CASE REPORT

“ HYPERTHYROIDISM “

Preseptor : dr. Ihsanil Husna, Sp.PD

Arranged by : Ana Nurrida (2011730003)

 PATIENT’S IDENTITY

• Name : Mrs. P
• Age : 34th years old
• Education : Junior High school
• Marital status : Divorced
• Occupation : Housemaid
• Religion : Moslem
• Date of admission : 1st of September 2016
• MR number : 00948664
 ANAMNESIS

• Chief complaint :
Patient complained of body weakness since 1 week ago

• Another complaint :
Can’t walk, dizziness, and decrease of appetite
 HISTORY OF PRESENT ILLNESS
• Patient came to the emergency room RSIJ
Cempaka Putih with complaints of her
body weakness since 1 week ago. Patient
said that her body weakness was so
deeply until she was not able to stand and
walk.
• Patient also admitted feeling dizzy but not
spinning.
• She claimed these complaints began to
arise due to reduce of appetite, she said
that she was so lazy to eat and have no
appetite. She said that her weight
decreased. Patien actually had
complaints of weakness like this since two
weeks ago, but it getting worse and she
couldn’t stand and walk since 1 week
before she came to the hospital.
• Patient said that sometimes her heart was
palpitate and her hands was trembling for
no reason.
• Patient was realized a lump in the right
neck since she had a second child delivery,
or about 9 years ago. Initially the size of that
lump as big as marbles and it grew bigger
until today. Complaints of difficulty in
swallowing and hoarseness denied
• Complaints for heat intolerance, increased
perspiration, shortness of breath, nausea,
vomiting, impaired visions, hyperdefecation
and reduction in menstrual flow denied.
HISTORY OF PAST ILLNESS

• No history of same problem

• No history of Hypertension
• No history of DM
• No history of urinary or kidney disease
• No history of asthma
• No history of allergic
• No history of hematologic disease
 HISTORY OF FAMILY

• None of her family has same problem

• Patient’s mother has history of hypertension
• No history of DM
• No history of allergic
• No history of hematologic disease
 HISTORY OF ALLERGY

• Patient has no allergy to food, drugs and weather.

 HISTORY OF TREATMENT

Patient wasn’t consumed any medication before

came to the hospital
 HABITS

• Smoking habits : Denied

• Drinking alcohol : Denied
• Taking any medication : Patient wasn’t
consumed any medication
 PHYSICAL EXAMINATION

• General condition : Moderate ill

• Conciousness : composmentis
Generalis Status • Body weight : 40 kg
• Body height : 157 cm
• Body mass index : 16,26 (underweight)

• Blood pressure : 130/90 mmHg

Vital Sign • Heart rate : 120x/minute
• Respiratory rate : 20x/minute
• Temperature : 36.9° C
 GENERAL PHYSICAL EXAMINATION

Eyes : Head :
• Anemic conjungtiva (-/-), normocephal,
• Icteric sclera (-/-) deformity (-)
• Exophthalmos (-/-)

Nose :
• Septal deviation (-)
• Secret (-)

Mouth :
• Oral mucosa moist
• Stomatitis (-)
Ear :
• Normotia
Neck :
• Secret (-/-)
• Mass (+)
 • Inspection : ictus
cordis not seen
• Palpation : ictus cordis
• Inspection : the palpable in ICS-V
movement of the medioclavicula
chest symmetrical, • Percussion : left heart
intercosta retraction (-) margin midclavicula
• Palpation : same vocal ICS-V. right heart
fremitus in dextra and margin sternalis line
sinistra ICS-V
• Percussion : sonor • Auscultation : Regular
1st & 2nd heart sounds,
• Auscultation : VBS + /
tacichardia, murmur
+, ronkhi - / -, wheezing
(-), gallop (-)
-/-
 • Inspection: looked flat
Abdomen • Auscultation: bowel (+) sounds, 7x/minutes
• Palpation: pressure pain (-), Ascites (-)
• Percussion: timpani, shifting dullness (-)

• Superior: Edema (- / -), warm akral(+ / +), RCT

Extremities <2 seconds (+ / +)
• Inferior: Edema (-/ -), warm akral (+ / +), RCT
<2 seconds (+ / +)
 LOCALIZE STATUS

COLLI DEXTRA REGION

(I)
There are a mass, round
shape, diameter ± 10 cm, it
moves when the patient
swallowed, no hyperemia.

