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Putu Moda ArsanaFKUB,2011
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Guidelines is a Health
professionals consensus basedof evidence,to guide clinical
health professional in managing
health problems to achievedbetter results.
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Evidence based
Medicine
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1++ High-quality meta-analyses, systematic reviews of randomized controlled trials
(RCTs), or RCTs with a very low risk of bias
1+ Well-conducted meta-analyses, systematic reviews of RCTs or RCTs with a low
risk of bias)
1 Meta-analyses, systematic reviews of RCTs or RCTs with a high risk of bias *
2++ High-quality systematic reviews of non-RCT, case
control, cohort, controlledbefore-and-after study (CBA) or interrupted time series (ITS) studies
High quality non-RCT, casecontrol, cohort, CBA or ITS studies with a very low risk of
confounding, bias or chance and a high probability that the relation is causal
2+ Well-conducted non-RCT, casecontrol, cohort, CBA or ITS studies with a very low
risk of confounding, bias or chance and a moderate probability that the relation is causal
2 Non-RCT, casecontrol, cohort, CBA or ITS studies with a high risk of confounding,
bias or chance and a significant risk that the relationship is not causal *
3 Non-analytic studies (for example, case reports, case series)
4 Expert opinion, formal consensus
* Studies with a level of evidence '' should not be used as a basis for making a
recommendation.
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Class I
Benefit >>> Risk
Procedure/ Treatment
SHOULD be
performed/
administered
Class IIa
Benefit >> Risk
Additional studies with
focused objectives
needed
IT IS REASONABLE
to perform
procedure/administer
treatment
Class IIb
Benefit Risk
Additional studies with
broad objectives
needed; Additionalregistry data would be
helpful
Procedure/Treatment
MAY BE CONSIDERED
Class III
Risk Benefit
No additional studies
neededProcedure/Treatment
shouldNOT be
performed/administered
SINCE IT IS NOT
HELPFUL AND MAY BE
HARMFUL
shouldis recommendedis indicatedis useful/effective/
beneficial
is reasonablecan be useful/effective/
beneficialis probably recommended
or indicated
may/might be consideredmay/might be reasonableusefulness/effectiveness is
unknown /unclear/uncertain
or not well established
is not recommendedis not indicatedshould notis not
useful/effective/beneficialmay be harmful
Applying Classification of Recommendations
and Level of Evidence
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Class I
Benefit >>> Risk
Procedure/ Treatment
SHOULD be
performed/
administered
Class IIa
Benefit >> Risk
Additional studies with
focused objectives
neededIT IS REASONABLE to
perform
procedure/administer
treatment
Class IIb
Benefit Risk
Additional studies with
broad objectives needed;
Additional registry data
would be helpful
Procedure/Treatment
MAY BE CONSIDERED
Class III
Risk Benefit
No additional studies
neededProcedure/TreatmentshouldNOT be
performed/administered
SINCE IT IS NOT
HELPFUL AND MAY
BE HARMFUL
Level B Limited (2-3) population risk strata evaluatedLevel A Multiple (3-5) population risk strata evaluated
General consistency of direction and magnitude of effect
Level C Very limited (1-2) population risk strata evaluated
Applying Classification of Recommendations
and Level of Evidence
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The objective of guidelines is toprovide guidelines to clinicalprofessional for the management
of health problems
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Diagnosis procesTreatment procesSpecial coditions/considerations
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Is a combination of intellectual and
manipulative activities by whichdisease is identified and illness is
evaluated.
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Complaint Diagnosis Treatment
Diagnosis
Process
Clinical Process
reatmentprocess
Putu Moda Arsana,2006
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1. Data collection2. Data synthesis3. Problem identification
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History taking Physical examination Additional examination ( laboratory
testing, X-ray, etc )
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The most important step: History of present illness Personal history Medical history Family history Review of system
Accuracy of the data collected baseon : Knowledge Doctor-patient relationship
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Collecting data from inspection,palpation, percussion and
auscultation Should be done systematically
Vital sign From head to lower extremities
The Physicians must know about thebasic technique of physicalexamination
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Is a process to translate illnessinto problem / Diagnosis
Based on Diagnosis criteria
Is preceded by problem Cue and clue
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Chief
complaint
historyPhysical
examinat
ion +
basic
test tests
15
10
5
PROBLEM / HIPOTESIS
VERIFICATION
CONCLUSION /
FINAL DIAGNOSIS
DATA COLLECTION
Differentialdiagnosis
Putu Moda Arsana,2006
Iterative hypothesis / Initial
DDDD
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DATADiagnosis criteria
(Diabetes )
Diagnosis criteria
(Graves diseases)
Diagnosis criteria
(Tuberculosis)
Decrease BW +
Chief
complaint
Diagnosis
process
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Non pharmacologic treatment :General :Diet, Activities, etc
Specific : Surgery procedure, X-ray, Psychotherapy, etc
Pharmacologic treatment : Causative Symptomatic Supportive Palliative
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Empirical Evidence Base Medicine
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The objective of thyroid guidelinesis to provide guidelines to clinicalprofessional for the management
of thyroid problems
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Initial/First visit
History of present illnessPhysical examination
Laboratory examination
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Nervousness, fatigue, palpitations, exertional dyspnea,weight loss, heat intolerance, irritability, tremor, muscleweakness, decreased menstrual flow in women, sleepdisturbance, increased perspiration, increased frequency of
bowel movements, change in appetite, and thyroidenlargement
photophobia, eye irritation, diplopia, or a change in visualacuity.
