
still don't know how to write a SIM yet, but you are
going to learn how to do it in a short while.
Before you embark on the task itself, you must do some

planning, isn't it?
Planning, in your case, will involve considering two things:
1. How to write a SIM in medicine and
2. What to write to come out with a SIM in medicine
There are various steps and many phases in planning.
The basic steps in planning are situational analysis,

formulation of objectives, formulation of strategies on how to
achieve the objectives, and determination of evaluation
indicators.
There are many phases in planning, mainly because of the

leeway given the planner to revise or to change as new thoughts,
ideas, and decisions crop up all for the sake of coming out with
a good product.
In this self-study program, as we illustrate the different

steps and phases of planning, we simply label them as Planning 1,
Planning 2, and so on. Bear in mind that the number of phases of
planning is infinite.
1. Planning 1
Initially, your planning will involve answering the

following questions:
1. What is the title (or subject matter) of the SIM

that I am going to write?
2. Who are my intended learners?
3. What is my goal or objective in writing the SIM?
4. What outcome do I expect the students to achieve

after going through my SIM?
3
Planning 1 Activity
Think of a lesson in medicine which you are a content expert

of and which you want to write for DE use in the print medium.
Suggestions:
1. Get hold of the DE program that you had previously

designed. Consider the first module, unit, or
lesson in your design. Determine if the print
medium is appropriate to use in making the SIM. If
yes, you have found a lesson in medicine which you
are a content expert of and one that you may want to
write for DE use.
If the instructional material for the first

module, unit, or lesson in your DE program is best
constructed in the nonprint medium, I suggest you
look for another lesson, one whose
instructional material can best be presented in the
print medium.
2. Although I strongly recommend my first suggestion in

looking for a lesson in medicine to write for DE
use, I am giving you another option. You can choose
any topic or any lesson in medicine as long as the
instructional material to be constructed is best
presented in the print medium and one that can be
studied in 1 to 2 hours.
After you have decided on the lesson in medicine to write

for DE use, fill up the form in the next page entitled "Planning
1 Activity."
4
PLANNING 1 ACTIVITY
Name ___________________________________________ Date ___________
INSTRUCTIONS: Accomplish in duplicate. Furnish me a copy.

Thanks.
TITLE OF SIM:
INTENDED LEARNERS:
YOUR GOAL IN WRITING THE SIM:
THE OUTCOME YOU ARE EXPECTING FROM YOUR LEARNERS:
STOP HERE FOR A WHILE. START FILLING UP THE ABOVE FORM.

------------------------------------------------------------
RESUME HERE AFTER YOU ARE THROUGH FILLING UP THE ABOVE FORM.
5
PLANNING 1 ACTIVITY
Name ___________________________________________ Date ___________
INSTRUCTIONS: Accomplish in duplicate. Furnish me a copy.

Thanks.
TITLE OF SIM:
INTENDED LEARNERS:

------------------------------------------------------------
5-Duplicate
Now, take a look at my Planning 1 Activity output on the
lesson "How to Write a Distance Education Lesson in Medicine"
below.
As you go through my output, learn from it, either through

critiquing or picking up something which will help you improve
your own output.
After you are through, proceed to Planning 2.
PLANNING 1 ACTIVITY OUTPUT
Name: Dr. Reynaldo O. Joson Date: 6 - 8 - 95
TITLE OF SIM:
How to Write a Distance Education Lesson in Medicine
INTENDED LEARNERS:
Medical educators
To teach medical educators how to write a DE lesson in

medicine using a self-instructional material in the print medium.
The medical educators as students must be able to learn how

to write a DE lesson in medicine after going through the self-
instructional material that I will write or make in the print
medium.
6
Planning 2
In Planning 1, you have decided on the following:
1. The SIM in medicine you are going to write.
2. The intended learners.
3. The goal in writing, which is to teach.
4. The expected outcome, which is student learning

after reading your SIM.
Now, focus on the outcome, which is student learning.
In Planning 2, you should be concerned in how to attain your

outcome. More specifically, you should be thinking of how to
make your SIM attain your outcome. In other words, you should be
thinking of how you can construct your SIM in such a way that it
will facilitate learning when your students go through it even in
your physical absence.
There are three areas in the construction of a SIM where

strategies to facilitate student's learning are very important.
These three areas are, namely: the structure, the content, and
the writing.
The Structure
The structure refers to the organization of the parts of the

SIM.
What are the parts of a SIM? The elemental parts are the
introduction, the body, and the closing.
You can add any other parts which you think are necessary in
facilitating your student's learning. Other parts may include a
foreword, a guide on how to use the SIM, pretest and posttest,
recommended follow-up activities, etc.
A SIM will facilitate learning if it has a well-organized

structure, meaning,
1. The different parts that make up the whole are

readily evident to the learner.
2. The learner is aware of the purpose and importance

of the different parts.
3. The different parts are systemically organized and

arranged in a logical sequence.
7
The Content
The content refers to what is written in the different parts

of the SIM.
A SIM will facilitate learning if the content is adequate

and appropriate, meaning,
1. It gives the learner direction on what and how to

study.
2. It gives adequate and appropriate information based

on the learning objectives of the SIM.
3. It gives adequate and appropriate active learning

activities based on the learning objectives.
4. It gives adequate and appropriate self-assessment

exercises based on the learning objectives.
The Writing
The writing refers to how the content of the different parts

of the SIM is written.
A SIM will facilitate learning if the writing is easy to

understand and it is interactive, meaning,
1. The words and phrases used are commonplace and

familiar.
2. The constructed sentences and paragraphs are simple

and easy to understand.
3. There is a clear expression of ideas and a

systematic flow of thought.
4. The writing exudes an atmosphere of informality,

which in turn contributes to an atmosphere of
learning.
5. The writing is such that the learner feel the

teacher is nearby interacting with him.
Above, I have given you some tips that will help make your
SIM facilitate your student's learning.
8
Have these tips in mind when you construct your SIM.
Remember there is more than one way of doing things. There is no
such thing as the only way to construct a SIM in medicine. You
can initially adopt the strategies of other writers. As you go
on writing more SIMs, feel free to be innovative and creative.
Remember what matters in the end is whether your SIM will
facilitate student's learning or not.
Please proceed to Planning 2 Activity on the next page.
9
PLANNING 2 ACTIVITY
Name ___________________________________________ Date ___________
INSTRUCTIONS: With your planned self-instructional material in

mind, make tentative decisions or strategies on
how to construct it in order that it will
facilitate student's learning. Fill up the items
asked for. Accomplish in duplicate. Furnish me a
copy. Thanks.
TITLE OF SIM:
INTENDED LEARNERS:
STRATEGIES TO FACILITATE LEARNING:
| CONTENT | WRITING
| |
| How should the | How should the
| content be to | writing be to
| facilitate | facilitate
| learning? | learning?
| (At least 3) | (At least 3)
___________________| |
| |
STRUCTURE | 1. | 1.
| |
Give the parts. | |
(At least 3) | 2. | 2.
| |
1. | |
| 3. | 3.
2. | |
| |
3. | |
| |
| |
| |
How should the | |
structure be to | |
facilitate | |
learning? | |
(At least 2) | |
| |
1. | |
| |
2. | |
| |
| |
10
PLANNING 2 ACTIVITY
Name ___________________________________________ Date ___________

mind, make tentative decisions or strategies on
how to construct it in order that it will
facilitate student's learning. Fill up the items
asked for. Accomplish in duplicate. Furnish me a
copy. Thanks.
TITLE OF SIM:
INTENDED LEARNERS:
| CONTENT | WRITING
| |
___________________| |
| |
STRUCTURE | 1. | 1.
| |
Give the parts. | |
(At least 3) | 2. | 2.
| |
1. | |
| 3. | 3.
2. | |
| |
3. | |
| |
| |
| |
How should the | |
structure be to | |
facilitate | |
learning? | |
(At least 2) | |
| |
1. | |
| |
2. | |
| |
| |
10-Duplicate
------------------------------------------------------------

lesson: "How to Write a Distance Education Lesson in Medicine"
at the next page.

