SCENARIO 2

BY: Group 26

Scenario 2A patient Mrs. SS 26-year-escorted her husband to

come to you when on duty at the clinic with complaints of palpitations since 4 months ago. Another complaint is not stand hot weather and prefer cool weather. In the last 3 months the patient complained of weight loss as much as 5 kg when good appetite. Other complaints are easy fatigue during mild activity and painless lump arose in front of the neck since 1 year.

KeyWords• Palpitation• Weigth loss• Not stand heat weather• Easy fatigue• Lump on the neck

Minimal Problem• 1. What causes a lump in the neck?

2. Why Mrs. SS can not stand the hot weather and prefer the cold weather?3. Pathogenesis underlying the emergence of whether the patient's complaint?4. What other complaints information necessary to establish the diagnosis?5. How the management of complaints Mrs.SS?

Keywords Analysis• Palpitation : a sense in which we are aware of or can sense when

our heart beats. This feeling can be described as a leap, bounce or vibrate. Palpitations are biased benign but can be life threatening if ignored.

• Weight loss: The loss of fat, water / electrolyte and protein may result in decrease of body mass. Proteins and fats are the body's reserve energy source that synthesized by the body in a state where the primary energy (glucose) in generating little or no energy. Lack or absence of the energy generated by glucose can be caused by the presence of metabolic disturbances, impaired absorption or impaired cell uptake of food. Metabolic disorders such as hyperglycemia, or hipertioid can lead to weight loss.

• Not resistant to hot weather is due to increased metabolism and heat production, which is usually a manifestation of hyperthyroidism. Where the basal metabolic nearly doubled. People affected will tend to prefer cool temperatures, when the heat tends to sweat more (heat intolerance).

• easily tired: Fatigue is feeling tired or energetic body does not have enough rest. Fatigue arising not only from the physical, but also fatigue of the mind. In terms of physical, fatigue occur with symptoms such as body overwritten pounds of sandbags. In terms of the mind, it's hard to concentrate and suddenly fell ill in the morning when you wake up feeling lazy or do everyday tasks.

• Lump on the neck: There are many factors that can cause a lump in the neck, such as trauma, infection, hormones, neoplasms and hereditary disorders. These factors work in their own way in the cause lumps. The thing to emphasize is that there is not always a lump in the neck caused by abnormalities that exist in the neck. Not uncommon disorder that just comes from systemic disorders such as lymphoma and tuberculosis.

Pathogenesis of Palpitation• In ordinary circumstances arrythmic heartbeats (regular) is not felt

by healthy people who are calm and even-tempered or average. Palpitations may be experienced by normal people who are busy in heavy physical effort or arising out emotionally or sexually. This type of palpitation is physiological and normal consciousness describes an overactive heart beat that is quick and with an increased contractility. Heart palpitations caused by overactive maybe also found in particular pathological states, such as fever, acute or severe anemia or thyrotoxicosis (hyperthyroidism)

• When the great and irregular, palpitations are usually caused by an increased of large stroke volume. Pathological circumstances such as aortic regurgitation or a variety of hyperkinetic circulatory conditions (eg anemia, arteriovenous fistula, and thyrotoxicosis) should be considered, as well as idiopathic hyperkinetic heart syndrome. Palpitations can also occur immediately after the beginning of deceleration of heart rhythm, as if there is a sudden development atrioventricular total block, or the conversion

Pathogenesis of Weight LossWeight Loss

Decreased in body mass

The loss of fat, protein, water and electrolytes in large numbers

The use as an energy reserve

Proteinolisis and lipolysis

Proteinolisis and lipolysis

gluconeogenesis

glycogenolysisketogenesisGlukogenesis

generate energy

Primary energy decreases (glucose)

hyperglycemiahyperthyroidism

Anorexia

Patient’s Identity• Name : mrs. "SS"

Age : 26 years Occupation : Private Employees Address : Jl. Soka 23 Gedangan Sidoarjo Gender : Female Status : Married

Anamnesa• The main complaint:

Palpitation

History of present illness:- Chest frequent palpitations since last 4 months- Complaints pounding felt during the activity and rest, but not accompanied by chest pain or tightness- Not resistant lebin likes hot weather and cold weather- In the last 3 months of weight loss from 55 kg to 50 kg, whereas a good appetite, and even tended to increase- Easily fatigued while doing light activity was 1 month since last- Hand tremble always wet and often in conjunction with weight loss

