04. Kuliah Tiroid (Prof.dr. Harsinen S, Sp.pd-kEMD)

8/19/2019 04. Kuliah Tiroid (Prof.dr. Harsinen S, Sp.pd-kEMD)

http://slidepdf.com/reader/full/04-kuliah-tiroid-profdr-harsinen-s-sppd-kemd 1/138

HARSINEN SANUSIHARSINEN SANUSI



THE THYROID GLAND

Pyramidal

lobe

Left lobe

Right lobe

Isthmus

Internal

jugular vein

Thyroidcartilago

Externalcarored arteri



http://arbl.cvmbs.colostate.edu/hbooks/pathphys/endocrine/thyroid/anatomy.html

THYROID GLAND HISTOLOGY



Thyroid hormone synthesis, storage and release

CAPILLARY FOLLICULAR CELL COLLOID

TRAPPING

DEIODINTION

PROTEOL!"I"

"TOR#E$O%PLIN#

OR#NI&I$TIONI PEROXIDASE

!O!OXIDI"ED

IODIDE

$I% DI%

%&'

MIT DIT T3

TGB TGB

T3 --TGB

T4 --TGB

%(T3

T4

DIT DIT T4

TGB TGB

Tyr Tyr

AA TGB

Tyrosine

Protease

$I%

DI%

Iodinase

%yrosine)

RELE"E

I

Cryer PE. Diagnostic endocrinology 1976:35

%*



asi! elements in reg"lation

o# thyroid #"n!tion

THYROID

TISSUE

TRH

HYPOTHALA$US

PORTAL SYSTE$

TSH

ANTERIOR

PITUITARY

%&REE'

T(

T(

T)

T)

I

I

*

T)

+

T(

+



Us"ally om-lain thyroid

disease

' Thyroid enlargement .hi!h

may /e di##"se or nod"lar ' Sym-tom o# thyroid de#i!ien!y

or Hy-othyroidism

' Sym-toms o# thyroid hormone0!ess, or Hy-erthyroidism



Physi!al E0aminationPhysi!al E0amination' Ins-e!tion 1

#ood light coming from behind the

examiner( The )atient is instructed tos*allo* a si) of *ater( Observe the

gland as it moves u) and do*n+

Enlargement and nodularity can oftenbe noted+



Physi!al E0aminationPhysi!al E0amination

' Pal-ate the gland 1

&rom behind the )atient *ith themiddle threes fingers on eachlobe *hile the )atients s*allo*s+

Nodules can be measured in asimilar .ay2



Physi!al E0aminationPhysi!al E0amination

' The normal thyroid gland about ,cm in verticaldimension and about -cm in hori.ontal

dimention above the isthmus' Enlarged thyroid gland is called #oiter/"truma

' The generali.ed enlargement is termed diffuse

goiter ( irreguler or lum)y enlargement is callednodular goiter



Diffuse goiter

' Sim-le di##"s goiter ' Hy-erthyroidism

' Hashimoto thyroiditis

Nod"lar goiter -+ Thyroid nodul

,+ Thyroid cyst

0+ denomatosa goiter

1+ "ubacut 2chronis thyroiditis

3+ Plummer thyroiditis



THYROID DISEASES

HYPERTHYROIDIS$HYPOTHYROIDIS$

THYROIDITIS

THYROID NODUL



T4!ROID D!"&%N$TION PRE5LEN$E

• Hypothyroidism 2 %

• Sublinical hypothyroidism 5-7 %

• Hyperthyroidism 0,2%

• Subclinical hypothyroidism 0,1-6,0%



Hy-erthyroidism 3 Thyroto0i!osisHy-erthyroidism 3 Thyroto0i!osis

' Thyrotoxicosis is the clinical syndrome thatresults *hen tissues are ex)osed to high levels

of circulating thyroid hormone+' 4y)erthyroidism 6 Thyroxicosis is due tohy)eractivity of the thyroid gland