recent iodine exposure, prior or current thyroid hormoneuse, anterior neck pain, pregnancy, or history of goitershould be included.
A family history of thyroid disease
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Weight and height, pulse rate and regularity, blood
pressure, cardiac examination, thyroid enlargement
(diffuse or nodular), proximal muscle weakness,
tremor, an eye examination (for evidence ofophthalmopathy), and a skin examination (forpretibial myxedema).
Older individuals may have few if any symptoms
and signs of hyperthyroidism except for weight loss
and cardiac abnormalities, in particular atrial
fibrillation and/or congestive heart failure.
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True hyperthyroidism must be distinguished from "euthyroid
hyperthyroxinemia," which may be caused by certain drugs,
nonthyroidal illness, and a variety of other less common factors.
Specific tests to establish the diagnosis of hyperthyroidism :
thyroxine (T[sub]4[/sub]) (which is elevated in hyperthyroidism),as well as a serum thyroid-stimulating hormone (TSH)
measurement (which is suppressed in hyperthyroidism). The TSH
level should be measured in an assay that is sensitive enough to
clearly discriminate euthyroid from hyperthyroid individuals.
When the free T[sub]4[/sub] level is elevated in a clinicallyhyperthyroid patient, a serum TSH level that is not suppressed
should alert the clinician to the possibility of hyperthyroidism due
to a TSH-producing pituitary adenoma.
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If hyperthyroidism is confirmed, other testsmay be performed according to the clinical
situation. These may include totaltriiodothyronine (T[sub]3[/sub]), thyroidautoantibodies, and a radioactive iodineuptake test.
Specific treatment should generally bewithheld until the biochemical diagnosis andcause of hyperthyroidism are confirmed
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The treatment of Graves' hyperthyroidism isdirected toward lowering the serum
concentrations of thyroid hormones toreestablish a eumetabolic state
Antithyroid drug
Radioactive iodine
Surgery
Ajunctive therapy
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Antithyroid drug Radioactive iodine
Surgery Ajunctive therapy
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Long-term ATD therapy may lead toremission in some patients with Graves'
disease Initial daily doses of methimazole generally
range from 10 to 40 mg, Initial daily doses of propylthiouracil, 100 to
600 mg Duration of treatment is for 6 months to 2
years
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Most common used in USA Relatively safe
SE : hypothyroidism HRT Contra indicated in pregnant and breast
feeding women Elderly and/or individuals at risk for
developing cardiac complications may bepretreated with ATDs prior to therapy.
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Recommended for:
Graves disease with very large goiter
Resistent to I 131Thyroid nodules
Pregnan woman allergic to ATD
Allergic to ATD and/or do not wish toradioactive iodium therapy
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Beta adrenergic-blocker
Calcium chanel blocker
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4 12 weeks
Complaint, physical examination,lab. Examination
Effect therapy: T4 , TSH
Side effect: leucocyte count, liverfunction test
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Hyperthyroidism and pregnancy
Graves ophthalmopathyToxic Nodular Goiter
Thyroid Storm Iatrogenic Hyperthyroidism
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Increased rate of fetal loss The goal of treatment during pregnancy is to
maintain euthyroidism using the smallestdoses of ATDs Propylthiouracil is preferred in pregnancy
because it crosses the placenta less thanmethimazole
Should be seen at 4- to 6-week intervals
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No specific laboratory tests are required to confirm
the diagnosis.
When ophthalmopathy occurs in patients who are
biochemically euthyroid, autoimmune thyroiddisease should be suspected, and the diagnosis canbe confirmed by the finding of antimicrosomal
(antithyroperoxidase [anti-TPO]) antibodies or
thyroid-stimulating antibodies in the serum Treatment: ATD, symptomatic, diuretics,
glucocorticoid
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Common than Graves' disease in elderlypatients
Ophthalmopathy is not present in patientswith TNG Absence of thyroid autoantibodies Diagnosis: Thyroid scan and Iodium uptake Treatment : Radioactive Iodium therapy or
surgery.