(Pa)
Palpable mass, solid
consistency, clear bound,
mobile, tenderness (-), flat
surface, regional
lymphadenopathy (-).

(A)
Bruit sounds (-)
 LABORATORY EXAMINATION
(1 SEPTEMBER 2016)

Value Units Normal

Hemoglobin 13 (L) 11.7 – 15.5 g/dL

Leukocytes 14.37 (H) 3.60-11.00 103 𝜇𝐿

Hematocrit 38 (L) 35– 47 %

Platetlets 262 (H) 150-440 103 𝜇𝐿

Erythrocyte 4.82 (L) 3.80 – 5.20 106 𝜇𝐿
MCV/VER 78 80-100 fL
MCH/HER 27 26-34 pg
MCHC/KHER 35 32-36 g/dL
Kalium (K) 3.7 3.5-5.0 mEq/L
Free T4 5630 0.930 – 1.700 ng/dL
Sensitive TSH 0.001 0.270 – 4.200 μIU/mL
THYROID USG

• Right thyroid enlarged, not clear bound,

multiple solid lesions appear, doppler :
excess vascularization.
• Left thyroid not enlarged, clear bound,
no cystic or solid lesions .
Tracheal pushed to the left

Impression : Right Nodusa Struma dd /

malignant process
 RESUME

Mrs. P 34th years old came to the emergency room RSIJ Cempaka Putih with complaints
of her body weakness since 1 week ago. Patient said that her body weakness was so deeply
until she was not able to stand and walk. Patient also admitted feeling dizzy but not spinning.
She claimed these complaints began to arise due to reduce of appetite, she said that she was
so lazy to eat and have no appetite. She said that her weight decreased. Patien actually had
complaints of weakness like this since two weeks ago, but it getting worse and she couldn’t
stand and walk since 1 week before she came to the hospital.
Patient said that sometimes her heart was palpitate and her hands was trembling for no
reason. She admitted that during this week she didn’t do an activities and just lying in bed all
day long. Patient was realized a lump in the right and left neck since she had a second child
delivery, or about 9 years ago. Initially the size of that lump as big as marbles and it grew bigger
until today. Complaints of difficulty in swallowing and hoarseness denied

Physical examination : BP: 130/90 mmHg, HR: 120x/minute, RR: 20x/minute, Temp : 36.9° C. There
are a mass at colli dextra anterior region, round shape, diameter ± 10 cm, it moves when the
patient swallowed, no hyperemia. chewy consistency, clear bound, mobile, tenderness (-), flat
surface, regional lymphadenopathy (-), bruit sounds (-)
Laboratory : Free T4 5630, Sensitive TSH 0.001
USG : Right thyroid enlarged, not clear bound, multiple solid lesions appear, doppler : excess
vascularization. Impression : Right Nodusa Struma dd / malignant process
PROBLEM LIST
• Body Weakness
• Hyperthyroidism
• Goitre
 ASSESMENT

1. Hyperthyroidism e.c Toxic Nodusa Goiter

2. Differential Diagnosis :
Grave’s disease
• S : Patient complaints of her body weakness since 1 week ago, have no
appetite. Patient said that sometimes her heart was palpitate and her hands
was trembling for no reason. Patient was realized a lump in the right and left
neck since she had a second child delivery, or about 9 years ago. Initially the
size of that lump as big as marbles and it grew bigger until today. Complaints of
difficulty in swallowing and hoarseness denied