' Occasionally( thyrotoxicosis may be due to

other causes such us excessive ingestion ofthe thyroid hormone or excessive thyroidhormon from ecto)ic site



onditions ass!osiated .ith

thyroto0i!osis

' Diffuse toxic goiter 7#raves8 disease9

' Toxic adenoma 7Plummer8s disease9

' Toxic multinodular goiter

' "ubacute thyroiditis

' 4y)erthyroid )hase of 4ashimoto8s thyroiditis

' Thyrotoxicosis factitia

' Rare6 Ovarian struma( metastatic thyroidcarcinoma( hydatiform mole(



ETIOLOGY 3 PATHOGENESIS

' #raves8 Disease 7#D9 is currently vie*ed asan autoimmun disease of un:no*n cause

' There is a strong familial )redis)osition in that

about -3;+' 3<; #D have circulating thyroid autoantibodies

' Pea: incidence ,<=1<=year

' T=lym)hocytes sensiti.ed to antigen *ithinthyroid gland and stimulate > lym)hocyte antibodies



GR!"S# $S"S"GR!"S# $S"S"

&$''(S" )*+ G*)"R&$''(S" )*+ G*)"R' #D is the most common form of thyrotoxicosis(

may occur at any age( more commonly in

females than in males 73?9' The syndrome consist one or more of the

follo*ing features6

-+ T4!ROTO?I$O"I"

,+ #OITER

0+OP4T4L@OPT4!7Exo)hthalmos9

1+ DER@OPT4! 7Pretibial myxedema9



lini!al #eat"res

Gra4es5s disease' Sym-toms1 in younger )atients6 )al)itation(

nervousness( easy fatigability( hy)er:inesia(

diarhhea( excessive s*eating( intolerance to heat(*eight loss *ithout loss a))etite

' Signs1 Thyroid enlargement( exo)hthalmos(tachycardia( muscle *ea:ness( tremor Older

)atients cardiovascular A myo)atic )redominateclinical manifestation )al)itatation( dys)nea onexersice( tremor( nervousness( *eight loss



O)htamo)athy #raves disease

' Non In#itrati# sym-atheti! o4erstim"lation

Lid retraction 7Dalrym)he8s sign9

5an #raves sign late )al)ebra su)

"tell*at8s signthe *in: eyes late

Befroy8s sign fold of forehead not see

@obius8sign convergention of the eyes late

' In#iltrati# a"toimm"ne

E0o-hthalm"s1 Oculo)athy congestif6 cheimosis( conjunctivitis(

)eriorbital edema

%lcerasi $ornea

Neuritis o)tica

tro)hi nervus o)ticus



LIDLID

RETRACTIONRETRACTION



Thyroid Dermo)athy

' Thi!6ening o# the s6in, o4er the

lo.er ti/ia d"e to a!!"m"lation

gly!osamin gli!ans , rare 789(:;' TSH9R A/ high titer

' Osteo-athy in the meta!ar-al

/ones



NON PITTING OEDE$A



<ITILIGO



Suspected hyperthyroidism



Suspected hyperthyroidism

%S +,%*

NormalFT4 &TSH

yperthyroidism

e-cluded

o %S

+ 0ormal

,%*

$easure ,%(

0ormal ,%( i1h ,%(

Subclinical hyperthyroidism

Evolvin1 &raves2 disease

Or to-ic nodular 1oiter

E-cess thyro-ine replacement

0on thyroidal illness

Repeat tests in 2-3 ont!s" ann#a$

%o$$o&-#p i% no pro'ression

%( yperthyroidism

o %S +

hi1h ,%*

0ormal /

hi1h %S +

hi1h ,%*

%S3 secretin1

pituitary adenoma.