• Past history of disease:- Since a year ago came a lump in the neck front and gradually increase in size- Because painless lump is considered the norm and never sent to the doctor

History of treatment:- Every now and then to a public clinic near the house because it is easily tired, just take vitamin

Family history:- No one suffers from disease like this

Social History:- Married a year, not have children yet

• Physical ExaminationGeneral condition: Good

Awareness: Compost Metis- BH: 160 cm- BW: 50 kgVital Sign:- Blood Pressure : 140/60 mmHg- Pulse: 108 x / minute- Respiratory rate: 26 x / minute- Temperature: 37.20 ○ C

• Head / neck:• anemia -/icterus - / cyanosis - / dyspnea -• both eyes exoftalmus• diffuse lump in the neck forward, moving up and down during swallowing, found sounds 'bruit'

thorax:• heart was enlarged• tachycardia• normal heart sounds with no noise• Pulmonary within normal limits

Abdomen: no abnormalities

Extremitas:• Hiperrefleksia (+)• Warm and moist palms• The radius of subtle tremors (+)

The Examination Support:• laboratory

1. CBC:- Hb: 12.3 g / dl- Leukocytes: 7800/mm32. Blood analysis:- Fasting blood sugar of 130 mg / dl; Total Cholesterol 125 mg / dl; Triglycerides 120 mg / dl- Liver and kidney function tests within normal limits- Total T4: 22 g / dl (Normal: 4.5-12.5 g / dl)- Total T3: 3.4 g / dl (Normal: 1.3-2.9 g / dl)- TSH: <0003 IU / L (normal: 0.3-5.0 IU / L)

Radiological• Ultrasound Thyroid gland: solid goitre with

hipervascularisation• Thyroid scanning: thyroid gland enlargement

with homogeneous hyperactivity

Differential Diagnosis• Hyperthyroidism• Hypoglycemia • Pheocromocythoma

Hyperthyroidism• Hyperthyroidism is a clinical condition caused by excessive

secretion of thyroid hormones. Found also increased production of triiodothyronine (T3) as a result of increased conversion of thyroxine (T4) in peripheral tissues. The cause of increased release of thyroid hormone (hyperthyroidism) are most often is a long-acting thyroid stimulator (lats) or thyroid stimulating immunoglobulin (TSI), an IgG which seems in accordance with the TSH receptor (Graves disease). Among the various kinds of consequences this causes the release of hormone stimulation and thyroid enlargement

Hypoglycemia• Definition : blood glucose levels below the

normal price.In this case established the diagnosis of hypoglycemia when blood glucose <50mg% 2.8 mmol / L or even <40 mg% 2.2 mmol / L. Despite this variety of physiological studies have demonstrated impaired brain function may occur in blood glucose levels 3 mmol / L (55mg%)

Pheochromocytoma• Pheochromocytoma is a tumor of adrenal

gland hormones that produce epinephrine and norepinephrine. This hormone has many functions, some of them such as regulating blood pressure and heart rate. Pheochromocytoma commonly found in adults by age 30-60.

comparative hipertiroid hipoglikemia pheocromocytoma

Final Hypothesis• Based on the clinical symptoms of the results

obtained diagnose, physical abnormalities obtained from physical examination, and investigations, obtained some of the symptoms and signs of Hyperthyroid refers to can not stand the heat weight loss, palpitations and exophtalmus

• Symptoms and signs of whether a person suffering from hyperthyroidism or can also be seen or determined by an index or index newcastle wayne is as follows:

http://3.bp.blogspot.com/_I0UHlGxoP6A/SH68_rAYoEI/AAAAAAAAAIk/W9WI-pNB-9k/s1600-h/New+Picture+(1).bmp

http://4.bp.blogspot.com/_I0UHlGxoP6A/SH68Y4dUmRI/AAAAAAAAAIc/rYfgg3xR9OA/s1600-h/New+Picture.bmp

Castello’s Clinical Criteria of Thyrotoxicosis

Minor Criteria• sweating

• Moist hands

• Pulse > 90 x / mnt or Atrial Fibrilation

• Fine finger tremor

Major Criteria• Bruit above gland

• Hyperkinesia

• Exophstalmus

Thyrotoxicosis if: 1 major (+)or 4 minor (+)

Effects and Symptoms Hyperthyroidism

Sielbernagl, 2000

the respiratory system• Severe thyrotoxicosis can cause shortness of

breath accompanied by decreases in lung vital capacity.This condition is due to weakness of respiratory muscles are the direct result of thyrotoxicosis will return to normal when euthyroid.

