STEP 1 dan 2
Palpitation : jantung berdebar
Lump : tonjolan diarea leher
Step 3 :
1. Why the patient have trembling hands?
2. Why the patient complained of palpitations?
3. Why she is loss weight but appetite increased?
4. Why she cant stand for heat and easy to get sweat?
5. Why the frequency of bowel movement increased?
6. Why she difficult sleeping?
7. What is the diagnose and the DD of the scenario?
8. What are the differences of hyperthyroid and hypothyroid?
9. Why the blood pressure decreased?
10. Why did the patient feel itchy?
11. Explain the physiology of thyroid!
STEP 4
1. Why the patient have trembling hands?
Because the effect of nervous sinaps tonus sensitivity which containt of muscle
tonus so the trembling will be happened (10-50x/s)
Caused by increase activity of neuro sinapsys in the spinal cord
Tiroksin increased etiology of hypertyroidsm
Mechanism?
Graves : TSI wich attached on TSI reseptor, TSI is simillar with TSH
Terbentuk imunoglobulin.So tirodotironin increased
Adenoma pituitary : increase the secretion of TSH
2. Why the blood pressure decreased?
Usually, patient with hypertiroidsm the blood pressure will be increased about
10-15 mmhg
Respiration rate will be increased
Function of tiroksin : increased metabolism RR increased, blood pressure
increased
The cardiac output increased vasodilatation
Titik tangkap kerja tiroksin? Simpatis/ parasimpatis?
Mekanisme tekanan darah?
3. Why did the patient feel itchy?
4. Why the patient complained of palpitations?
Caused by increase of T3 & T4. It makes metabolism increased. Peredaran O2 di
tubuh meningkat shg kerja jantung meningkat.
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T3 is stimulated of transcription HcBeta. And blocked of myosin HcBeta. That
makes contraction of myocard muscle increased heart rate increased
(takikardi) (buku ATLS)
5. Why she is loss weight but appetite increased?
Hipertiroidisme metabolisme kh meningkat, glikolisis & glukoneogenesis
meningkat, BB turun
Hormon tiroid meningkat sekresi cairan di sal. Cerna meningkat lbh encer
motilitas makan meningkat (waktu yg diperlukan utk mencerna lbh singkat)
diare bb turun
Makanan blm bisa diserap lapar
6. Why she cant stand for heat and easy to get sweat?
Sifat hormon tiroid kalorigenik, suka dingin, tdk suka panas
Kalorigenik : meningkatkan jmlh kalori yg digunakan
Fungsi tiroksin : meningkatkan BMR
Hipertiroidisme RR meningkat, intake O2 meningkat, metabolisme
meningkat berkeringat
T3 & T4 meningkat produksi ATP butuh O2 sbg transport RR meningkat,
intake meningkat
Saat metabolisme berlebih tubuh lbh panas
Hipotalamus menerima rangsangan panas hipotalamus merangsang kel.
Keringat utk mengekskresikan keringat (homeostatis)
Termostat panas di hipotalamus. Hipotalamus terangsang shg suhu tubuh
meningkat
Banyak keringat :
ANATOMI:
Mirip kupu-kupu
Terdiri dari 2 lobus dekstra dan sinistra, dibatasi oleh ismus
Terletak didekat kartilago
Mekanisme :
Iodide trapping : mengambil iodida dlm pembuluh darah
Setiap 100.000 komponen garam terdapat 1 iodide
Tiroid menangkap iodida RER memproduksi prekusor tiroglobulin pindah ke
badan golgi untuk di modifikasi eksositosis
I- + tiroglobulin = iodination
T2 + T2 T4 (> T3)
T3 & T4 tdk larut dlm air shg butuh transport. Diikat oleh albumin / globulin. Setelah
sampai di sel target, T4 diubah jd T3 bereaksi.
hipertiroid hipotiroid
T3 & T4 naik T3 & T4 turun
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TSH turun TSH naik
Suka dingin Suka panas
Tinggi Pendek
Kurus gemuk
berkeringat
STEP 5
STEP 6 (belajar mandiri)
STEP 7
11. Why the patient have trembling hands?
trembling hands
Salah satu gejala yang paling khas dari hipertiroidisme adalah timbulnya tremor halus pada
otot. Tremor ini bukan merupakan tremor kasar seperti yang timbul pada penyakit
Parkinson atau pad awaktu menggigil, sebabk tremor ini timbul dengan frekuensi cepat
yakni 10-15 kali per detik. Tremor ini dianggap disebabkan oleh bertambahnya kepekaan
sinaps saraf di daerah medula yang mengatur tonus otot. Tremor ini merupakan cara yang
penring untuk memperkirakan tingkat pengaruh hormon tiroid pada sistem saraf pusat.
guyton
The pathophysiology of generalised pruritus in autoimmune thyroid disorders is still unclear. Neither
the levels of free T4 nor autoantibody correlate well with the presentation of pruritus. Therefore, it
is postulated that pruritus in autoimmune thyroid disorders is a manifestation of cell-mediated
immunity, which lowers the mast cell threshold for the release of histamine. However, this does not
adequately explain the non-response to antihistamines.