%hyroid hormone3

resistance syndrome

yperthyroidism

Gra(es)*isease

To+i, no*#$ar 'oiter

T!yroi*itis

Gestationa$ ypert!yroi*is

Fa,titio#s or iatro'eni, !ypert!yroi*is

T!yroi* Car,inoa

.tr#a O(arii

T#or se,retin' C!orioni, 'ona*otropin

Fai$ia$ nona#toi#n !ypert!yroi*isLa/oratoy tests "se#"l in DD o# hy-erthyroidism



Aty-i!al #ashion Gra4es5

Disease' )ethetic hy)erthyroidism6

Older )atients6*eight loss( small goiter( &(

severe de)ression *ith none

clinical features

At i l # hi G 5



Aty-i!al #ashion Gra4es5

Disease' Thyroto0i! -eriodi! -aralysis6

sian males( sudden attac: flacid )aralysis(hy)o:alemia( usualy subsides s)ontaneously+

Prevention6 C su))lement A >etabloc:ers

' Thyro!ardia! disease1Primarily *ith sym)toms of heart involvement6

refrsctory & insensitif digoxin or high out)ut heartfailure( no evidence underlying heart disease73<;9+ Treatment of thyrotoxicosis cure

T t t # G 5T t t # G 5



Treatment o# Gra4es5Treatment o# Gra4es5

DiseaseDisease

-2 Antithyroid dr"g thera-y1 Yo"ng -ts, small glands, mild disease

Pro)ylthiouracil 7PT%9( methima.ole 7m=-3 y9( rela)s3<=<;+

PT% inhibits the conversion T1T0( effect more Fuic:ly

com)are methima.ole

@ethima.ole 6 longer duration of action("ingle dose

Thera)y 0= months ta)ering dose and

combination levothyroxin <+- mg2d -,=,1 months

llergic reaction 7rash( agranulocytosis9

Treatment o# Gra4es5Treatment o# Gra4es5



' S"rgi!al treatment

"urgical subtotal thyroidectomy

treatment of choice for very large glands(

or multinodular goiter

Pre)ared *th anti thyroid drug 7about

months9

$om)lication6 4y)othyroidism( recurent

laryngeal nerve injury

Treatment o# Gra4es5Treatment o# Gra4es

diseaediseae



Treatment o# Gra4es5 diseaseTreatment o# Gra4es5 disease

' Radioa!ti4e

iodine thera-y

%" NaI -0-I

euthyroid over =

-, *ee:s(

$om)licationhy)othyroidism



' Other medical measures6>eta=adrenergic bloc:ing agents Pro)ranolol -<=1< mg every hours(

multivitamin su))lements( )henobarbitalas sedative to lo*er T1 levels

$om)lementer thera)y6

Gi:ir( !oga( semedi( rei:i(

Treatment o# Gra4es5 diseaseTreatment o# Gra4es5 disease

li ti # G 5



om-li!ation o# Gra4es5

DiseaseThyroto0i! !risis 7thyroid storm;

cute exacerbation sym)toms thyrotoxicosis+

@ay be mild A febrile until life threatening+Etiology 6 after thyroid surgery in )atients

*ho has been inadeFuatlely )re)ared(

RI-0-

( )arturition in adeFuately controlledthyrotoxicosis or stressfull illnes+



lini!al mani#estation1&ever("*eating( flushing( tachycardia2&( heart

failure( agitation(delirium( coma( jaundice( nausea

vomiting and diarhea+

Treatment1"u))ortive thera)y

Pro)ranolol -=, mg I5(

PT% ,3< mg every hours+

4ydrocortison"ol lugol

ntibiotic

"edative



HYPOTHYROIDIS$HYPOTHYROIDIS$

O O S



Etiology' Primary6Hashimoto thyroiditis, Radio

a!ti4e iodine thera-y #or Gra4es5 disease,

S"/total thyroide!tomy, E0!esi4e iodide

inta6e, s"/a!"te thyyroiditis, Iodide

de#i!ien!y

' "econdary 6 Hy-o-it"itarism d"e to -it"itary adenoma

' Tertiary 6 Hy-othalami! dis#"n!tion 7rare;

HYPOTHYROIDIS$HYPOTHYROIDIS$



lini!al #inding' In!iden!e 1 <ario"s !a"ses de-ending

geogra-hi! 3 en4iromental #a!tors

' Hashimoto thyroiditis the most !ommon!a"se o# hy-erthyroidism

' Ne./orn in#ants 7retinism;

' &atig"e, !oldness, .eight gain, !onsti-ation,menstr"al irreg"larities, m"s!le !ram-s