• O : BP: 130/90 mmHg, HR: 120x/minute, RR: 20x/minute, Temp : 36.9° C. There are
a mass at colli dextra anterior region, round shape, diameter ± 10 cm, it moves
when the patient swallowed, no hyperemia. chewy consistency, clear bound,
mobile, tenderness (-), flat surface, regional lymphadenopathy (-), bruit sounds
(-) Laboratory : Free T4 5630, Sensitive TSH 0.001 USG : Right thyroid enlarged, not
clear bound, multiple solid lesions appear, doppler : excess vascularization.
Impression : Right Nodusa Struma dd / malignant process
• A : Hyperthyroidism e.c Toxic Nodusa Goiter
• P : - Propanolol 3 x 10 mg
- PTU 3 x 100 mg
- Ranitidine inj
- IVFD RL 20 tpm
- Pro thyroidectomy
- Bed rest
 FOLLOW UP
• 2nd September 2016
• S: body weakness, nausea, dizzy
• O : TD : 120/80 mmHg
• RR : 20 times/minute
• Pulse : 112 times/ minute
• Temperature : 36,8 C
• A : Hyperthyroid ec struma
nodosa toxic
• P : - Propanolol 3 x 10 mg
• - PTU 3 x 100 mg
• - Ranitidine inj
• - IVFD RL 20 drops/minute/8 hr
• - Pro isthmulobectomy
• - Bed rest
• 3rd September 2016
• S: body weakness, nausea
• O : TD : 120/80 mmHg
• RR : 20 times/minute
• Pulse : 96 times/ minute
• Temperature : 36,7o C
• A : SNNT
• P : - PTU 3 x 100 mg
• - Ranitidine inj
• - IVFD RL 20 drops/minute/8 hr
• - Pro isthmulobectomy
• - Bed rest
• 5th September 2016
• S: body weakness, nausea,
patient can stand and walk
• O : TD : 110/70 mmHg
• RR : 20 times/minute
• Pulse : 92 times/ minute
Temperature : 36,5o C
• A : SNNT
• P : - PTU 3 x 100 mg
• - Ranitidine inj
• - IVFD RL 20
drops/minute/8 hr
• - Pro isthmulobectomy
• - Bed rest
• 6th September 2016
• S: nausea
• O : TD : 110/70 mmHg
• RR : 19 times/minute
• Pulse : 100 times/ minute
Temperature : 36,7o C
• A : SNNT
• P : - PTU 3 x 100 mg
• - Ranitidine inj
• - IVFD RL 20
drops/minute/8 hr
• - Pro isthmulobectomy
• - Bed rest
EKG ( 6th SEPTEMBER 2016)
 PROGNOSIS

• Quo ad vitam : bonam

• Quo ad functionam : dubia ad bonam
• Quo ad sanationam : dubia ad bonam
LITERATURE
REVIEW
ANATOMY

The thyroid is a highly vascular, brownish-red gland

located anteriorly in the lower neck, extending from
the level of the fifth cervical vertebra down to the first
thoracic. It is an endocrine gland, divided into two
lobes which are connected by an isthmus, with an
average height of 12-15 mm, overlying the second to
fourth tracheal rings. It shapes like a butterfly shape.

Principal innervation of the thyroid gland derives from

the autonomic nervous system. Parasympathetic
fibers come from the vagus nerves, and sympathetic
fibers are distributed from the superior, middle, and
inferior ganglia of the sympathetic trunk. These small
nerves enter the gland along with the blood vessels.
Autonomic nervous regulation of the glandular
secretion is not clearly understood, but most of the
effect is postulated to be on blood vessels, hence the
perfusion rates of the glands
VASCULAR SUPPLY

Blood supply to the thyroid gland is achieved by

two main arteries ; the superior and inferior
The superior thyroidthryoid
arteryarteries
is the first branch of the
external carotid artery. After arising, the artery
descends toward the thyroid gland. As a
generalisation, it supplies the superior and
anterior portions of the gland.
The inferior thyroid artery arises from the
thyrocervical trunk (which in turn is a branch of
the subclavian artery). The artery travels
superomedially to reach the inferior pole of the
thyroid. It tends to supply the postero-
inferior aspect.
Thyroid Gland’s Control

Hipotalamus

TRH

_
Pituitari anterior _

TSH

Tiroid

T3 T4
 Equitable enlargement of the
Difus gland, the right and left gland
enlarges and called difusa goitre
According
to deformity Bump as big as the ball, can be
Nodule single or multiple, can be solid or
liquid, and can be either benign /
malignant
Disorders of
thyroid