your own output.
Note: Your Planning 2 Activity output which consists of a

set of criteria can serve as a guide, checklist, or rating scale
to evaluate your SIM. You can use it as you write your SIM as
well as after you have written it.
After you are through reading my Planning 2 Activity output,

please proceed to Planning 3.
11
TITLE OF SIM:
INTENDED LEARNERS: Medical educators
| CONTENT | WRITING
| |
___________________| |
| |
STRUCTURE | 1. Gives direction | 1. Easy to
| | understand
Give the parts. | | words/phrases
(At least 3) | Adequate and | sentences/
| appropriate - | paragraphs
1. Introduction | | ideas/thoughts
| 2. information |
2. Body | | 2. Interactive
| 3. active learning |
3. Closing | activities | 3. Informal
| |
| 4. self-assessment |
| exercises |
How should the | |
structure be to | |
facilitate | |
learning? | |
(At least 2) | |
| |
1. Distinct parts | |
2. Parts with | |
purpose | |
3. Parts well | |
organized, | |
with | |
systematic | |
and logical | |
sequence | |
12
Planning 3
With your planned SIM in mind, decide on the specific

learning objectives for your intended learners. Remember that
the learning objectives form the basis for writing the SIM. Use
the following guidelines in formulating your learning objectives:
1. Include objectives which are "must know".
2. Include objectives which can be reasonably completed

in 1 to 2 hours.
3. Focus on your intended learners and not on yourself

as the medical educator. Do not think of what you
can accomplish for the learner as you formulate the
learning objectives.
4. Think of what behavior you expect your intended

learners to be able to do after going through your
SIM. The behavior must be specific, observable, and
measurable. Do not use such nonbehavioral terms as
know, understand, realize, appreciate, believe,
enjoy, and the like. Use action verbs that can
elicit a behavior which is observable and
measurable.
5. State the learning objectives in such a way that

they can be easily understood by your intended
learners.
As mentioned earlier, the learning objectives form the very

basis for writing the SIM.
For the medical educator writer, the set of learning

objectives serves as the steering wheel of the whole SIM. It
determines the content, the learning activities, and the
assessment methods that the medical educator writer should
include in the SIM.
For the intended learners, the set of learning objectives is

very useful. It can facilitate learning when it serves as a
guide on what to learn and also, when it serves as a criterion
or reference for self-assessment of learning.
Please proceed to the next page for the Planning 3 activity.
13
PLANNING 3 ACTIVITY
(Formulation of Specific Learning Objectives)
Name ___________________________________________ Date ___________

mind, formulate the specific learning objectives.
Accomplish in duplicate. Furnish me one copy.
Thanks.
TITLE OF SIM:
INTENDED LEARNERS:
SPECIFIC LEARNING OBJECTIVES:
At the end of the self-study program, the student should be

able to:
1.
2.
3.
Note: As the content expert, you decide on what and how many
learning objectives to include in your SIM.

------------------------------------------------------------
14
PLANNING 3 ACTIVITY
Name ___________________________________________ Date ___________

mind, formulate the specific learning objectives.
Thanks.
TITLE OF SIM:
INTENDED LEARNERS:

able to:
1.
2.
3.
Note: As the content expert, you decide on what and how many
learning objectives to include in your SIM.

------------------------------------------------------------
14-Duplicate
lesson: "How to Write a Distance Education Lesson in Medicine"
below.

your own output.
Use the following criteria to evaluate both of our outputs

as far as the formulation of learning objectives is concerned:
1. Must Know
2. Can be reasonably completed in 1 to 2 hours
3. Clear
4. Specific
5. Observable
6. Measurable
After you are through with Planning 3 Activity, please

proceed to "Writing a Draft of the Self-instructional Material."
TITLE OF SIM:
INTENDED LEARNERS:
Medical educators

able to:
1. Write a distance education lesson in medicine.
2. Critique a distance education lesson in medicine in the

print medium.
15
II. Writing a Draft of the Self-instructional Material
After you are through formulating the specific learning

objectives, you can now start writing a draft of your planned
SIM.
There are many approaches in making the draft.
One approach, which I find very systematic, consists of the

following steps:
1. Make a tentative decision on the parts to include.
Example 1
Introduction
Body
Summary
Example 2
Introduction
Pretest
Body
Summary
Posttest
Note: I like to emphasize the phrase "tentative

decisions" in the parts to be included.
Addition and substraction may be done as you go
on drafting and finalizing your SIM. I suggest
that you start with the basic parts as enumerated
in Example 1. As you write your draft, if you
feel you have to add more parts, then do so.
2. Make a tentative outline of the content to be

included in the various parts you have previously
decided on.
2.1 In the "Introduction", as you try to outline

the content, think of the "objectives" of this
part, which are to orient and to motivate.
Thus, the "Introduction" should contain at

least the following:
1. What the SIM is all about

2. Why it is important and useful to
study the subject matter of the SIM
16
2.2 For the "Specific Learning Objectives", these
have already been formulated before the start
of the draft.
2.3 In the "Body", as you try to outline the

content, use the specific learning objectives
you have formulated as a guide.
2.4 In the "Summary", as you try to outline the

content, think of the "objective" of this
part, which is to put together all the items
of the SIM in a brief and concise form.
3. After you have made a tentative outline of the

content, start writing the draft of the SIM itself.
3.1 Put meat on the skeletal framework. Add,

substract, and revise the skeletal outline as
you go along writing the draft, all for the
purpose of coming out with a SIM that will
facilitate learning of students at a geographic
distance from you.
3.2 Write in such a way that you will be easily

understood by your intended learners. Create a
learning atmosphere, that of informality. Make
the learners feel as if you are nearby
interacting with them.
3.3 In the "Body", provide adequate and

appropriate information based on the specified
learning objectives.
3.4 In the "Body" too, provide adequate and

appropriate active learning activities and self-
assessment exercises. Make sure to provide
immediate feedback to the learning activities
and self-assessment exercises.
Note: As I said before, there is no one way of

constructing a SIM in print. You can
construct a SIM in any way you wish (freedom to
be creative) as long as you accomplish the
ultimate objective of the SIM, which is to
facilitate student's learning just by going
through the SIM without your physical presence.
17
In Planning 2, I gave you some guidelines that
will help you achieve this ultimate objective of
the SIM. Do you still remember them? Have
those guidelines in mind when you write your
SIM. Okay?
Now, please proceed to do the Preliminary Drafting Activity

on the next page.
18
PRELIMINARY DRAFTING ACTIVITY
Name ___________________________________________ Date ___________
INSTRUCTIONS: Make an outline of your planned self-instructional

material in medicine. Include the parts and an
outline of the content of each part.
Thanks.
TITLE OF SIM:
INTENDED LEARNERS:
INTRODUCTION:
BODY:
19
PRELIMINARY DRAFTING ACTIVITY
Name ___________________________________________ Date ___________
INSTRUCTIONS: Make an outline of your planned self-instructional

material in medicine. Include the parts and an
outline of the content of each part.
Thanks.
TITLE OF SIM:
INTENDED LEARNERS:
INTRODUCTION:
BODY:
19-Duplicate
BODY (Continuation):
CONCLUSION:
Note: You can add more parts to the above form. You are the
content expert and you are the writer of your SIM.

------------------------------------------------------------
20
BODY (Continuation):
CONCLUSION:
Note: You can add more parts to the above form. You are the
content expert and you are the writer of your SIM.

------------------------------------------------------------
20-Duplicate
Now, take a look at my Preliminary Drafting Activity output
on the lesson: "How to Write a Distance Education Lesson in
Medicine" below:
After you are through with the Preliminary Drafting

Activity, please proceed to "How to Write a Self-Instructional
Material."
PRELIMINARY DRAFTING ACTIVITY OUTPUT
TITLE OF SIM:
INTENDED LEARNERS:
Medical educators
INTRODUCTION:
Constructing instructional materials is a must in DE.
Instructional materials may be print or nonprint. Even for

nonprint instructional materials, "writing" is needed to be used
as a script.
Learning how to write a DE lesson is a must. Skill and

format are different from those needed for instructional
materials in residential education.
This self-study program is on how to write a DE lesson in

medicine.
BODY:
1. Embarking on a task to write a DE lesson in medicine
Planning
Goal and objective
Expected output
Strategies to achieve goal or output
2. Writing a draft of the self-instructional material
Approaches or steps
21
3. How to write a self-instructional material
Comparison of conventional instructional materials with

those used for DE
Pointers in writing a DE lesson
4. Developmental testing of self-instructional materials
Critiquing a self-instructional material
SUMMARY:
Essential steps in writing a DE lesson in medicine
Planning
Drafting
Testing and critiquing
Importance of creativity
Importance of goal in writing a self-instructional material
III. How to Write a Self-instructional Material
An approach which I will use in teaching you how to write a

SIM is demonstration by me and return demonstration by you.
Before I present to you my demonstration, I like you first

to read and compare three manuscripts written by yours truly and
which I shall label as:
Manuscript 1: Distance Education in Medicine. An Off-

campus Study. (You have gone through this
before.)
Manuscript 2: Distance Education in Medicine. (Seen at

the Appendix of Manuscript 1)
Manuscript 3: Clinical Diagnosis of Thyroid Disorders.