HYPOTIROIDIS$HYPOTIROIDIS$



' Physi!al #indings1 $ool(rough( dry s:in( )uffy face and hands(

ahoarse voice( slo* reflexes$ardiovascular sign6 bradycardia( diminished $O(

lo* voltage HR"( cardiac enlargementPulmonary function6 Res)iratory failureIntestinal )aralysis slo*ed ( chronic consti)ation(ileus

Renal function+ Decresed #&R( renal im)airement nemia( "evere muscle cram)( )arestesias(muscle *ea:nes$N" sym)toms6 fatigue( inability to concentrate

HYPOTIROIDIS$HYPOTIROIDIS$



li ti



om-li!ation-+ @yxedema coma end stage of untreated

hy)othyroidism( $ause Radiothera)y in

#raves8 Disease

,+ @yxedema A 4eart disease $D

0+ 4y)othyroidism Neuro)sychiatric disease

de)ression( confuse( )aranoid( manic



Treatment Hy-othyroidism

' Le4othyro0ine 7T);

not liothyronine 7T09 because ra)id

absor)tion( short half life( transient effect+

Dosis T1( -? in the morning to avoid insomnia<+<3 mg=<+, mg2d

@ixedema coma I$%( intubation A

mechanical ventilation( Treat infection(heart failure( I5 dri)s *ith caution( l

levothyroxin I5



E=A$PLES O& THYROID DISEASES



.hsc.missouri.edu/4dave1/thyroid/thy5dis.html

E=A$PLES O& THYROID DISEASES

>? Hy-othyroidism Hy-erthyroidism

om-li!ation



om-li!ation

'@yxedema coma

end stage ofuntreated hy)othyroidism( $ause

Radiothera)y in #raves8 Disease

' @yxedema A 4eart disease $D' 4y)othyroidism Neuro)sychiatric

disease de)ression( confuse(

)aranoid( manic



D f iti



Defnition• Thyroiditis hetero!eno"s !ro"# o$

in%amatory disorders the thyroid !land

• Etiolo!ies ran!e $rom a"toimm"ne to

in$etio"s ori!ins• Clinial o"rse A"te' s"(a"te' or

hroni) Can (e e"thyroid' transient

#hase thyroto*iosis and + orhy#othyroidism) ,ainless or #ain$"ll

lassi#i!ation o# thyroiditis



. utoimmune thyroiditisChroni a"toim"ne thyroiditis

Hashimoto-s thyroiditis

Atro#hi thyroiditis

Foal thyroiditis ."/enile thyroiditis

Silent thyroiditis + ,ost#art"m thyroiditis

. Subacute thyroiditis

. cute suppurati/e thyroiditis!. Riedel#s thyroiditis

lassi#i!ation o# thyroiditis

Hashimoto5s thyroiditis



4a:aru 4ashimoto 7--,9 1 )atients chronic

disorder of the thyroid

diffuse lym)hocytic

infiltration( fibrosis()arenchymal atro)hy( andeosino)hilic change insome acinar cells

autoimmune or chronic

lym)hocytic thyroiditis

Hashimoto s thyroiditis

7hroni! thyroiditis;

Dr Ha6ar" Hashimoto

H hi - h idi i



Hashimoto thyroiditis

is the most common

cause o hypothyroidism oiter

in the (nited States

Hashimoto-s thyroiditis

Statosky J et al. Am Acad o !amily "#ysicians $%%%&61:1%5'

Hashimoto#s



Hashimoto sthyroiditis

Etiology 3 -athogenesis4T is immunologic disorder *hichlym)hocytes become sensiti.ed to thyroidal

antigens and autoantibodies are )erformed+

Thyroid anti/odies in HT are1

>2 Thyroglobulin antibody 7Tg b9

,+ Thyroid )eroxidase antibody

7TPO b9 / @icrosomal antibody90+ T"4 Rece)tor bloc:ing antibody

7T"4=R b bloc:;

lini!al $ani#estationlini!al $ani#estation



lini!al $ani#estationlini!al $ani#estation

Hashimoto5s ThyroiditisHashimoto5s Thyroiditis

Sym-tom 3 Signs

4T usually )resents *ithgoiter ( euthyroid or mild

hy)othyroidism+

"ex distribution 6 &2@ 16-

Painless A )atients may be

an*are of the goiter

L b t fi di



Laboratory findings

' T) N@ lo., TSH .ill /e ele4ated2

RAIU may /e high, normal or

lo.