Collection of clinical manifestations

result of decreases or cessation of
According Hypothyroid the production of thyroid hormones
to function
disorder Also called thyrotoxicosis, is a
Hyperthyroid collection of clinical manifestations
of excess thyroid hormone
HYPERTHYROIDISM

Hyperthyroidism is a set of
disorders that
involve excess synthesis and secretion of
thyroid hormones by the thyroid gland,
which leads to the hypermetabolic condition
of thyrotoxicosis.
The most common forms of hyperthyroidism
include diffuse toxic goiter (Graves disease),
toxic multinodular goiter (Plummer disease),
and toxic adenoma.
 RISK FACTORS

 Having a history of previous thyroid disorders such as goiter or had

had surgery of the thyroid gland.
 Having a history of autoimmune diseases such as diabetes mellitus
and hormonal disorders.
 A history of thyroid disorders in the family.
 Using drugs that cause thyroid disease such as amiodarone, lithium
carbonate, aminogluthetimide, interferon alpha, thalidomide,
betaroxin, stavudine
 Aged over 60 years.
 Gender, women are more at risk
 Smoking
 Stress
 Environment , low iodine content in water
 ETIOLOGY

Grave’s disease

Etiology of hyperthyroidism
can be divided into several
Toxic adenoma
category

Multinodular goiter
PATOPHYSIOLOGY
 CLINICAL MANIFESTATIONS
Organs
CNS Emotional, irritable, psychosis, tremor, nervous, insomnia
Eyes Diplopia, exophthalmos
Thyroid gland Enlargement of the thyroid gland
Heart and lung Dispneu, hypertension, tachycardia, arrhythmia,
palpitations, heart failure
GI tract Hyperdefecation, plenty to eat, hungry, thirsty, vomiting,
weight loss, drug tolerance
Reproductive organs Decreased fertility, reduced menstruation, no
menstruation, decreased libido
Blood and lymphatic Lymphocytosis, anemia, spleenomegaly, enlarged lymph
nodes of the neck
Bone Thyrotoxic periodic paralysis, osteoporosis, epiphyseal
rapidly closing, bone pain
Muscle Increased reflexes, hiperkenesis, tired
Skin Increased perspiration
DIAGNOSIS
WAYNE INDEX

• Euthyroid : (-11) – (23)

• Prob. Hyperthyroid : (24) –
(+39)
• Hyperthyroid : 40 - 80

Hyperthyroid if score ≥ 20
Diagnosis Free T4 and T3 TSH

Hyperthyroidism

Hypothyroidism
Hormone Function Test
 Levels of serum total thyroxine and
triyodotiroin measured by
radioligand assay
 Serum free thyroxine measuring
thyroxine circulating metabolically
active.
 Plasma TSH levels can be measured
by assay radioimunometric.
 Uptake of radioactive iodine tests
(RAI) is used to measure the ability
of the thyroid gland in the capture
and convert iodide.
Radiology
 Neck Radiographs
- This examination is intended to
see goitre has been pressed or
block the trachea (airway).
 ULTRASOUND
- Shows the size of mumps
- The possibility of the presence
of cysts / nodules that may not
be detected when the
examination of the neck.
40
 FNAB

 Specifically in suspicious
circumstances of a
malignancy.
 Which must be considered :
- Location biopsy to be precise
- Making good preparations
- To avoid false positive test
results interpretation by
cytologists.
 Patient

Clinical hipertiroid (+) Clinical hipertiroid (-)

FT4 and/ without TSHs TSHs

FT4 ↑ FT4 N FT4 N

TSHs ↑ Normal TSHs ↓
TSHs ↓ TSHs ↓ TSHs N

Subclinic Not Hypothyroid Hyperthyroid

Hyperthyroid
hyperthyroid hyperthyroid

FT4 N FT4 ↓ FT4 N FT4 ↑

Subclinic Subclinic
Hypothyroid Hyperthyroid
hypohyroid hyperthyroid
TREATMENT
 PTU ( 100 mg)
Dose : initial dose 300 – 600 mg/day, maximum dose 2000 mg/day

 Metimazole ( 5 mg, 10 mg)

Dose : initial dose 20 -30 mg/day

 Thiamazole ( 5mg)
Mild cases : 2 x 10 mg/day
Severe cases : 2 x 20 mg/day (for 3-8 weeks)
Maintenance dose : 5 – 20 mg/day