(See "Attachment" in this self-study
program)
Take hold of these three manuscripts. Rapidly read through

them, one by one. Read only. You don't have to do the
activities and exercises mentioned in the manuscripts.
Analyze and compare the three manuscripts concentrating on

the structure, the content, and the writing. Then, answer the
questionnaire on the following page.
22
ANALYSIS AND COMPARISON OF MANUSCRIPTS
Name ___________________________________________ Date ___________

INSTRUCTIONS: You have read the following manuscripts:

2. Distance Education in Medicine.
3. Clinical Diagnosis of Thyroid Disorders.
Answer the questions below by encircling a number that

corresponds to the manuscript listed above.
Accomplish in duplicate. Furnish me one copy. Thanks.
Which among the 3 manuscripts Manuscript
1. Provides active teaching activities

for the learner
1.1 The most? 1 2 3

1.2 The least? 1 2 3
2. Provides self-assessment exercises
2.1 The most? 1 2 3

3. Provides feedback to the learning activities

and self-assessment exercises
3.1 The most? 1 2 3

4. Has a writing which is
4.1 Informal? 1 2 3
4.2 Formal? 1 2 3
5.1 Interactive? 1 2 3
5.2 Non-interactive? 1 2 3
6. Facilitates learning of the student in the

physical absence of the teacher
6.1 The most? 1 2 3

7. Do you recommend as a prototype of SIM for

distance education use? 1 2 3
23
ANALYSIS AND COMPARISON OF MANUSCRIPTS
Name ___________________________________________ Date ___________

INSTRUCTIONS: You have read the following manuscripts:

Answer the questions below by encircling a number that

corresponds to the manuscript listed above.
Accomplish in duplicate. Furnish me one copy. Thanks.

for the learner
1.1 The most? 1 2 3

2.1 The most? 1 2 3


3.1 The most? 1 2 3

4.1 Informal? 1 2 3
4.2 Formal? 1 2 3
5.1 Interactive? 1 2 3
5.2 Non-interactive? 1 2 3

6.1 The most? 1 2 3


distance education use? 1 2 3
23-Duplicate
------------------------------------------------------------
Now, take a look at how I answered the questionnaire.
ANALYSIS AND COMPARISON OF MANUSCRIPTS OUTPUT


for the learner
1.1 The most? (1) 2 3

1.2 The least? 1 (2) 3
2.1 The most? (1) 2 3

2.2 The least? 1 (2) 3

3.1 The most? (1) 2 3

3.2 The least? 1 (2) 3
4.1 Informal? (1) 2 3

4.2 Formal? 1 (2) 3
5.1 Interactive? (1) 2 3

5.2 Non-interactive? 1 (2) 3

6.1 The most? (1) 2 3

6.2 The least? 1 (2) 3

distance education use? (1) 2 3
24
Do we have any differing answers?
If yes, let us review our answers and see if we can do some

adjustments and come out with a common understanding.
Manuscript 2 is the one you are most familiar with, isn't

it? For sure, a reader can learn or pick up something just by
reading it. In this sense, it is a self-instructional material.
Manuscript 3 is also a self-instructional material. It has

active learning activities and self-assessment exercises not seen
in Manuscript 2. For this reason, we can predict that Manuscript
3 can better facilitate learning than manuscript 2.
Because of the active learning activities, the self-

assessment exercises, and the accompanying feedback that it
contains and because of the interactive and informal way of
writing, Manuscript 1 is the self-instructional material that
will facilitate learning the most. It is the one that is being
recommended for DE use.
After those explanations, do we now have a common

understanding?
With the above exercise, I believe I have demonstrated to

you what a SIM for DE use should be and how it is written. Don't
you think so?
Actually, you can now start drafting or writing your planned

SIM using Manuscript 1 as a model or as a pattern. Remember what
I said before regarding creativity and innovativeness? As a
beginner, although you usually start by adopting the strategies
of veteran writers, you are free to innovate. In fact, you are
encouraged to be creative. You can write a SIM in any style or
format you want as long as it facilitates the learning of your
students. To facilitate learning, use the general guidelines I
gave you in Planning 2 activity. Remember?
As I have said, after the analysis and comparison of the

three manuscripts, you can now start drafting or writing your
planned SIM. But, hold it for a while until we finish with one
more learning activity, which is "Critiquing and Developmental
Testing of the Self-instructional Material."
25
IV. Critiquing and Developmental Testing of a Self-instructional
Material
Critiquing and developmental testing are done after you have

drafted and have revised for the nth time a SIM which you now
think is ready for publication. Before the publication, however,
if you want to improve further on your SIM, have it critiqued by
your medical educator colleagues. Do also a developmental
testing of your SIM.
Developmental testing simply means trying out your SIM on

"sample" learners and revising it before the final version is
published. Ideally, the "sample" learners should be as like the
intended learners as possible.
Developmental testing can be in the form of face-to-face

tryouts or field trials. It is advisable to have both forms of
testing if you want to have maximum improvement for your SIM.
Face-to-face tryout, as the phrase implies, is conducted on

a one-to-one basis, meaning, you sit across your student. You
give him your SIM. You ask him to go through the SIM without
asking you any question during the tryout proper. As your
student goes through your SIM, you observe what he is doing and
how he is reacting to your SIM. After he is through with the
SIM, you can ask him questions about the lesson in the SIM and
the SIM itself. From your observations and from the answers
given to you by the student, you decide which areas in your SIM
need improvement. Then, you make the necessary revisions.
In the face-to-face tryout, it is recommended that you get a

representative sample of your potential learners, representing
the three groups of learners: fast, average, and slow.
Later on, I will give a checklist which you can use for a
face-to-face tryout.
Now, let's talk about field trials. In field trials, you

send your SIM to a group of potential learners who are at a
geographic distance from you. You ask them to go through your
SIM. Then you ask for feedback regarding the lesson in the SIM
and the SIM itself. You can ask for feedback through a
questionnaire that you provide, through interview, or both. From
the feedback, you then decide on the improvement and revision of
your SIM.
I shall now give you checklists and questionnaires which you

can use for developmental testing and critiquing.
26
CHECKLIST FOR FACE-TO-FACE TRYOUT OF A SIM
Name of Learner:
Self-instructional Material:
Time started: _______ Time Finished: _______ Total time: _______
Observations: Possible Reasons given

reasons by learner
1. Seem not to be following

instructions?
- Activities and exercises
- Sequence
- Others:
2. Seem to have undue difficulty?
3. Seem to be bored?
4. Others:
Note: Beside your personal observation, it is recommended that

you also ask the learner to fill up a questionnaire.
27
QUESTIONNAIRE FOR FIELD TRIAL AND FACE-TO-FACE TRYOUT OF A SIM
Name of Learner:
INSTRUCTIONS: Please assess the self-instructional material by

answering the items below as comprehensively and as
accurately as possible. Use the back page or
additional papers if necessary.
1. How long did it take you to finish the SIM?
__ 1 hr __ 2 hr __ 3 hr __ 4 hr __ 5 hr Others ________
2. How difficult was the instruction?
__ very difficult __ fairly difficult/easy __ very easy
Where/what was it very difficult or very easy?
3. Were there any parts, concepts, or words that you found

particularly difficult or not well explained? If there were,
please give details.
4. Was the SIM well structured and well programmed?
5. The "Introduction" in the SIM
Did it adequately and appropriately orient you?
Did it adequately and appropriately motivate you?
6. The "Learning Objectives" in the SIM
Were they clear (specific, observable, measurable)?
Were they "must know" objectives?
Were they too heavy?
28
7. Did you achieve the learning objectives after going through
the SIM?
How confident are you of your achievement of the learning

objectives?
8. The "Content" in the SIM
Was it adequate based on the stated learning objectives?
Was it appropriate based on the stated learning objectives?
Was it clear?
Was it well structured?
9. The "Active Learning Activities" in the SIM
Were they adequate?
Were they appropriate and effective?
10. The "Self-assessment Exercises" in the SIM
Were they adequate?
11. The "Feedback" or "Responses" in the SIM
Were they adequate?
12. The "Summary" or "Review" in the SIM
Was it brief and concise?
Was it appropriate and effective (helpful)?
29
13. The "Writing" in the SIM
Were the directions clear or confusing?
Was the pacing too slow or too fast?
How was the vocabulary in the SIM?
How was the grammar in the SIM?
How was the sentence and paragraph construction?
Was there a clear expression of ideas?
Was there a smooth and proper flow of thought?
What was your general impression of the SIM's appearance?