' Tg A/ 3 TPO A/ -ositi#

' &ine needle as-iration /io-sylarge in#iltration lym-ho!ytes

H"rttle !ells

Diagnosti! -ro!ed"res



Diagnosti! -ro!ed"res

' Test o# thyroid a"toimm"nity1TPOA/ B: + in Hashimoto

thyroiditis 3 C: Atro-hi! thyroiditis

TgA/ less #re"ently +

Diagnostic specificity of thyroidantibody tests is not absolute.

' Test #or thyroid #"n!tion TSH, #T)' RAIU1 normal, lo. or high2

' USG1di##"sely red"!ed e!hogene!ity2' &NA not ne!essary,e0!e-2 ra-idly

enlarging goiter

Diagnosis o# Hashimoto5s thyroiditis



Diffuse goiter

Anti mi!rosomal 7or TPO; anti/odyAnti9thyroglo/"lin anti/ody Positive

Hashimoto5s

thyroiditis

Positive%" >io)sy

Other diseasesJNegative

Negative

"ign sym)tom of

hy)othyroidism

JSimple goiter,

adenomatous goiter etc

Diagnosis o# Hashimoto s thyroiditis



)reatment Hashimotos



)reatment Hashimotosthyroiditis



Treatment



Treatment

' #oiter small A asym)tomatic notreFuire thera)y

' Levo=thyroxine is given over

hy)othyroidism to su)ress T"4 A

decreased serum thyroid antibody+

Levo=thyroxine in euthyroid( still

controversial

)reatment



)reatment

' $orticosteroids 6 regression )ain(

reduction in si.e of the goiter( thyroidantibody( not recommended in benigndisease+

' "urgery indicated )ain( cosmetic(

or )ressure sym)toms afterlevothyroxine and corticosteroidthera)y+

Riedel5s thyroiditis



Riedel s thyroiditis

' Rare >,C@>CC2CCC, middle age or elderly

.omen

' Etiology "n6no.n 7a"toimm"ne

-ro!ess or -rimary #i/roti! disorder;

' hara!teriFed #i/rosis re-la!es

normal thyroid -aren!hyma,>@(

!ases m"lti#o!al #i/ros!lerosis





' Thyroid

#i/rosis 7stony hard,.oody;,-ainless, -rogressi4e anterior ne!6 mass,

' GeneraliFed #i/rosing 7>@( -atients;, -ress"re

sym-toms laryngeal ner4e -aralysis or

hy-o-arathyroidism 7rare;' Us"ally e"thyroidism, hy-othyroidism 7(C:;

' La/oratori"m 1 non s-esi#i!

' USG@T9S!an in!on!l"si4e' Di#initi4e diagnosis o-en io-sy




' Treatment6$orticosteroids medical treatment of choice

Tamoxi)en( methotrexate inhibitor fibroblast)roliferation 7 early stages9

Levothyroxine hy)othyroidism

"urgical care diagnosis( relieving trachealcom)ression

' @ortality as)hyxia 7=-<;9( extrathyroidalfibrotic lesions may com)licate the )rognosis

S"/a!"te thyroiditis




' a"se "n6no.n 7 4iral in#e!tion7; -re!eded URT in#e!tion,

!oin!iden!e 4iral disease 7m"m-s,

measles, E!ho 4ir"s, adeno 4ir"s,e-st2 arr 4ir"s, in#l"enFa;

' omen 1 $en 7(9B1>;

' Onset1 8C9C yr

' S"mmer





' Pal-ation thyroid1 enlarged, asymetri!al,nod"l, #irm, tender 3 -ain#"l2

' Thyroto0i!osis d"ring in#lamatory -hase

e"thyroidism

hy-othyroidism

e"thyroidism 7)th -hases;

