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“ HYPERTHYROIDISM “
• Name : Mrs. P
• Age : 34th years old
• Education : Junior High school
• Marital status : Divorced
• Occupation : Housemaid
• Religion : Moslem
• Date of admission : 1st of September 2016
• MR number : 00948664
ANAMNESIS
• Chief complaint :
Patient complained of body weakness since 1 week ago
• Another complaint :
Can’t walk, dizziness, and decrease of appetite
HISTORY OF PRESENT ILLNESS
Eyes : Head :
• Anemic conjungtiva (-/-), normocephal,
• Icteric sclera (-/-) deformity (-)
• Exophthalmos (-/-)
Nose :
• Septal deviation (-)
• Secret (-)
Mouth :
• Oral mucosa moist
• Stomatitis (-)
Ear :
• Normotia
Neck :
• Secret (-/-)
• Mass (+)
• Inspection : ictus
cordis not seen
• Palpation : ictus cordis
• Inspection : the palpable in ICS-V
movement of the medioclavicula
chest symmetrical, • Percussion : left heart
intercosta retraction (-) margin midclavicula
• Palpation : same vocal ICS-V. right heart
fremitus in dextra and margin sternalis line
sinistra ICS-V
• Percussion : sonor • Auscultation : Regular
1st & 2nd heart sounds,
• Auscultation : VBS + /
tacichardia, murmur
+, ronkhi - / -, wheezing
(-), gallop (-)
-/-
• Inspection: looked flat
Abdomen • Auscultation: bowel (+) sounds, 7x/minutes
• Palpation: pressure pain (-), Ascites (-)
• Percussion: timpani, shifting dullness (-)
(I)
There are a mass, round
shape, diameter ± 10 cm, it
moves when the patient
swallowed, no hyperemia.
(Pa)
Palpable mass, solid
consistency, clear bound,
mobile, tenderness (-), flat
surface, regional
lymphadenopathy (-).
(A)
Bruit sounds (-)
LABORATORY EXAMINATION
(1 SEPTEMBER 2016)
Mrs. P 34th years old came to the emergency room RSIJ Cempaka Putih with complaints
of her body weakness since 1 week ago. Patient said that her body weakness was so deeply
until she was not able to stand and walk. Patient also admitted feeling dizzy but not spinning.
She claimed these complaints began to arise due to reduce of appetite, she said that she was
so lazy to eat and have no appetite. She said that her weight decreased. Patien actually had
complaints of weakness like this since two weeks ago, but it getting worse and she couldn’t
stand and walk since 1 week before she came to the hospital.
Patient said that sometimes her heart was palpitate and her hands was trembling for no
reason. She admitted that during this week she didn’t do an activities and just lying in bed all
day long. Patient was realized a lump in the right and left neck since she had a second child
delivery, or about 9 years ago. Initially the size of that lump as big as marbles and it grew bigger
until today. Complaints of difficulty in swallowing and hoarseness denied
Physical examination : BP: 130/90 mmHg, HR: 120x/minute, RR: 20x/minute, Temp : 36.9° C. There
are a mass at colli dextra anterior region, round shape, diameter ± 10 cm, it moves when the
patient swallowed, no hyperemia. chewy consistency, clear bound, mobile, tenderness (-), flat
surface, regional lymphadenopathy (-), bruit sounds (-)
Laboratory : Free T4 5630, Sensitive TSH 0.001
USG : Right thyroid enlarged, not clear bound, multiple solid lesions appear, doppler : excess
vascularization. Impression : Right Nodusa Struma dd / malignant process
PROBLEM LIST
• Body Weakness
• Hyperthyroidism
• Goitre
ASSESMENT
2. Differential Diagnosis :
Grave’s disease
• S : Patient complaints of her body weakness since 1 week ago, have no
appetite. Patient said that sometimes her heart was palpitate and her hands
was trembling for no reason. Patient was realized a lump in the right and left
neck since she had a second child delivery, or about 9 years ago. Initially the
size of that lump as big as marbles and it grew bigger until today. Complaints of
difficulty in swallowing and hoarseness denied
• O : BP: 130/90 mmHg, HR: 120x/minute, RR: 20x/minute, Temp : 36.9° C. There are
a mass at colli dextra anterior region, round shape, diameter ± 10 cm, it moves
when the patient swallowed, no hyperemia. chewy consistency, clear bound,
mobile, tenderness (-), flat surface, regional lymphadenopathy (-), bruit sounds
(-) Laboratory : Free T4 5630, Sensitive TSH 0.001 USG : Right thyroid enlarged, not
clear bound, multiple solid lesions appear, doppler : excess vascularization.
Impression : Right Nodusa Struma dd / malignant process
• A : Hyperthyroidism e.c Toxic Nodusa Goiter
• P : - Propanolol 3 x 10 mg
- PTU 3 x 100 mg
- Ranitidine inj
- IVFD RL 20 tpm
- Pro thyroidectomy
- Bed rest
FOLLOW UP
Hipotalamus
TRH
_
Pituitari anterior _
TSH
Tiroid
T3 T4
Equitable enlargement of the
Difus gland, the right and left gland
enlarges and called difusa goitre
According
to deformity Bump as big as the ball, can be
Nodule single or multiple, can be solid or
liquid, and can be either benign /
malignant
Disorders of
thyroid
Hyperthyroidism is a set of
disorders that
involve excess synthesis and secretion of
thyroid hormones by the thyroid gland,
which leads to the hypermetabolic condition
of thyrotoxicosis.