Was it friendly or cold? Was it formal or informal?
Was it interactive or not?
14. What did you particularly like about this SIM?
15. What did you particularly dislike about this SIM?
16. Any suggestions on what might have helped you in this

instruction? Give suggestions to improve the SIM.
30
CHECKLIST OR QUESTIONNAIRE FOR CRITIQUING A SIM
Name of Critique:

1. How long did it take you to finish the SIM? How long do you
think it will take a learner to finish the SIM?

31
the SIM? What are the chances that a learner can achieve the
learning objectives fairly easily after going through the
SIM?
Was it clear?
Were they adequate?
Were they adequate?
Were they adequate?
32

16. Suggestions on what might help improve the SIM.
33
I have just presented to you samples of checklists and
questionnaires for critiquing and developmental testing a SIM.
In a little while, after you have completed this self-study

program, you will have the opportunity to use the checklist on
critiquing a SIM. I am going to ask you to critique this self-
study program that I wrote.
After you will have written your planned SIM, which I am

going to ask you to do as part of your summative evaluation
activity, you will have the opportunity to use the checklist and
questionnaire for developmental testing.
At this moment, I think we are ready to wind up this self-

study program.
Summary
The essential steps in writing a DE lesson in medicine

consists of planning, drafting, and finalizing for publication.
In planning, the following should be spelled out:
1. The subject matter or title of the self-

instructional material or SIM.
2. The intended learners.
3. The objective of writing the SIM, which is to teach

through the DE mode using the print medium.
4. The specific learning objectives for the SIM.
5. The strategies to make the SIM facilitate learners'

achievement of the learning objectives.
6. The evaluation indicators that will show that the

SIM has in fact facilitated learning of the students
who went through it.
7. The evaluation indicator that will show that the

students have achieved the learning objectives as
stated in the SIM.
Drafting is implementing the plan. It usually starts with a

preliminary drafting activity which consists of deciding on the
parts to include and outlining the content of the parts. This is
34
followed by the actual writing of the full content of the SIM.
Initial drafts undergo a number of revisions until such a time
that you as the medical educator writer feel it is final and
about ready to be published.
After the so called final draft is reached, you can subject

it for further improvement through critiquing by your peers and
developmental testing by representative "sample" learners. After
the critiquing and developmental testing, you make further
revisions as necessary until you decide that your SIM is ready
for publication.
In closing, I like to re-emphasize the leeway and

encouragement for creativity and innovativeness when you write a
SIM. You can use any style or format you want as long as your SIM
facilitates the learning of your students.
35
SUMMATIVE EVALUATION
The specific learning objectives of this self-study program

consist of the following:
1. You must be able to write a distance education

lesson in medicine.
2. You must be able to critique a distance education

lesson in medicine in the print medium.
Summative Evaluation Activity 1
Using the checklist for critiquing a SIM, critique this

self-study program of mine, "How to Write a Distance Education
Lesson in Medicine."
At the end of this program, I have provided you with an

extra copy of the checklist. Use it.
Summative Evaluation Activity 2
Using your Preliminary Drafting Activity output as the take-

off point, write your planned SIM.
After you have written your SIM, subject it to developmental

testing. Use 3 sample students each for both face-to-face tryout
and field trial.
Use the observational checklist and the questionnaire for

developmental testing.
Again, at the end of the program, I have provided you with

extra copies of the said checklist and questionnaire. Use them.
36
STUDENT'S ASSESSMENT OF THE SELF-STUDY PROGRAM
Name ___________________________________________ Date ___________
PROGRAM: ________________________________________________________
AUTHOR: _________________________________________________________
INSTRUCTIONS: Please assess the program through the following

statements. Use the key below:
KEY : 5 = Strongly Agree

4 = Agree
3 = Uncertain
2 = Disagree
1 = Strongly disagree
1. The objectives were clear. 5 4 3 2 1
2. The objectives were "must knows." 5 4 3 2 1
3. The objectives were too heavy. 5 4 3 2 1
4. The content was appropriate based on 5 4 3 2 1

the stated objectives.
5. The content was adequate based on 5 4 3 2 1
the stated objectives.
6. The content was clear. 5 4 3 2 1
7. The content was presented in logical 5 4 3 2 1

sequence.
8. The learning activities were 5 4 3 2 1
appropriate based on the objectives.
9. The learning activities were 5 4 3 2 1
effective in facilitating learning.
10. The summative assessment was appropriate. 5 4 3 2 1
INSTRUCTIONS: Please answer seriously. Use back page if needed.
Were there any parts, concepts, or words that you found

Any suggestions on what might have helped you in this instruction?

Any suggestions to improve the self-study program?
37
LIST OF PAPERS TO SUBMIT
Planning 1 Activity Output
Preliminary Drafting Activity Output
Analysis and Comparison of Manuscripts
Critique of "How to Write a DE Lesson in Medicine"
Your Self-instructional Material
Developmental Testing Results
Face-to-face Tryout
Field Trial
Student's Assessment of Self-Study Program
Deadline for Submission: ___________________________________
NOTE: You can only proceed to the next self-study program

after you have submitted all of the above and have
satisfactorily passed the summative evaluation.
Remedials may be given if you don't pass the summative
evaluation.
38
Recommended Follow-up
After this self-study program, I recommend that you write

more distance education lessons or self-instructional materials
in medicine. Doing so will not only promote mastery but will
also give you satisfaction and the other benefits of writing
distance education lessons in medicine. Let me enumerate some of
these benefits that you can get by writing more self-
instructional materials:
1. Efficiency in teaching, in the sense that more

medical learners can be reached within a set period
of time.
2. Avoidance of burnt-out syndrome that usually results

from repetitive teaching because of different
batches of medical learners.
3. Release from the time pressure/load of frequent

face-to-face meeting with medical learners as seen
in the residential mode.
4. Improvement in teaching skills because of additional

training (in distance education).
To obtain proficiency in distance education in medicine, you

should accomplish at least the following modules:
1. Distance Education in Medicine

(which you have accomplished before)
2. How to Design a Distance Education Program in

Medicine
(which you also have accomplished before)
3. How to Write a Distance Education Lesson in Medicine

(which you have just accomplished)
4. How to Make a Distance Education Lesson Using a

Nonprint Medium
There is only one module left before you attain proficiency

in distance education in medicine.
I hope you continue on to the fourth module.
39
CHECKLIST FOR FACE-TO-FACE TRYOUT OF A SIM
Name of Learner:
Time started: _______ Time Finished: _______ Total time: _______
Observations: Possible Reasons given

reasons by learner
1. Seem not to be following

instructions?
- Activities and exercises
- Sequence
- Others:
2. Seem to have undue difficulty?
3. Seem to be bored?
4. Others:
Note: Beside your personal observation, it is recommended that

you also ask the learner to fill up a questionnaire.
QUESTIONNAIRE FOR FIELD TRIAL AND FACE-TO-FACE TRYOUT OF A SIM
Name of Learner:

1. How long did it take you to finish the SIM?


the SIM?
How confident are you of your achievement of the learning

objectives?
Was it clear?
Were they adequate?
Were they adequate?
Were they adequate?


16. Any suggestions on what might have helped you in this

instruction? Give suggestions to improve the SIM.
CHECKLIST OR QUESTIONNAIRE FOR CRITIQUING A SIM
Name of Critique:

1. How long did it take you to finish the SIM? How long do you
think it will take a learner to finish the SIM?


the SIM? What are the chances that a learner can achieve the
learning objectives fairly easily after going through the
SIM?
Was it clear?
Were they adequate?
Were they adequate?
Were they adequate?


16. Suggestions on what might help improve the SIM.

CLINICAL DIAGNOSIS
OF
THYROID DISORDERS
REYNALDO O. JOSON, M.D., D.P.B.S.