Effects and Symptoms Hyperthyroidism

Sielbernagl, 2000

Energy metabolism

O2 con-sumption

Hyper-ventilation

Lipolysis

Hyperlipid-acidemia

Weight loss

Proteolysis

Decreased in muscle mass Muscle weakness

Heat metabolism Hyperthermia Sweating

DIGESTION SYSTEM• Severe thyrotoxicosis, increased metabolism, increased appetite,

but does not increase the calories resulting in weight loss.

In younger patients weight loss is not prominent due to intake more calories than on their specific needs.

In elderly patients more frequently anorexia, weight loss so many so-called apathetic thyrotoxicosis.

Increased intestinal peristalsis, increasing intestinal motility, often defecate, feeling nausea, vomiting, can affect the liver (hepatomegaly) with liver function, jaundice.

Effects and Symptoms Hyperthyroidism

Sielbernagl, 2000

Effects and Symptoms Hyperthyroidism

Accelerated

breakdown of VLDL

and LDL, stimulation

of bile secretionVLDL Cholesterol

Stimulation of

glycogenolisis,

gluconeogenesis Hyperglycemia

Sielbernagl, 2000

Effects and Symptoms Hyperthyroidism

Accelerated

growth

in children

Bone metabolism Osteoporosis

Hypercalcemia Hypercalciuria

Sielbernagl, 2000

Therapy• 1. Rest:

* Lying mild* Limit the energy expenditure* Max: working light

• 2. Low Iodine Diet* Limit salt iodine- Marine plants - Saltwater fish* Limit: - seawed- Brown bread

3. Medical: anti thyroid drugs + Adjuvan* Dose Titration down® central & peripheral* PTU ® divided doses of 100-200 mg, 3 times a day® W.P 1-3 hours* Carbimozole (® methimazole)Central: a single dose of 30-60 mg / hrW.P 6-8 hoursRemission ® 2.5 years old 51%; <2 years: 9%(non surgical) Variation Remission 90-80%

4. Radio Iodine - 131* I - 131:- W.P 8 days- Particles (10% Beta and Gamma)¯Power of destruction a few mm* Liquid or capsules:- 50 grams Thyroid (Thyroid 150-200μC1/gram)

Take up 75% ® ± 10 MC1 ® Improved: average 6-8 weeksHypo> 12 weeks (90%> 1 year)Early symptoms obstipation+ krampNeed Levo thyroxine for Hypo

• 1. Thyroidectomyindications:- Cosmetics- large Goitre- Severe complications of Anti Thyroid drugs, I131- RelapsePreparation: 7-10 H. Preop ® Lugol Euotikoid + 10 drops / day

• complications of Thyroidectomy- 3.4% recurrence (check TRAb Post OP)- 53% hypothyroid- 1-2% of lesions n. laryngeal- hypoparathyroidismObservation Post OP 1-2 th(Check ® TRAb, FT4; TSH)

Prognosis• remission: 34-46%

recurrence occurs months to years after therapy is stopped

• Treatment or surgery subthyroidektomi radioiodinvery effective but many patients had hypothyroid after the procedure

• Patient education: essential compliance & side effect

COMPLICATIONS• Complications that can be life-threatening hyperthyroidism is

thyrotoxic crisis (thyroid storm). It can develop spontaneously hyperthyroid patients who underwent therapy, the thyroid gland during surgery, or occur in patients with undiagnosed hyperthyroidism. The result is the release of thyroid hormone in a very large amount causes tachycardia, agitation, tremors, hyperthermia (up to 106 oF), and, if untreated, death.

• Heart disease of Hyperthyroidism, Grave,s oftalmopati, dermopati Graves, in the treatment of infections due to agranulocytosis with antithyroid drugs. Thyroid crisis: mortality