tirotoksikosis

By GROUP 5

SCENARIO• Mrs. “H” 33 years old came to your clinic

because she easily get tired, often sweating, shaking fingers, hard to sleep and heartbeat increase since 3 month ago. Two month ago, her right eyes blown out than left eye. Her weight when three month ago is 65 kg, now 61 kg without diet. When she is teenager ever like this, and medicated in regency hospital with oral medicine during three month and getting better.

KEYWORDSShaking Fingers Eyes Blown OutEasily get tiredOften sweatingHard to sleepHeartbeat increaseLoss weight without diet

MINIMAL PROBLEMWhat cause the symptoms and how its

happens ?How to diagnose ?How to medicate and give a therapy to

patient ?How to communicate, give information and

education to patient ?How to prevent this problem ?

ANAMNESEIDENTITY :Name : Mrs. “H”Age : 33 years oldOccupation : Bank Teller Sex : Female

ANAMNESECHIEF COMPLAINTShaking Fingers and Eyes Blown Out

ANAMNESESTORY OF DISEASEEasily get tiredOften sweatingHard to sleepHeartbeat increaseLoss weight without diet

ANAMNESESTORY OF DISEASE IN THE PASTEver like this when teenagerEver take medicine and heal

ANAMNESESTORY OF FAMILY DISEASE2 from 4 brothers and sisters have the same

symptom

ANAMNESESTORY OF SOCIAL-ECONOMYBecause the eyes blown out, she become not

confidenceHard to write in the office because the

shaking fingers

EXAMINATIONVITAL SIGNBlood Pressure : 150/100 mmHgArtery pulse : 84 time/minute, regulerRespiratory rate : 20 time/minute Temperature : 37○C

EXAMINATIONHEAD AND NECKanemi + /icterus - /cyanosis - /dyspnea –Right visus : 5/12 ; Left visus : 5/15Right Exophtalmus : 23 ; Left Exophtalmus :

18Diffuse enlargement of thyroid glandUnable bruit

EXAMINATIONTHORAX• Normal

ABDOMEN• Normal

UROGENITALIA• Normal

EXAMINATIONEXTREMITASFine Tremor

SUPPORTING EXAMINATIONFree T4 : 38,5 μg/dl (Normal : 4,4-10,8 μg/dl)TSH : 0,93 μIU/ml (Normal : 0,3-4,2 μIU/ml)

MINIMAL PROBLEMWhat cause the symptoms and how its

happens ?How to diagnose ?How to medicate and give a therapy to

patient ?How to communicate, give information and

education to patient ?How to prevent this problem ?

PATOMECHANISM

DIAGNOSE TIROTOKSIKOSISKLINIS

Indeks klinis Wayne (Eutiroid < 10)Indeks klinis New Castle [Eutiroid (–11) –

(+23)]Kriteria klinis Castello

PENUNJANG Pemeriksaan kadar hormon (FT3, FT4, TSHs)Pemeriksaan kadar tiroglobulin Uji tangkap I131Scintigraphy Fine needle aspiration biopsy Antibodi tiroid (ATPO-Ab, ATg-Ab)

INDEX WAYNE

KELUHAN NILAI TANDA ADA TIDAK

Sesak nafas +1 Pembesaran kel. Tiroid +3 -3

Berdebar +2 Bising kel. Tiroid +2 -2

Lemah +2 Eksoftalmus +2 0

Senang panas -5 Retraksi mata +2 0

Senang dingin +5 Lid lag +1 0

Banyak keringat +3 Hiperkinetik +4 -2

Nafsu makan naik +3 Tremor halus +1 0

Nafsu makan turun -3 Tangan panas +2 -2

Berat badan naik -3 Tangan berkeringat +1 -1

Berat badan turun +3 Fibrilasi atrium +4 0

Gelisah +3 Nadi : < 80 x/menit -3 -

Nadi : 81 – 90 x/menit 0 -

Nadi : > 90 x/menit +3 -

Jumlah (a) (b) (c)

Jumlah Nilai : Index Wayne = (a) + (b) + (c)

INTERPRETASI 1. >20 : Hipertiroid

2. 10 – 20 : Mungkin Hipertiroid

3. < 10 : Tidak Hipertiroid

INDEX NEWCASTLENO GEJALA DERAJAT NILAI

1 Umur saat timbul 15 – 24 0 25 – 34 +4 35 – 44 +8 45 – 54 +12 ≥ 55 +16

2 Pencetus psikologi Ada -5 Tidak 0

3 Frequent checking Ada -3 Tidak 0

4 Severe anticioatory anxiety Ada -3 Tidak 0

5 Nafsu makan menurun Ada +5 Tidak 0

6 Goiter Ada +3 Tidak 0

7 Bising tiroid Ada +18 Tidak 0

8 Eksoftalmus Ada +9 Tidak 0

9 Lid Retraction Ada +2 Tidak 0

10 Tremor halus Ada +7 Tidak 0

11 Nadi (permenit) >90 +16 80 – 90 +8 <80 0

INTERPRETASI JUMLAH Eutiroid (-11) – (+23) Mungkin Hipertiroid (+24) – (+39) Pasti Hipertiroid (+40) – (+80)

Kriteria Klinis Tirotoksikosis Castello

Kriteria Minor

• Berkeringat banyak

• Tangan lembab

• Nadi > 90 x / mnt atau Fibrilasi atrial

• Tremor halus jari

Kriteria Major

• Bruit diatas kelenjar

• Hiperkinesia

• Eksoftalmus

Tirotoksikosis apabila : 1 kriteria major (+) atau 4 kriteria minor (+)

DIFFERENTIAL DIAGNOSEHipertiroidDiabetes MellitusPsikosomatik

DIAGNOSE MECHANISM

DIAGNOSISPhysiology Diagnose is “Hyperthyroid”, andAnatomy Diagnose is “diffuse enlargement of

Thyroid gland”

THERAPY• Rest• Diet low yodium• Medicine :

– Anti thyroid medicine + adjuvant– Combination therapy (anti thyroid medicine +

tiroksin)– β – blocker– Iodine Inorganik – Lithium

• Radio Iodine – 131• Thyroidectomy

COMPLICATIONARITMIATIROTOKSIK (TIROID STORM)

tachycardi, agitasi, tremor, hipertermia (until 106oF)

PROGNOSEIf thyroid gland removed (thyroidectomy),

patient can be hypothyroid