TABLE OF CONTENT
Introduction ............................................ 1
Objectives .............................................. 1
Recommended Preparations ................................ 2
I. Methods of Clinical Evaluation of Thyroid Patients . 2
Review Questions I ................................. 4
II. Identification of Patients with a Thyroid Disorder . 5
Review Questions II ................................ 6
III. Nomenclature of Thyroid Disorders .................. 7
Review Questions III ............................... 8
IV. Clinical Classification of Goiters ................. 9
Review Questions IV ................................ 11
V. Physical Signs of Thyroid Malignancy ............... 11
Review Questions V ................................. 12
VI. Clinical Diagnosis of Thyroid Disorders ............ 12
Review Questions VI ................................ 16
Answers to Review Questions ............................. 18
References .............................................. 21
Post-Test ............................................... 22
Answers to Post-Test .................................... 27
Recommended Follow-up ................................... 28
About the Author ....................................... 28
Primary Intended Users - Students of Medicine.
Estimated Study Time - 2 hours

INTRODUCTION
Thyroid disorders are very common in the Philippines. They

are so common that practically all physicians will every now and
then be confronted with a patient with a thyroid problem. For
these reasons, it is recommended that all physicians know at
least how to arrive to a clinical diagnosis of a thyroid disorder.
The phrase "clinical diagnosis" is used here to mean the

utilization of history and physical examination in arriving to a
diagnosis. Although there are other diagnostic procedures which
may be done to evaluate patients with a possible thyroid problem,
this program will be limited to clinical diagnosis. Furthermore,
it will be limited to the evaluation of patients without a
history of previous treatment to their thyroid gland.
This program is designed to be a practical theoretical course

on how to go about evaluating patients with a possible thyroid
disorder just based on history and physical examination. It
discusses the proper utilization of the methods of clinical
evaluation; the identification of patients with and without
thyroid disorders; the nomenclature of thyroid diseases; the
clinical classification of goiter; the physical signs of thyroid
malignancy; and lastly, the clinical diagnosis of patients with
thyroid disorders.
OBJECTIVES
Upon completion of this program, the user is expected to be

able to:
1. Utilize properly the two basic methods of clinical

evaluation in patients with a possible thyroid problem.
2. Determine which patients have and do not have a thyroid

disorder.
3. Cite the nomenclature of thyroid disorders.
4. Explain the clinical classification of goiters.
5. Enumerate the physical signs of thyroid malignancy.
6. Make a logical clinical diagnosis of patients with

thyroid disorders.
1
RECOMMENDED PREPARATIONS
Before going through this program, the user should have a

basic background knowledge of the anatomy, physiology, and
pathology of the thyroid glands. He also must know the
fundamental principles in the diagnostic process. The user is
also advised to study the following glossary before going through
the program:
1. Thyroid patient - Any patient presenting with a pos-

sible, actual, or obvious thyroid problem.
2. Thyroid disorder - Thyroid disease or problem.
3. Goiter - Originally used to mean a benign enlargement

of the thyroid gland; may be used loosely to mean any
thyroid disorder.
I. METHODS OF CLINICAL EVALUATION OF THYROID PATIENTS
There are two methods in the clinical evaluation of thyroid

patients. These are history and physical examination. Although
these two methods are complimentary to each other, in thyroid
patients, physical examination plays a more important role in the
clinical diagnosis.
A. CHIEF COMPLAINT
The clinical evaluation of a thyroid patient starts

with the physician inquiring on what the problem of the
patient is or what is the reason for the medical consulta-
tion. A Filipino thyroid patient will usually point to his/
her neck while at the same time uttering any of the follow-
ing usual sentences or phrases:
1. I think I have a goiter.

2. I was told I may have a goiter.
3. I have a lump here in my neck.
4. I have this feeling of obstruction in my neck. I
may have a goiter.
B. PHYSICAL EXAMINATION
Once the physician gets the cue that the chief com-
plaint of the patient is a possible thyroid problem, he
2
should right away start an examination of the patient's
neck. He can continue asking questions while he performs
the physical examination.
The physician, positioned in front of the patient,

first inspects the patient's neck. He looks for an inci-
sional scar that may signify previous operative treatment.
He also looks for obvious paratracheal nodule and enlarge-
ment that may signify a thyroid disorder.
After inspection, the physician then positions himself

at the back of the seated patient to start the neck palpa-
tion. He first identifies the position of the trachea. He
then places the 2nd, 3rd, and 4th fingers of both hands
along the vertical structure of the trachea.
The patient is now asked to swallow. As the patient

swallows, the physician initially tries to feel for any
enlarged thyroid lobes or for any thyroid nodules. A mass in
the paratracheal area that moves with deglutition is a
thyroid disorder until proven otherwise. In the presence of
abnormalities, the physician studies and describes them in
terms of symmetry, size, location, consistency, mobility,
and tenderness.
After palpating the paratracheal area to evaluate the

thyroid gland, the physician then palpates the lateral neck
for any enlarged lymph nodes.
After completion of the neck examination, the physician

counts the pulse rate. During this time that the physician
is examining and talking to the patient, he should look for
other signs that may suggest a thyroid disorder. Specifical-
ly, he should look for exophthalmos; hoarseness of voice;
and a distant mass that may be a metastatic thyroid cancer.
Thus, at the very least, the physical examination of a

thyroid patient should include the following:
1. Inspection of the neck

2. Palpation of the paratracheal area
3. Palpation of the lateral neck
4. Pulse rate
5. Looking for signs that may suggest thyroid disor-
der such exophthalmos, hoarseness of voice, and a
distant mass that may be metastatic thyroid cancer.
3
C. IN-DEPTH INTERVIEW
Once a thyroid disorder is detected or suspected through

physical examination, an in-depth interviewing or history taking
may now be undertaken. In patients who have no previous treat-
ment, the following are some pertinent questions that may be
asked:
1. When was the thyroid disorder first noted?

(Not when did it start?)
2. If there is hoarseness of voice, when did it occur?
3. If there is a regional or distant mass noticeable by
the patient, when was it first discovered?
4. Is there any accompanying pain?
The physician should avoid asking irrelevant questions or

questions that seek answers that are considered not reliable
clues for a thyroid disorder, such as excessive sweating, easy
fatigability, and excessive appetite.
Although this is not part of this program, in patients with

a history of previous treatment, inquiries have to be made
regarding laboratory examinations, medications, operative records,
and biopsy results.
REVIEW QUESTIONS I
DIRECTION: Supply the appropriate answers.
A. Name the two methods utilized in the clinical evaluation of

thyroid patients.
1.
2.
B. Enumerate in a logical sequence the minimum physical exami-

nation that a physician must do to be able to arrive to a
clinical diagnosis in a thyroid patient.
3.
4.
5.
6.
7.
4
C. Name at least five characteristics of a thyroid nodule that
must be described during physical examination.
8.
9.
10.
11.
12.
DIRECTION: Indicate which of the following statements are

true (T) and which are false (F) by circling the
appropriate letter.
T F 13. In thyroid patients, physical examination plays a

more important role than history in the clinical
diagnosis.
T F 14. The best position that the physician must assume

when palpating a thyroid patient's neck is in
front of the patients.
T F 15. Asking the patient to swallow is part of the phy-

sician's technique in palpating a thyroid pa-
tient's neck.
T F 16. A history of excessive sweating is an important

information that must be looked for during history
taking of a thyroid patient.
T F 17. In-depth history taking should be done before phy-

sical examination in a thyroid patient.
Please check your answers on page 18.
II. IDENTIFICATION OF PATIENTS WITH A THYROID DISORDER
After the physical examination and history taking, the phy-

sician should decide whether a thyroid disorder is present or not.
A thyroid disorder is considered not to be present if the

thyroid gland is not palpable; if no thyroid nodule is palpated;
if the pulse rate is less than 90/min; and if there is no
regional or distant mass to suggest a metastatic cancer from an
occult primary thyroid cancer.
5
Normally, a thyroid gland is not clinically palpable on the
neck. There is, however, a situation in which a normal thyroid
gland can be clinically palpable on the neck. This is in very
thin patients with minimal subcutaneous tissues and thinned-out
strap muscles.
There are also situations in which the thyroid gland is dif-

fuse and slightly enlarged and yet a thyroid disorder is not
considered to be present. Physiologic goiters are examples of
these situations. These are seen in adolescent and pregnant or
postpartum thyroid patients.
A thyroid disorder is considered to be present in the fol-

lowing conditions:
1. If the patient manifests signs of hyperthyroidism.