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life-threatening Severe sign and symptoms of hyperthyroidism,
fever, altered mental status Presipitating factor: ATD caesation, concurent
illness or injury, radio active iodine therapy. Treatment: PTU or methimazole, Potassium
iodide, lithium carbonate, ipodate,corticosteroid, beta blocker, Tx for presipitatingfactor
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History
Physical examination Laboratory examination
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Tiredness, weakness, fatigue, sleepiness, coldintolerance, dry hoarseness, constipation,joint pains, muscle cramps, mentalimpairment, depression, menstrualdisturbances in women and especially
menorrhagia, infertility, and weight gain Medical and non medical hystory
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Goiter or a nonpalpable thyroidgland,
Bradycardia, edema, hoarseness,
delayed relaxation of deep tendon
reflexes, slow speech, and cool, dryskin, change of bowel habbit.
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serum TSH measurement and a freeT[sub]4[/sub] estimate (or direct
measurement) should be performed. When autoimmune thyroiditis is the
suspected underlying cause, it is helpful toconfirm antithyroid antibody titers, either
antimicrosomal antibody (anti-TPO antibody)or antithyroglobulin antibody
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Hormon replacement:
Levothyroxine sodium is the treatment of choice
Adults with hypothyroidism require approximately 1.7microg/kg of body weight per day for full replacement. Childrenmay require higher doses (up to 4 microg/kg of body weight perday). Older patients may need less than 1 microg/kg per day
Therapy is initiated in patients under the age of 50 years withfull replacement. For patients who are older than 50 years, or
in younger patients with a history of cardiac disease, a lowerinitial dosage is indicated, starting with 0.025 to 0.05 mg oflevothyroxine daily, with clinical and biochemical reevaluationsat 6- to 8-week intervals until the serum TSH concentration isnormalized.
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Clinic: Clinical response to treatment,patient compliance in taking the
medication, and development of druginteractions,
Lab:TSH.
Evaluated initially about every 6 to 8weeks
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Elderly
PregnancySubclinical hypothyroidismMixedema coma
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Hoarseness, deafness, confusion,dementia, ataxia, depression, dry
skin, or hair loss screened with a serum TSH
measurement
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During pregnancy, many hypothyroid patients have
an increase in levothyroxine requirement, which can
be detected with a TSH measurement. The patient
should be checked during each trimester to makesure that the TSH concentration is still normal, withfurther adjustments as indicated by the appropriate
testing. The levothyroxine dose should return to the
prepregnancy dose immediately after deliveryand a
serum TSH level should be obtained 6 to 8 weeks
post partum.
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Elderly patients, tolerate the effects of excess T[sub]4[/sub]poorly. If symptoms of palpitations, tremor, difficulty inconcentrating, or chest pain develop, the patient should beevaluated with appropriate tests, and if hyperthyroidism is
confirmed, the current dose of levothyroxine should bewithheld for 1 week and restarted at a lower dose.
Other patients remain asymptomatic despite elevations of freeT[sub]4[/sub] and/or suppression of TSH concentrations. Sincelevothyroxine overreplacement has been associated with
reduced bone mineral content, particularly in postmenopausalwomen, it is recommended that these patients have their dosereduced until the TSH concentration is normalized, unless TSHsuppression is the objective, as in patients with a history of
well-differentiated thyroid cancer.
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Normal free T[sub]4[/sub] estimate (or normal direct freeT[sub]4[/sub] measurement) and an elevated TSH concentration,This state is referred to as "subclinical hypothyroidism.
Some patients with this mild disorder feel better when treatedwith levothyroxine. Therapy for subclinical hypothyroidism isprobably advisable, especially if thyroid autoantibodies arepositive, because overt hypothyroidism develops with highfrequency in such patients.
If the physician decides not to treat these patients, they shouldbe evaluated at yearly intervals for evidence of more severeclinical and biochemical loss of thyroid function.
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Coma caused by myxedema is a rare, life-threatening statein which severe, usually long-standing hypothyroidismmarkedly worsens. In general, it occurs in elderly individuals
and is usually precipitated by an intercurrent medical illness.The clinical manifestations, in addition to obtundation orcoma, may include hypothermia, bradycardia, respiratoryfailure, and even cardiovascular collapse. Therapy ofmyxedema coma includes intravenous administration of
levothyroxine and/or liothyronine sodium as well aspharmacologic doses of glucocorticoids. Also, precipitating orassociated disorders must be aggressively treated.
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