The most common forms of hyperthyroidism
include diffuse toxic goiter (Graves disease),
toxic multinodular goiter (Plummer disease),
and toxic adenoma.
RISK FACTORS
Grave’s disease
Etiology of hyperthyroidism
can be divided into several
Toxic adenoma
category
Multinodular goiter
PATOPHYSIOLOGY
CLINICAL MANIFESTATIONS
Organs
CNS Emotional, irritable, psychosis, tremor, nervous, insomnia
Eyes Diplopia, exophthalmos
Thyroid gland Enlargement of the thyroid gland
Heart and lung Dispneu, hypertension, tachycardia, arrhythmia,
palpitations, heart failure
GI tract Hyperdefecation, plenty to eat, hungry, thirsty, vomiting,
weight loss, drug tolerance
Reproductive organs Decreased fertility, reduced menstruation, no
menstruation, decreased libido
Blood and lymphatic Lymphocytosis, anemia, spleenomegaly, enlarged lymph
nodes of the neck
Bone Thyrotoxic periodic paralysis, osteoporosis, epiphyseal
rapidly closing, bone pain
Muscle Increased reflexes, hiperkenesis, tired
Skin Increased perspiration
DIAGNOSIS
WAYNE INDEX
Hyperthyroid if score ≥ 20
Diagnosis Free T4 and T3 TSH
Hyperthyroidism
Hypothyroidism
Hormone Function Test Radiology
40
FNAB
Specifically in suspicious
circumstances of a
malignancy.
Which must be considered :
- Location biopsy to be precise
- Making good preparations
- To avoid false positive test
results interpretation by
cytologists.
Patient
Subclinic Subclinic
Hypothyroid Hyperthyroid
hypohyroid hyperthyroid
TREATMENT
PTU ( 100 mg)
Dose : initial dose 300 – 600 mg/day, maximum dose 2000 mg/day
Thiamazole ( 5mg)
Mild cases : 2 x 10 mg/day
Severe cases : 2 x 20 mg/day (for 3-8 weeks)
Maintenance dose : 5 – 20 mg/day
Carbimazole ( 5 mg)
Initial dose : 15 – 40 mg/day ( for 4-8 weeks)
Maintenance dose : 5 – 15 mg/day (12-18 months)
Propanolol
Therapy with propranolol should be initiated at 10 to 20 mg every six hours. The dose. should
be increased progressively until symptoms are controlled. In most cases, a dosage of 80 to
320 mg per day is sufficient.
PROGNOSIS
Based on Nodule
clinical
Goitre
Nodule
Euthyroid
Based on the
physiological
Hypothyroid
Hyperthyroid
CLINICAL MANIFESTATION
TSH causes the thyroid cells secrete Pituitary secrete excessive levels of
thyroglobulin in high level (colloidal) into the TSH
follicles and glands grow increasingly growing
larger
Operations / Surgery
Radioactive iodine
Thyroxine and Anti-thyroid drugs ( PTU,
methimazole)
REFERENCES
• Sherwood, L. 2014. Fisiologi Manusia dari Sel ke Sistem. Edisi 2, Alih Bahasa: Brahm U.
Pendit. Jakarta, Penerbit Buku Kedokteran EGC. pp: 463-475.
• Buku Ajar Ilmu Penyakit Dalam Jilid III Ed VII. 2015; 1993-2008.
• http://www.endocrineweb.com/conditions/thyroid-nodules/thyroid-gland-controls-
bodys-metabolism-how-it-works-symptoms-hyperthyroid
• Fitzgerald PA. Endocrinology. In: Tierny LM, McPhee SJ, Papadakis MA, eds. Current
medical diagnosis and treatment. 44th ed. New York: McGraw-Hill, 2005:1102-10.
• American Academy of Clinical Endocrinologists. American Association of Clinical
Endocrinologists medical guidelines for clinical practice for the evaluation and
treatment of hyperthyroidism and hypothyroidism. Endocr Pract 2002;8:457-69
• Jansson S, Lie-Karlsen K, Stenqvist O, Korner U, Lundholm K, Tisell LE. Oxygen
consumption in patients with hyperthyroidism before and after treatment with beta-
blockade versus thyrostatic treatment: a prospective randomized study. Ann Surg
2001;233:60-4.
• Fontanilla JC, Schneider AB, Sarne DH. The use of oral radiographic contrast agents in
the management of hyperthyroidism. Thyroid 2001;11:561-7. 27. Nedrebo BG, Holm PA,
Uhlving S, Sorheim JI, Skeie S, Eide GE, et al. Predictors of outcome and comparison of
different drug regimens for the prevention of relapse in patients with Graves’ disease.
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