2. If the patient manifests signs of hypothyroidism.
3. If the thyroid gland is abnormally enlarged.
4. If the thyroid gland contains a nodule or multiple
nodules.
5. If the patient has a regional or distant mass consi-
dered to be metastatic cancer from an occult primary
thyroid cancer.
REVIEW QUESTIONS II
A. Enumerate the four physical examination findings (positive

as well as negative findings) on which to base your
decision that a thyroid disorder is not present.
1.
2.
3.
4.
B. Name three situations in which the thyroid gland may be

palpable but yet a thyroid disorder is not considered to
be present.
5.
6.
7.
6
C. Name five situations in which a thyroid disorder is consi-
dered to be present.
8.
9.
10.
11.
12.
III. NOMENCLATURE OF THYROID DISORDERS
When making a diagnosis, a physician must know the name of

the disease. In the clinical diagnosis of thyroid patients,
knowledge of the nomenclature of thyroid disorders is of great
help. A practical nomenclature is presented below:
1. COLLOID ADENOMATOUS GOITERS
1.1 Diffuse colloid goiter

1.2 Colloid cyst
1.3 Colloid adenomatous nodule
1.4 Multiple colloid adenomatous goiter
2. HYPERTHYROIDISM
3. THYROID CANCER
3.1 Papillary carcinoma

3.2 Follicular carcinoma
3.3 Anaplastic carcinoma
3.4 Medullary carcinoma
4. THYROIDITIS
4.1 Acute thyroiditis

4.2 Thyroid Abscess
4.3 Chronic thyroiditis
5. HYPOTHYROIDISM
*6. FOLLICULAR ADENOMA (See explanation below)
The above nomenclature is deemed practical for the follow-

ing reasons:
7
1. It is a simplified nomenclature. For example, patients
with hyperthyroidism can present with a diffuse or
nodular goiter. They can present with or without exoph-
thalmos. Instead of the traditional terms, such as dif-
fuse toxic goiter, nodular toxic goiter, Graves' di-
sease and Plummer's disease, the word "hyperthyroidism"
as a clinical diagnosis is sufficient.
2. It has a clinical basis. It is descriptive of the phy-

sical findings. For example, a cystic mass which most
likely contains colloid fluid is a colloid cyst. A
diffuse goiter without hyperthyroidism and signs of
malignancy is a diffuse colloid goiter. A colloid
adenomatous goiter with multiple nodules is a
multiple colloid adenomatous goiter.
*3. There are no clearcut clinical clues for a diagnosis of

follicular adenoma. Thus, no clinical diagnosis of
follicular adenoma should be made.
REVIEW QUESTIONS III
A. Enumerate the five major types of thyroid disorders.
1.
2.
3.
4.
5.
B. Enumerate the four types of thyroid cancer.
6.
7.
8.
9.
C. Enumerate the four clinical forms of colloid

adenomatous goiter.
10.
11.
12.
13.
8
D. Enumerate the three clinical forms of thyroiditis.
14.
15.
16.
IV. CLINICAL CLASSIFICATION OF GOITERS
There is a clinical classification of goiters which is very

helpful in arriving to a clinical diagnosis. The classification
consists of combining the physiologic and anatomic abnormalities
of the thyroid gland. The clinical classification is as follows:
1. Diffuse toxic goiter

2. Diffuse nontoxic goiter
3. Nodular toxic goiter
4. Nodular nontoxic goiter
The nodular goiters can further be subdivided into the fol-

lowing:
3.1 Uninodular toxic goiter

3.2 Multinodular toxic goiter
4.1 Uninodular nontoxic goiter
4.2 Multinodular nontoxic goiter
A diffuse goiter is said to be present if all the lobes of

the thyroid gland are almost symmetrically enlarged and there are
no discrete nodules. If a lobe of the thyroid gland is smoothly
enlarged (diffusely, without discrete nodule on palpation), the
clinical classification is not a diffuse goiter but a nodular
goiter. The first reason for a nodular classification is that
there is only a unilobar enlargement. The second reason is that
such a unilobar enlargement usually contains a nodule within it.
A nodular goiter is one that contains nodule, either single

or multiple.
A toxic goiter is present if there are signs of hyperthy-

roidism. A nontoxic goiter is present if there are no signs of
hyperthyroidism. The patient is usually euthyroid; rarely is
hypothyroidism present.
A practical rule of thumb to follow is that if the pulse
9
rate is less than 9O/min, then the goiter that is palpably
present is nontoxic. If the pulse rate is equal to or greater
than 9O/min, a hyperthyroidism has to be ruled out in the
presence of a goiter, using other data in the physical examina-
tion. It must be borne in mind that tachycardia may be present
even in nontoxic goiter.
Each of the categories in the clinical classification of

goiters can be represented by several common and uncommon thyroid
diseases. If a patient is classified under a specific category,
then the differential diagnosis will include all the diseases
listed under it. If there are common and uncommon diseases under
the said category, then the more common disease is the more
likely diagnosis, unless there are objective data to point to the
less common disease.
Below is a tabulation of the different thyroid diseases

under each clinical classification of goiters together with their
relative prevalence:
DIFFUSE TOXIC GOITER
Hyperthyroidism (common)
DIFFUSE NONTOXIC GOITER
Diffuse colloid goiter (common)

Chronic thyroiditis (not common)
UNINODULAR TOXIC GOITER (not common)
Hyperthyroidism
MULTINODULAR TOXIC GOITER (not common)
Hyperthyroidism
UNINODULAR NONTOXIC GOITER
Colloid cyst (very common)

Colloid adenomatous nodule (very common)
Thyroid cancer (common)
MULTINODULAR NONTOXIC GOITER
Multiple colloid adenomatous goiter (very common)

Thyroid cancer (common)
1O
REVIEW QUESTIONS IV
Enumerate the six categories in the clinical classification of

goiters that combine physiologic and structural abnormalities of
the thyroid gland and give one common representative thyroid
disease under each category:
1.
2.
3.
4.
5.
6.
Please check your answers on page 2O.
V. PHYSICAL SIGNS OF THYROID MALIGNANCY
As a rule, it is only in euthyroid patients with thyroid no-

dules or nodular goiters that a thyroid malignancy can be inclu-
ded as one of the differential diagnoses.
Thyroid nodules on palpation may be cystic or solid. A

cystic thyroid nodule is one that contains fluid, specifically
colloid fluid. A solid thyroid nodule is one that does not con-
tain fluid. As a rule, it is only in solid nodules that a
thyroid malignancy can be included as one of the differential
diagnoses.
Solid thyroid nodules may be hard or not hard. Although

thyroid malignancies may present as hard and not hard solid, the
former consistency has a higher positive predictive value.
Solid thyroid nodules may be fixed or mobile. Fixation

comes in three forms. One is fixation to the tracheal fascia.
Another is fixation to the overlying skin and soft tissue.
Still another form is fixation to the prevertebral fascia as is
usually seen in anaplastic carcinomas. The presence of fixation
of the thyroid nodule should arouse suspicion of malignancy.
In addition to the hardness and fixation of thyroid nodules,

the other physical signs of thyroid malignancy are:
11
1. Hoarseness of voice that is due to an involvement of the
recurrent laryngeal nerve.
2. Neck nodes, especially on the side of the thyroid nodule,
considered to be metastatic.
3. Distant mass that is considered to be a metastatic
lesion.
Any one sign mentioned above, if present, is enough ground to

suspect thyroid malignancy.
REVIEW QUESTIONS V
Enumerate five physical signs of thyroid malignancy.
1.
2.
3.
4.
5.

appropriate letter.
T F 6. Thyroid malignancy should be one of the most

probable differential diagnoses in diffuse
goiters.
T F 7. Malignancy should be one of the most probable

differential diagnoses in cystic thyroid nodules.
Please check your answers on page 2O.
VI. CLINICAL DIAGNOSIS OF THYROID DISORDERS
A clinical diagnosis of patients with thyroid disorders is

an educated guess that is derived based primarily on the objec-
tive data obtained from the physical examination and secondarily
on the prevalence of the diseases and statistical probabilities.
12
The diagnostic process is greatly facilitated if the physi-
cian has obtained the following knowledge and skills:
1. Proper methods of clinical evaluation.