' La/oratori"m1 ESR in!rease, le"6o!yt N@

in!rease, #T),,TSH, RAIU

' Re!o4ery )9 months, s-ontaneo"s

remitting

Treatment S"/a!"te



thyroiditis' "ym)tomatic6 cetamino)hen 1? <(3g( N"ID or

glucocorticoid 7)rednison 0 ? ,< mg 7K=-< days9

' >etabloc:ers sym)toms of thyrotoxicosis

' L=thyroxine <+-=<+-3 mg 2daily hy)othyroid)hase+ Long=term L=thyroxine )ermanent

hy)othyroidism 7-<;9

' ntibioticsno value

' Thyroidectomy rarely

lini!al Di##erentiating o# the S"/ty-e Thyroiditis



NE PAIN

RAIU

PRESENTING SY$PTO$S

YESNC

INREASED

RAIU

SUAUTE

GRANULO$ATOUS

THYROIDITIS

$IROIAL

IN&LA$$ATORY

THYROIDITIS

HYPERTHYROIDIS$DEREASED HYPOTHYROIDIS$

HRONI

LY$PHOYTI

THYROIDITIS

GRA<ES DISEASE SUAUT

LY$PHOYTI

THYROIDITIS

"tatos:y B et al+ m cad of &amily )hysicians ,<<<-6-<31

A!"te s"--"rati4e



--

thyroiditis' Rare, serio"s, /a!terial in#lamatory

disease, !hildren, 8C9)C yr, se0 ratio

>1>

' Etiologi1 In#e!tio"s1 Sta-h2 a"re"s,

stre-2-yogenes, stre-2 -ne"monia,

es!h2!oli, -se"domonas aer"ginosa

' In#e!tion /y hematogeno"s, dire!t

tra"ma



Thyroid nodules AThyroid nodules A

Thyroid cancer Thyroid cancer



Thyroid nod"les 9 -re4alen!e



Thyroid nod"les 9 -re4alen!e

' Thyroid nod"les !ommon, in!rease .ithThyroid nod"les !ommon, in!rease .ithageage

' (C9C: o# thyroids ha4e nod"les at a"to-sy(C9C: o# thyroids ha4e nod"les at a"to-sy

' Pal-ation1 B98C: 7J>!m;Pal-ation1 B98C: 7J>!m;

' USG1 >B9BC: 7 J 8mm;USG1 >B9BC: 7 J 8mm;

Thyroid nodule



Thyroid nodule

' One in -, to -3 young *omen has athyroid nodule+

' One in 1< young men has a thyroid

nodule+' @ore than 3; of all thyroid nodules are

benign 7

' The incidence of thyroid nodulesincreases *ith age+

Three K"estions a/o"t



Thyroid Nod"les

' Is the nodule one of the fe* that arecancerousM

' Is the nodule causing trouble by )ressing

on other structures in the nec:M' Is the nodule ma:ing too much thyroid

hormoneM



Diagnosti! a--roa!h



' &ine Needle As-iration 7&NA;

-<=,<; ris: of sus)icious cytology( therefore→ thyroid

surgery

3; of histology *ill be benign( and surgeryunnecessary

' Isoto- S!ann7T;

(sed or e)al*ation <; of nodules are cold

small cold nodules may be missed

hot nodules may be malignant

' Ultrasonogra-hy 7USG;



