TUTORIAL 1

PAGE 1
Mrs. Yodi, a 38-year-old woman come to the outpatient clinic at Tangerang hospital with chief complaint
of some heat intolerance, increased perspiration and a 6-kg weight loss over the last few months. She had
no history of drug or steroid ingestion, alcohol intake, or systemic illness. There was no history of fever,
chills, arthralgies, myalgies, neurological symptoms, polyuria or polydipsia, and no history of any recent
infection. She had worked as a consultant worker in Jakarta for ten years.

1. What are the patient’s problems?

a. Heat intolerance
b. Increased perspiration
c. Loss 6kg over the last few months

2. What are the possible causes and explanations of the problems?

a. Hyperthyroidism

3. What are the possible explanations for the possible etiology?

a.
PAGE 2
Physical examination revealed a cachectic woman with a blood pressure of 130/80 mmHg and a
temperature of 37,4 o C. On clinical findings of warm and moist extremities with fine hand tremors, and a
heart rate of 100 beats per minute. Eyes and vision were normal. Cardiac and respiratory examination
were normal. Her body habitus and hair distribution were normal for an adult female. Body weight was
42 kg. On direct questioning, she had experienced hand tremors, Increased sweating, occasional
palpitations and breathlessness on exertion for 3 to 4 months.

1. How do you explain each of the findings?

a. Hand tremors
b. Increased sweating
c. Occasional palpitations
d. Breathlessness on exertion

2. What are your next steps?

TUTORIAL 2
PAGE 1
Laboratory results returned:
The Electrolytes, glucose, creatinine, and liver enzymes were all normal. There was Thyroid parameters
showed

 TSH : < 0,06 mU/l ( Normal 0,30-4,20 mU/l )

 Free Thyroxin : 31 pmol/l ( Normal 13-23 pmol/l )
 Free Triodothyronine : 10,0 nmol/L ( Normal 10,0 nmol/L )

Anti-thyroperoxidase antibody measured by semi-quantitative method was positive 1/400 dilution.

Treatment was started on medication 3 times daily.

1. What are the clinical patterns confirm the laboratory findings of this case?
a. TSH turun, T4 naik
b. Anti TPO + -> Grave disease

2. How do these information help with the diagnosis?

3. What is your opinion about the treatment?
PAGE 2
Mrs. Yodi was not diligent and sometimes missed her medication and did not return for thyroid function
testing after 6 weeks of treatment.
Two days later she returned to the emergency department with diarrhea and vomiting and temperature of
37.7 o C. Body weight was only 38 kg ( Normal body weight was 48 kg ), pulse 90 and blood pressure:
140/75 mmHg.
The patient was capable of drinking, but had no appetite. She also had a mildly enlarged, diffuse, and
symmetric enlargement of her thyroid gland. She was admitted to hospital. The doctor planned to check
some laboratory examination.

1. What are Mrs.Yodi’s problem now?

2. What are the possible causes and explanations of these problems?
3. What further information do you want?
4. What are your next steps?
TUTORIAL 3
PAGE 1
Blood sample showed: Plasma glucose, electrolytes and liver enzymes were all normal. Thyroid function
tests revealed:

 TSH : < 0.003 mU/l,

 Free thyroxin : 79 pmol/l
 Total T3: 8.3 nmol ( Normal 1.3-2.5 nmol/l )
The patient had tremor and tachycardia of 120x/mnt.

1. What are the clinical patterns confirm the laboratory findings of this case?
a. Condition patient
 TSH < 0,06 mU/I -> Sekarang TSH < 0,003 mU/I jadi turun
 Free Thyroxin naik
 Total T3 naik ( gabungan dari free T3 dan Bound T3 ) bound T3 itu yang terikat
sama TBG dan TTG
 Tremor
 Tachycardia

b. Clinical patterns -> Thyroid storm

c. Test T4 dan T3 high, TSH low ( TSH turun bgt menandakan pituitary glandnya masih
normal krn menyeimbangkan dengan T3 dan T4 )
PAGE 2
The dose of Propylthiouracil was increased to 200 mg x 3 daily, and Propranolol 20 mg x 2 daily was
added to the treatment
Four days later the patient’s symptoms began to improve and she was discharged from the hospital.
1. What kinds of goiter management are now available?
a. Thyroidectomy
b. Radioactive iodine therapy
c. Monitor levothyroxine therapy -> Menjada kadar TSH tetap rendah sambil menunggu T3
dan T4 menurun
PAGE 3
She subsequently underwent treatment with I 131. Three months later she had gained 8 kg’s of weight, had
no nausea and a good appetite. She still experienced 3 episodes of loose stool every evening. Thyroid
function tests were normalized.
1. How should thyroid hormone be regulated?

2. What factors could gibe the influence to the thyroid level?

TRH, TSH iodine

3. What is the prognosis of this patients?

Dubia ad bonam

4. What if the hormone replancement after I131?

If there is subsequent hypothyroidism, levothyroxine 100 μg/day should be given. TSH levels
were monitored periodically to ensure a euthyroid state.