2. Identification of patients with and without a thyroid
disorder.
3. The functional nomenclature of thyroid disorders.
4. The clinical classification of goiters.
5. The physical signs of thyroid malignancy.
Below is a tabulation showing the essential data obtained

from a patient and the corresponding clinical diagnosis that
should be made:
DATA CLINICAL DIAGNOSIS
Case 1. Diffuse goiter 1. To rule out hyperthyroidism

PR > 9O/min before accepting diffuse col-
No signs of malig- loid goiter
nancy
Case 2. Diffuse goiter 2. Hyperthyroidism with exoph-

PR > 9O/min thalmos
No signs of malig-
nancy
Exophthalmos
Case 3. Diffuse goiter 3. Diffuse colloid goiter

PR < 9O/min
No signs of malig-
nancy
Case 4. Solitary thyroid 4. To rule out hyperthyroidism

nodule, not hard before accepting colloid
solid adenomatous nodule
PR > 9O/min
No signs of malig-
nancy
Case 5. Solitary thyroid 5. Colloid cyst / colloid

nodule, cystic adenomatous nodule
PR < 9O/min
No signs of malig-
nancy
Case 6. Solitary thyroid 6. Thyroid cancer, most probably

nodule, hard solid papillary by prevalence
PR < 9O/min
13
Case 7. Solitary thyroid 7. Thyroid cancer, most probably
nodule, hard, papillary by prevalence
fixed, solid
PR < 9O/min
Case 8. Solitary thyroid 8. Follicular carcinoma with

nodule, not hard, skull metastasis
solid
PR < 9O/min
Skull mass, lytic
No dysphagia, no
dyspnea
Case 9. Solitary thyroid 9. Papillary carcinoma with

nodule, not hard, neck node metastasis
solid
PR < 9O/min
Ipsilateral neck
nodes
Case 10. Huge thyroid nodule, 10. Anaplastic carcinoma

fixed to the pre-
vertebral fascia
with dysphagia and
dyspnea
PR > 9O/min
Case 11. Multiple thyroid 11. Multiple colloid adenomatous

nodules goiter
PR < 9O/min
No signs of malig-
nancy
Case 12. Multiple thyroid 12. To rule out hyperthyroidism

nodules before accepting multiple
PR > 9O/min colloid adenomatous goiter
No signs of malig-
nancy
Case 13. Nodular thyroid 13. Chronic thyroiditis

gland
No discrete mass
PR < 9O/min
No signs of malig-
nancy
14
Case 14. Tender, fluctuant 14. Thyroid abscess
mass on the thyroid
gland
PR > 9O/min
No signs of malig-
nancy
Case 15. Diffuse goiter 15. To rule out hypothyroidism

PR < 9O/min
Short obese stature
with unusually slow
body movements
In the above tabulation, there are situations in which

clinical diagnosis can be made with ease and certainty. There
are also situations in which the clinical diagnosis is made with
reservations. The latter situations are encountered primarily in
those with a pulse rate of 9O/min or greater and in which there
are no reliable objective data available to rule out hyperthy-
roidism. These are seen in cases 1, 4, and 12. Another factor
that contributes to the equivocal clinical diagnosis is the
rarity of the disease as seen in cases 4, 12, and 15.
In case 5, the clinical diagnosis is colloid cyst/colloid

adenomatous nodule. Oftentimes, it is hard to differentiate the
two on clinical ground, especially if the nodule is small. Both
can have the same consistency, that is cystic, because both have
fluid content. It is only in a large colloid cyst (about 3 cm or
greater) that a confident diagnosis can be made. In such a
large size cyst, there is more elbow room to displace the fluid
inside so as to give the diagnosis away.
There are certain thyroid diseases which cannot be made on

clinical grounds. One reason is because of its rarity that it
should not be the primary diagnosis. An example is medullary
thyroid carcinoma. Another reason is that there are no clinical
data strong enough to support it. An example is follicular
adenoma. A solitary thyroid nodule can be a follicular adenoma.
However, since the characteristics of the nodule of follicular
adenoma are hard to differentiate from those of a colloid
adenomatous nodule and since the latter thyroid disease is more
common, the latter diagnosis is usually made.
A multinodular nontoxic goiter without physical signs of

malignancy can be a follicular carcinoma. However, a multiple
colloid adenomatous goiter is usually given as a clinical
15
diagnosis because it is the most common cause. It is only when
there is a distant mass suspected of metastasis that a diagnosis
of follicular carcinoma is made, as is seen in Case 8.
REVIEW QUESTIONS VI
DIRECTION: Given the clinical data in column A, make a

clinical diagnosis and write it down on the
space under column B.
A B
1. Diffuse goiter 1. ________________

PR = 12O/min
Exophthalmos
No signs of malignancy
2. Solitary thyroid nodule, 2. ________________

hard and fixed
PR = 8O/min
No distant mass
3. Solitary thyroid nodule 3. ________________

cystic
PR = 8O/min
4. Solitary thyroid nodule 4. ________________

cystic
PR = 8O/min
Collapse of vertebral bodies
No dyspnea
5. Solitary thyroid nodule, not 5. ________________

hard solid
PR = 8O/min
Ipsilateral neck nodes
6. Huge, thyroid mass, fixed 6. ________________

Dysphagia, dysnea
PR = 1OO/min
7. Multiple thyroid nodules 7. ________________

PR = 8O/min
16
8. Nodular thyroid gland 8. ________________
No discrete mass
PR = 7O/min
9. Diffuse goiter 9. ________________

PR = 6O/min
10. Diffuse goiter 10. ________________

PR = 12O/min
17
ANSWERS TO REVIEW QUESTIONS
I. 1. History
2. Physical examination
3. Inspection of the neck
4. Palpation of the paratracheal area
5. Palpation of the lateral neck
6. Pulse rate
7. Looking for other signs that will suggest thyroid

disorders
8. Size
9. Consistency
10. Fixation or mobility
11. Tenderness
12. Location
13. T
14. F
15. T
16. F
17. F
II. 1. The thyroid gland is not palpable.
2. There is no palpable thyroid nodule.
3. The pulse rate is less than 90/min.
4. There is no regional or distant mass to suggest a

metastatic cancer from an occult primary thyroid
cancer.
18
5. Very thin patients.
6. Physiologic goiter during adolescence.
7. Physiologic goiter during pregnancy.
8. If the patient manifests signs of hyperthyroidism
9. If the patient manifests signs of hypothyroidism
10. If the thyroid gland is abnormally enlarged
11. If the thyroid gland contains a nodule or multiple

nodules.
12. If the patient has a regional or distant mass

considered to be a metastatic cancer from an
occult primary thyroid cancer.
III. 1. Colloid adenomatous goiter
2. Hyperthyroidism
3. Hypothyroidism
4. Thyroid cancer
5. Thyroiditis
6. Papillary carcinoma
7. Follicular carcinoma
8. Anaplastic carcinoma
9. Medullary carcinoma
10. Diffuse colloid goiter
11. Colloid cyst
12. Colloid adenomatous goiter
13. Multiple colloid adenomatous goiter
14. Acute thyroiditis
19
15. Thyroid abscess
16. Chronic thyroiditis
IV. 1. Diffuse toxic goiter - hyperthyroidism
2. Diffuse nontoxic goiter - diffuse colloid

goiter
3. Uninodular toxic goiter - hyperthyroidism
4. Multinodular toxic goiter - hyperthyroidism
5. Uninodular nontoxic goiter - colloid adenomatous

goiter
- colloid cyst
- thyroid cancer
(Any of the above)
6. Multinodular nontoxic goiter - multiple colloid

adenomatous goiter
- thyroid cancer
- chronic thyroiditis
(Any of the above)
V. 1. Hard solid thyroid nodule
2. Fixed thyroid nodule
3. Hoarseness of voice
4. Cervical lymph nodes considered to be metastatic
5. Distant mass that is considered to be metastatic
6. F
7. F
2O
VI. 1. Hyperthyroidism
2. Thyroid cancer, most probably papillary cancer
3. Colloid cyst/colloid adenomatous nodule
4. Follicular carcinoma
5. Papillary carcinoma
6. Anaplastic carcinoma
7. Multiple colloid adenomatous goiter
8. Chronic thyroiditis
9. Diffuse colloid goiter
10. Hyperthyroidism
REFERENCES
1. DeGown EL, DeGown RL: Bedside Diagnostic Examination. New

York, Macmillan Publishing Co., Inc., 1976.
2. Delph MH, Manning RT (eds): Major's Physical Diagnosis. 7th

Ed. Philadelphia, W.B. Saunders Co., 1968.
3. Joson RO: Thyroid Surgical Diseases. Philippines, 1986.
4. Robbins SL: Pathology. 3rd Ed. Philadelphia, W.B. Saunders

Co., 1967.
5. Sabiston DC Jr (ed): Davis-Christopher Textbook of Surgery.