Is the nodule one of the fe* that are cancerousM

Is the nodule causing trouble by )ressing on

other structures in the nec:MIs the nodule ma:ing too much thyroid

hormoneM

Diagnosti! a--roa!h



Diagnosti! a--roa!h

"ltraso"nd

Identi#ies solid 42 !ysti! nod"les

Identi#ies $NG

$ay aid &NA

Does not e0!l"de malignan!y



Diagnosti! a--roa!h 9 other tests



al!itonin4ery high res"lts diagnosti! #or $T

ris6 o# /orderline #alse -ositi4es

not for routine useThyroglo/"lin

not hel-#"l #or e0!l"sion o# !ar!inoma1

o4erla- .ith /enign diseasebest for follow-up after thyroidectomy

Thyroid nod"les 3 ThyroidThyroid nod"les 3 Thyroid



!an!er !an!er

' In B: o# !ases , thyroid !an!er-resents as a nod"le or l"m- in the

thyroid nod"l thyroid2

' Thyroid nod"le

e0tremely!ommon, -arti!"larly

.omen2Pre4elan!e in USA ): in

ad"lt -o-"lation2 &1$ ratio )1>2

' Thyroid !an!er rare2 In!iden!e

C2CC): -er year

enign thyroid adenoma



enign thyroid adenoma

Etiology 6&o!al thyroiditis

$"ltinod"lar goiter Post

s"rgi!al remnant hy-er-lasiaenign adenoma1 &olli!"lar

Rare1 Teratoma,

li-oma, hemangioma

Di##rentiation /enign 3 $alignant

l i



lesions

' 4istory 6 &amily history o# goiter s"ggests/enign disease, endemi! goiter

' Physical characteristics6

enign1 older age, .oman, so#t nod"le, m"ltinod"lar goiter2

$alignant1 hildren, yo"ng, male, solitary,

#irm nod"le, 4o!al !ord -aralysis, #irm lym-h

nodes, distant metastasis



TreatmentTreatment



TreatmentTreatment

' Thyroide!tomi

' Modi"m >(>Radioa!ti4e

' Thyro0ine s"-ression



C"%"



"eorang *anita ,3 tahun datang dengan

:eluhan berdebar=debar( ce)at lelah( su:ar

berdiri dari dudu:+ &isis nadi -,<2menit )ulsus

seler( tensi -<2< struma difus( tremor( acral

)anas+

-+ Diagnosis+ QQQQQQQQQQQQ+

,+ %ntu: diagnosis )emeri:saan a)a yg )erluM

0+ >ila diagnosis benar ma:a )emeri:saan fisis

)emeri:saan laboratorium a)a lagi++++++++

1+ >ila diagnosis tega: )enya:it #raves

ma:a )emeri:saan



ma:a )emeri:saan QQ++

3+ Pengobatan )enya:it #raves antara lain

obat tabletQQQ++ >era)a lama

diberi:anQQ+

+ "elain obat a)a saja cara tea)i lainnyaQ

K+ Com)li:asi a)a saja biusa terjadiQQ

+ )a yang )erlu difollo*u) )d )asien

iniQ++

+ Cematian thyrotoxicosis a:ibat )a saja++

-<+ Cena)a :ambuh sesudah remissiQ

Casus ,



' "eorang la:i, umur 1 tahun denganbenjolan di leher :anan sebesar bola

)im)ong+ Celuhan tida: ada+

' -+ lang:ah a)a saja yang saudara inginla:u:an )ada )asien iniM

' ,+ bila diagnosis saudara ternyata

:arsinoma ana)lasti: tiroid a)alang:ah,nyaQ+

' 0+ bila hasil diagnosis :arsinoma )a)ilare

: h l : h d



a)a:ah lang:ah saudaraQQ++

' 1+ bila hasilnya hanya suatu adenoma tiroidfoli:ulare a)a:ah tinda:an saudaraQ+

' 3+ >agaimanaF mebeda:an :arsinoma dengan

adenomaQQ

' + bila )ada )emeri:saan T"4s mening:at

sedang &T1 menurun ma:a diagnosiusQ+

' K+ )emeri:saan imunologis a)a yang di)erlu:an

' +Pengobatan untu: )asien ini



g )

' + a)a sdr setuyju untu: oi)erasi )asien

ini

' -<+ :alau hasil usg ternyata :ista tiroid

ma:a )engobatan a)a yang saudara

)ilihM

04. Kuliah Tiroid (Prof.dr. Harsinen S, Sp.pd-kEMD)

Documents

Transcript of 04. Kuliah Tiroid (Prof.dr. Harsinen S, Sp.pd-kEMD)