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.

KEYWORDS
Shaking Fingers
Eyes Blown Out Easily get tired Often sweating Hard to sleep Heartbeat increase Loss weight without diet

MINIMAL PROBLEM
What 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 ?

ANAMNESE
IDENTITY : Name : Mrs. H Age : 33 years old Occupation : Bank Teller Sex : Female

ANAMNESE
CHIEF COMPLAINT Shaking Fingers and Eyes Blown Out

ANAMNESE
STORY OF DISEASE Easily get tired Often sweating Hard to sleep Heartbeat increase Loss weight without diet

ANAMNESE
STORY OF DISEASE IN THE PAST Ever like this when teenager Ever take medicine and heal

ANAMNESE
STORY OF FAMILY DISEASE 2 from 4 brothers and sisters have the same symptom

ANAMNESE
STORY OF SOCIAL-ECONOMY Because the eyes blown out, she become not confidence Hard to write in the office because the shaking fingers

EXAMINATION
VITAL SIGN Blood Pressure Artery pulse Respiratory rate Temperature
: 150/100 mmHg : 84 time/minute, reguler : 20 time/minute : 37C

EXAMINATION
HEAD AND NECK anemi + /icterus - /cyanosis - /dyspnea Right visus : 5/12 ; Left visus : 5/15 Right Exophtalmus : 23 ; Left Exophtalmus : 18 Diffuse enlargement of thyroid gland Unable bruit

EXAMINATION
THORAX Normal
ABDOMEN Normal UROGENITALIA Normal

EXAMINATION
EXTREMITAS Fine Tremor

SUPPORTING EXAMINATION
Free T4 : 38,5 g/dl (Normal : 4,4-10,8 g/dl)
TSH : 0,93 IU/ml (Normal : 0,3-4,2 IU/ml)

MINIMAL PROBLEM
What 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 TIROTOKSIKOSIS
KLINIS
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 I131 Scintigraphy Fine needle aspiration biopsy Antibodi tiroid (ATPO-Ab, ATg-Ab)

INDEX WAYNE
KELUHAN Sesak nafas Berdebar Lemah Senang panas Senang dingin Banyak keringat Nafsu makan naik Nafsu makan turun Berat badan naik Berat badan turun Gelisah NILAI +1 +2 +2 -5 +5 +3 +3 -3 -3 +3 +3 TANDA Pembesaran kel. Tiroid Bising kel. Tiroid Eksoftalmus Retraksi mata Lid lag Hiperkinetik Tremor halus Tangan panas Tangan berkeringat Fibrilasi atrium Nadi : < 80 x/menit Nadi : 81 90 x/menit Nadi : > 90 x/menit Jumlah (a) ADA +3 +2 +2 +2 +1 +4 +1 +2 +1 +4 -3 0 +3 (b) TIDAK -3 -2 0 0 0 -2 0 -2 -1 0 (c)

Jumlah Nilai : INTERPRETASI

Index Wayne = (a) + (b) + (c) 1. >20 : Hipertiroid 2. 10 20 : Mungkin Hipertiroid 3. < 10 : Tidak Hipertiroid

INDEX NEWCASTLE
NO 1 GEJALA Umur saat timbul 2 3 4 5 6 7 8 9 10 11 Pencetus psikologi Frequent checking Severe anticioatory anxiety Nafsu makan menurun Goiter Bising tiroid Eksoftalmus Lid Retraction Tremor halus Nadi (permenit)

DERAJAT 15 24 25 34 35 44 45 54 55 Ada Tidak Ada Tidak Ada Tidak Ada Tidak Ada Tidak Ada Tidak Ada Tidak Ada Tidak Ada Tidak >90 80 90 <80

NILAI 0 +4 +8 +12 +16 -5 0 -3 0 -3 0 +5 0 +3 0 +18 0 +9 0 +2 0 +7 0 +16 +8 0

INTERPRETASI Eutiroid Mungkin Hipertiroid Pasti Hipertiroid

JUMLAH (-11) (+23) (+24) (+39) (+40) (+80)

Kriteria Klinis Tirotoksikosis Castello

Kriteria Major
Bruit diatas kelenjar Hiperkinesia Eksoftalmus

Kriteria Minor
Berkeringat banyak
Tangan lembab Nadi > 90 x / mnt atau Fibrilasi atrial

Tremor halus jari

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

DIFFERENTIAL DIAGNOSE
Hipertiroid
Diabetes Mellitus Psikosomatik

DIAGNOSE MECHANISM

DIAGNOSIS
Physiology Diagnose is Hyperthyroid, and
Anatomy Diagnose is diffuse enlargement of Thyroid

gland

THERAPY Rest
Diet low yodium
Medicine : Anti thyroid medicine + adjuvant Combination therapy (anti thyroid medicine + tiroksin) blocker Iodine Inorganik Lithium Radio Iodine 131 Thyroidectomy

COMPLICATION
ARITMIA
TIROTOKSIK (TIROID STORM) tachycardi, agitasi, tremor, hipertermia (until 106oF)

PROGNOSE
If thyroid gland removed (thyroidectomy), patient can

be hypothyroid