The Biological Basis of Modern Surgical Practice. 12th Ed.
Philadelphia, W.B. Saunders Co., 1981.
6. Schwartz, SI: Principles of Surgery. 5th Ed. New York,

McGraw-Hill Book Co., 1988.
21
POST-TEST

appropriate letter.
T F 1. In the clinical evaluation of thyroid patients, phy-

sical examination plays a more important role than
history.
T F 2. A mass in the paratracheal area that moves with deglu-

tition is a thyroid disorder until proven otherwise.
T F 3. A patient with a diffuse goiter with a history of

excessive sweating and easy fatigability and a pulse
rate of less than 9O/min should be suspected to have
hyperthyroidism.
T F 4. A thyroid disorder is considered not to be present if

examination of the neck and the rest of the body
shows no abnormality and the pulse rate is 8O/min.
T F 5. A clinically palpable thyroid gland can be normal.
T F 6. It is only in thyroid nodules that a malignancy is

included in the differential diagnosis.
T F 7. A cystic thyroid nodule is benign until proven

otherwise.
T F 8. A hard solid thyroid nodule is malignant until

proven otherwise.
T F 9. Medullary thyroid carcinoma is very rare in the

Philippines.
T F 10. Nodular toxic goiters are rare compared to diffuse

toxic goiters.
T F 11. A nontoxic goiter is synonymous with euthyroid

goiter.
T F 12. Chronic thyroiditis is not common in the Philippines.
T F 13. Hyperthyroidism can present as a diffuse as well as a

nodular goiter.
22
T F 14. Follicular adenoma and colloid adenomatous nodule
are synonymous.
T F 15. A pulse rate of 1OO/min or greater is pathognomonic

of toxic goiter.
II. DIRECTION: Choose the best answer by circling the

appropriate letter.
16. A 14-year-old female presented with a solitary soft thyroid

nodule and multiple ipsilateral neck nodes. The pulse rate
was 1OO/min. What is your diagnosis?
a. Follicular carcinoma
b. Papillary carcinoma
c. Colloid adenomatous nodule and tuberculous

lymphadenopathy
d. Uninodular toxic goiter
17. A 5O-year-old female presented with a solitary thyroid

nodule, 4 cm in size, and cystic. There were no neck
nodes nor masses in other parts of the body. The pulse
rate was 8O/min. What is your diagnosis?
a. Papillary carcinoma
b. Follicular carcinoma
c. Colloid cyst
d. Colloid adenomatous goiter
e. Nodular toxic goiter
23
18. A 4O-year-old female presented with multiple nodules on the
thyroid gland. The nodules were of different consistencies.
Some were firm. Some were cystic. The pulse rate was 8O/min.
There were no neck nodes. There was no mass in other parts
of the body. What is your diagnosis?
a. Follicular carcinoma
b. Papillary carcinoma
c. Multiple colloid adenomatous goiter
d. Multinodular nontoxic goiter
e. Chronic thyroiditis
19. A 22-year-old female presents with a diffuse goiter and a

pulse rate of 12O/min. There was no exophthalmos. There was
a palpable lymph node in the right submandibular area. What
is your diagnosis?
a. Hyperthyroidism
b. Graves' disease
c. Diffuse toxic goiter
d. Diffuse nontoxic goiter
e. Papillary carcinoma
2O. A 4O-year-old female presented with a 2-cm hard thyroid

nodule together with a parieto-occipital mass which on
x-ray shows lytic changes on the skull. The pulse rate was
1OO/min. What is your diagnosis?
a. Anaplastic carcinoma
c. Medullary carcinoma
d. Papillary carcinoma
24
21. A 19-year-old female presented with a huge movable diffusely
enlarged thyroid gland. The pulse rate was 8O/min. There
were no neck nodes nor masses in other parts of the body.
What is your diagnosis?
a. Diffuse nontoxic goiter
b. Diffuse colloid goiter
c. Iodine-deficiency goiter
d. Physiologic goiter
22. A 4O-year-old female presented with a hard fixed nodule on

the right lobe of her thyroid gland. The pulse rate was 1OO/
min. There were no neck nodes nor other masses in other
parts of the body. What is your diagnosis?
c. Anaplastic carcinoma
d. Nodular toxic goiter
23. A 6O-year-old female presented with an 8-cm thyroid mass,

which was firm, non-tender, and fixed. The mass moves mini-
mally with deglutition. The pulse rate was 1OO/min. The
patient was dyspneic. What is your diagnosis?
c. Anaplastic carcinoma
d. Medullary carcinoma
25
24. A 14-year-old female presented with a solitary nodule on the
left lobe of her thyroid gland. The nodule was 2 cm in size,
soft, movable and not tender. There were no neck nodes nor
masses in other parts of the body. The pulse rate was 8O/min.
What is your diagnosis?
a. Follicular adenoma
b. Colloid adenomatous
c. Papillary thyroid carcinoma
d. Nodular nontoxic goiter
25. A 5O-year-old female presented with multiple thyroid nodule

of different consistencies. The pulse rate was 1OO/min.
There was a clavicular tumor which on x-ray shows lytic
changes. What is your diagnosis?
a. Multiple colloid adenomatous goiter with bone cancer
b. Anaplastic carcinoma
c. Papillary carcinoma
d. Follicular carcinoma
e. Medullary carcinoma
26
ANSWERS TO POST-TEST
I. 1. T II. 16. B
2. T 17. C
3. F 18. C
4. T 19. A
5. T 20. B
6. T 21. B
7. T 22. A
8. T 23. C
9. T 24. B
10. T 25. D
11. F
12. T
13. T
14. F
15. F
27
RECOMMENDED FOLLOW-UP
After completing this self-instructional program, the user

is advised to apply what he learns from this program in the
clinics. He is encouraged to discuss this program with his peers
and his teachers.
After a clinical diagnosis, thyroid function tests, needle

evaluation and other diagnostic procedures may have to be done.
If the user is interested in the further management of a thyroid
patient after clinical diagnosis, he can read on the different
diagnostic procedures.
ABOUT THE AUTHOR
Dr. Reynaldo O. Joson is presently an assistant professor at

the Department of Surgery of the University of the Philippines
College of Medicine. He is also presently the acting chief of
the Division of Head and Neck, Breast, Esophagus, and Soft Tissue
Surgery of the Department of Surgery at the Philippine General
Hospital. From 1988 to 1991, he was the Director of the U.P.
Postgraduate Institute of Medicine. He is a diplomate of the
Philippine Board of Surgery.
In 1986, he wrote a book entitled "Thyroid Surgical

Diseases" which is widely read by surgeons in the Philippines.
He has so far written eight books and manuals. He has twenty
four published research articles as senior author as of 1991.
He obtained a master degree in hospital administration in

1991 and he is the assistant medical director of the Manila
Doctor's Hospital from 1988 up to the present.
28

Distance Education in Medicine - Module 3: How To Write

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H O W T O W R I T E A

(An Off-Campus Study)

Reynaldo O. Joson, MD, MHA, MHPEd

Welcome to a learning experience in becoming a health

This program has been especially designed with you, the

As you go through this learning program, please bear in mind

1. I am treating you as an adult learner which

1.1 Assumes you have learning aspirations and

1.2 Gives you the privilege to use other learning

1.3 Welcomes you to go beyond the learning package

1.4 Expects discipline, honesty, and maturity in

2. We shall define learning as a positive observable

3. Active learning strategies and activities will be

4. The program will contain learning materials which I

5. The ultimate goal of the learning program is to

Best wishes for a fruitful learning with the help of this

Reynaldo O. Joson, MD, MHPEd

Welcome to an experience in self-instruction.

This program has been designed so that you learn on your

For effective learning, however, please follow the following

1. You should diligently and chronologically go through

- The Introduction gives you an orientation,

- The Prerequisites tells you what you must

- The Objectives tells you what you are expected

- The Text, of course, is the learning material

- Within the text are Activities where you will be

- The Summary helps you put together all

- The Summative Evaluation tells you what you

- The Student's Assessment of Self-Study Program

- The List of Papers to Submit will provide you

2. You must follow all the specific instructions to the

3. You must complete and submit all the assigned tasks

4. You need to have the following materials when you

- The self-instructional program written by yours

"Distance Education in Medicine. An Off-

The estimated study time for the program excluding the

Reynaldo O. Joson, MD, MHA, MHPEd

Learning Objectives .................................... 2

I Embarking on a Task to Write a Distance Education

II Writing a Draft of the Self-instructional Material ..... 16

III How to Write a Self-instructional Material ............. 22

Analysis and Comparison of Three Self-instructional

IV Critiquing and Developmental Testing of a

Checklists and Questionnaires .......................... 27

Summative Evaluation Activities ........................ 36

Critiquing a Self-instructional Material in Print

Student's Assessment of Self-Study Program ............. 37

List of Papers to Submit ............................... 38

Recommended Follow-up .................................. 39

Checklists and Questionnaires

Clinical Diagnosis of Thyroid Disorders

Conducting a distance education (DE) program in medicine

Self-instructional materials may either be in the print or

Writing self-instructional materials for DE use is quite

The self-instructional materials are usually constructed in

The self-instructional materials are usually written in

Thus, writing self-instructional materials for DE use

In this self-study program, you will learn how to write a

There are four prerequisites that you must possess before

First, you must understand fully the concept of DE.

Second, you must be convinced of the usefulness of DE in

The last prerequisite is that you are motivated and willing

If you don't possess these four prerequisites, you will

Name _________________________________ Date _

Name _________________________________ Date _