 Carbimazole ( 5 mg)
Initial dose : 15 – 40 mg/day ( for 4-8 weeks)
Maintenance dose : 5 – 15 mg/day (12-18 months)

 Propanolol
Therapy with propranolol should be initiated at 10 to 20 mg every six hours. The dose. should
be increased progressively until symptoms are controlled. In most cases, a dosage of 80 to
320 mg per day is sufficient.
 PROGNOSIS

The prognosis for a patient with hyperthyroidism is good with

appropriate treatment. Even with aggressive treatment, some
manifestations of the disease may be irreversible, including ocular,
cardiac, and psychologic complications. Patients treated for
hyperthyroidism have an increased all-cause mortality risk, as well as
increased risk of mortality from thyroid, cardiovascular and
cerebrovascular diseases, and hip fractures. Morbidity can be
attributed to the same causes, and patients should be screened and
treated for osteoporosis and atherosclerotic risk factors. Patients who
have been treated previously for hyperthyroidism have an increased
incidence of obesity and insulin resistance.
STRUMA/GOITRE

Struma also called goiter is a

swelling of the neck by due to an
enlarged thyroid gland due to
abnormalities of the thyroid gland
can be malfunctioning or changes in
the composition and morphology of
the gland
 Difus
Toxic

Based on Nodule
clinical

Non toxic Difus

Goitre
Nodule

Euthyroid

Based on the
physiological
Hypothyroid

Hyperthyroid
 CLINICAL MANIFESTATION

Most patients with non-toxic goitre is not symptomatic or

asymptomatic, although patients often complain of the sensation
of pressure on the neck. Pressure sensation symptoms such as
dyspnoea and dysphagia may occur. Patients may also complain
of throat is inflammation. Dysphonia are rare, unless there is a
malignancy
 PATHOPHYSIOLOGY

Inhibit the formation of Inhibit formation of TSH by the

Iodine thyroid hormones by thyroid anterior pituitary
deficiency gland

TSH causes the thyroid cells secrete Pituitary secrete excessive levels of
thyroglobulin in high level (colloidal) into the TSH
follicles and glands grow increasingly growing
larger

The size of the follicles become larger and thyroid

gland weight may gain about 300-500 gram
 TREATMENTS

Operations / Surgery
Radioactive iodine
Thyroxine and Anti-thyroid drugs ( PTU,
methimazole)
 REFERENCES

• Sherwood, L. 2014. Fisiologi Manusia dari Sel ke Sistem. Edisi 2, Alih Bahasa: Brahm U.
Pendit. Jakarta, Penerbit Buku Kedokteran EGC. pp: 463-475.
• Buku Ajar Ilmu Penyakit Dalam Jilid III Ed VII. 2015; 1993-2008.
• http://www.endocrineweb.com/conditions/thyroid-nodules/thyroid-gland-controls-
bodys-metabolism-how-it-works-symptoms-hyperthyroid
• Fitzgerald PA. Endocrinology. In: Tierny LM, McPhee SJ, Papadakis MA, eds. Current
medical diagnosis and treatment. 44th ed. New York: McGraw-Hill, 2005:1102-10.
• American Academy of Clinical Endocrinologists. American Association of Clinical
Endocrinologists medical guidelines for clinical practice for the evaluation and
treatment of hyperthyroidism and hypothyroidism. Endocr Pract 2002;8:457-69
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consumption in patients with hyperthyroidism before and after treatment with beta-
blockade versus thyrostatic treatment: a prospective randomized study. Ann Surg
2001;233:60-4.
• Fontanilla JC, Schneider AB, Sarne DH. The use of oral radiographic contrast agents in
the management of hyperthyroidism. Thyroid 2001;11:561-7. 27. Nedrebo BG, Holm PA,
Uhlving S, Sorheim JI, Skeie S, Eide GE, et al. Predictors of outcome and comparison of
different drug regimens for the prevention of relapse in patients with Graves’ disease.
Eur J Endocrinol 2002;147:583-9. 28. Cooper DS. Antithyroid drugs. N Engl J Med
2005;352:905-17