04. Kuliah Tiroid (Prof.dr. Harsinen S, Sp.pd-kEMD)
Transcript of 04. Kuliah Tiroid (Prof.dr. Harsinen S, Sp.pd-kEMD)
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HARSINEN SANUSIHARSINEN SANUSI
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THE THYROID GLAND
Pyramidal
lobe
Left lobe
Right lobe
Isthmus
Internal
jugular vein
Thyroidcartilago
Externalcarored arteri
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http://arbl.cvmbs.colostate.edu/hbooks/pathphys/endocrine/thyroid/anatomy.html
THYROID GLAND HISTOLOGY
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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
$I%
DI%
Iodinase
%yrosine)
RELE"E
I
Cryer PE. Diagnostic endocrinology 1976:35
%*
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asi! elements in reg"lation
o# thyroid #"n!tion
THYROID
TISSUE
TRH
HYPOTHALA$US
PORTAL SYSTE$
TSH
ANTERIOR
PITUITARY
%&REE'
T(
T(
T)
T)
I
I
*
T)
+
T(
+
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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
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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+
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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
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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
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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
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THYROID DISEASES
HYPERTHYROIDIS$HYPOTHYROIDIS$
THYROIDITIS
THYROID NODUL
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T4!ROID D!"&%N$TION PRE5LEN$E
• Hypothyroidism 2 %
• Sublinical hypothyroidism 5-7 %
• Hyperthyroidism 0,2%
• Subclinical hypothyroidism 0,1-6,0%
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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
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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(
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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
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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
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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
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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 $ornea
Neuritis o)tica
tro)hi nervus o)ticus
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LIDLID
RETRACTIONRETRACTION
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Thyroid Dermo)athy
' Thi!6ening o# the s6in, o4er the
lo.er ti/ia d"e to a!!"m"lation
gly!osamin gli!ans , rare 789(:;' TSH9R A/ high titer
' Osteo-athy in the meta!ar-al
/ones
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NON PITTING OEDE$A
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<ITILIGO
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Suspected hyperthyroidism
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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
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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
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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
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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
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' 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
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Treatment o# Gra4es5 diseaseTreatment o# Gra4es5 disease
' Radioa!ti4e
iodine thera-y
%" NaI -0-I
euthyroid over =
-, *ee:s(
$om)licationhy)othyroidism
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' 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
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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+
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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
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HYPOTHYROIDIS$HYPOTHYROIDIS$
O O S
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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$
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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$
8/19/2019 04. Kuliah Tiroid (Prof.dr. Harsinen S, Sp.pd-kEMD)
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' 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$
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li ti
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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
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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
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E=A$PLES O& THYROID DISEASES
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.hsc.missouri.edu/4dave1/thyroid/thy5dis.html
E=A$PLES O& THYROID DISEASES
>? Hy-othyroidism Hy-erthyroidism
om-li!ation
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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
8/19/2019 04. Kuliah Tiroid (Prof.dr. Harsinen S, Sp.pd-kEMD)
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D f iti
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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
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. 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
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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
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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
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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
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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
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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
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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
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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
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)reatment Hashimotos
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)reatment Hashimotosthyroiditis
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Treatment
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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
8/19/2019 04. Kuliah Tiroid (Prof.dr. Harsinen S, Sp.pd-kEMD)
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)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
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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
Riedel5s thyroiditis
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Riedel s thyroiditis
' 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
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Riedel5s thyroiditis
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Riedel s thyroiditis
' 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
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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
S"/a!"te thyroiditis
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S"/a!"te thyroiditis
' 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
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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
8/19/2019 04. Kuliah Tiroid (Prof.dr. Harsinen S, Sp.pd-kEMD)
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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
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--
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
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Thyroid nodules AThyroid nodules A
Thyroid cancer Thyroid cancer
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Thyroid nod"les 9 -re4alen!e
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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
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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
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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
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Diagnosti! a--roa!h
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' &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;
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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
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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
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Diagnosti! a--roa!h 9 other tests
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al!itonin4ery high res"lts diagnosti! #or $T
ris6 o# /orderline #alse -ositi4es
not for routine useThyroglo/"lin
not hel-#"l #or e0!l"sion o# !ar!inoma1
o4erla- .ith /enign diseasebest for follow-up after thyroidectomy
Thyroid nod"les 3 ThyroidThyroid nod"les 3 Thyroid
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!an!er !an!er
' In B: o# !ases , thyroid !an!er-resents as a nod"le or l"m- in the
thyroid nod"l thyroid2
' Thyroid nod"le
e0tremely!ommon, -arti!"larly
.omen2Pre4elan!e in USA ): in
ad"lt -o-"lation2 &1$ ratio )1>2
' Thyroid !an!er rare2 In!iden!e
C2CC): -er year
enign thyroid adenoma
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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
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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
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TreatmentTreatment
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TreatmentTreatment
' Thyroide!tomi
' Modi"m >(>Radioa!ti4e
' Thyro0ine s"-ression
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C"%"
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"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
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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 ,
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' "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
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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
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g )
' + a)a sdr setuyju untu: oi)erasi )asien
ini
' -<+ :alau hasil usg ternyata :ista tiroid
ma:a )engobatan a)a yang saudara
)ilihM