BB turun :
badan tetap kurus. Salah satu efek dari hormon tiroid adalah berpengaruh terhadap laju
metabolisme. Ini mengakibatkan peningkatan konsumsi bahan bakar daripada
penyimpanan bahan bakar. Terjadi penurunan simpanan lemak dan penciutan otot
akibat penguraian protein karena tubuh membakar bahan bakar dengan kecepatan
yang abnormal sehingga walaupun pasien banyak makan, tapi badan akan tetap kurus.
(Price, Sylvia A dan Wilson, Lorraine M. 2005.Patofisiologi-Konsep Klinis Proses-
Proses Penyakit Volume 2 Edisi 6. Jakarta : EGC.)
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Tiroid naik metabolisme kh naik glikolisis naik, glukogenesis naik, kecepatan absorbsi naik
16. Why she cant stand for heat and easy to get sweat?
Thyroid hormone increases the bodys overall basal metabolic rate (BMR). It is the most important
regulator of the bodys rate of O 2 consumption and energy expenditure under resting conditions.
Closely related to thyroid hormones overall metabolic effects is its calorigenic effect. Increased
metabolic activity reults in increased heat production.
In addition, in response to the heat load generated by the calorigenis effect of thyroid hormone,
peripheral vasodilatation occurs to carry the extra heat to the body surface for elimination to the
environment.
banyak berkeringat:
T3 dan T4 naik meningktakan glikolisis dihasilkan ATP dan panas berpengaruh pada
pusat hipotalamus pengatur suhu Karena efek dari panas yang dikeluarkan oleh tubuh
keringat keluar menstabilkan suhu
Buku ajar fisiologi guyton
Oleh karna efek yang melelahkan dari hormone tiroid pada otot dan system syaraf pusat
maka pasien hipertiroid sering kali merasa leleah terus menerus, tetapi karena efek
eksitasi dari hormone tiroid pada sinaps, timbul kesulitan tidur. Sebaliknya somnolen
yang berat merupak gejala khas hipotiroidisme, disertai dengan waktu tidur yang
berlangsung selama 12-14 jam/ hari.
SOURCE: IPD Jilid 3
ANATOMI:
ANATOMI:
Thyroid gland consist of 2 lobes an situed on the lateral side of trachea
level with the tracheal cartilage II-IV
the anterior part connected with ishmus
weighing 15-20 grams
Morfologi.
- Folikel adalah unti fungsional kelenjar tiroid. Setiap folikel ditutup sebuah
lapisan sel-sel folikular epitel tunggal yang membungkus suatu rongga
sentral. Epitel folikular beebentuk kolumnar jika distimulasi TSH dan
berbentuk kuboid jika kelenjar tidak aktif.
- Rongga folikel berisi koloid, yang tersusun terutama dari protein globular
tiroglobulin.
- Jika TSH mengikat reseptor sel folikel, maka akan mengakibatkan terjadinya
sintesis dan sekresi tiroglobulin, yang mengandung asam amino tirosin.
- Iodium yang tertelan bersama makanan dibawa aliran darah dalam bentuk
ino (Iodida) menuju kelenjar tiroid. Sel sel folikular memisahkan bentuk
iodide dari darah dan mengubahnya menjadi molekul iodium.
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Target cell :
Reseptor di dalam inti sel, di dkt retinoid reseptor. Meningkatkan transkripsi
Regulasi sekresi :
tsh terbanyak
hipertiroid hipotiroid
T3 & T4 naik Gejala Hipotiroid :
TSH turun Kelelahan, kelemahan
kulit kering
Suka dingin
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tanda :
Kulit kasar kering, ekstremitas
perifer keren
Wajah bengkak, tangan, dan kaki
(myxedema)
diffuse alopecia
bradikardia
edema perifer
Tertunda relaksasi refleks
tendon
Carpal tunnel syndrome
Efusi rongga serosa
The thyroid gland is controlled by thyroid-stimulating hormone (TSH; also known as thyrotropin), secreted from
the pituitary gland, which in turn is influenced by the thyrotropin-releasing hormone (TRH) from the
hypothalamus. TSH permits growth, cellular differentiation, and thyroid hormone production and secretion by
the thyroid gland. Thyrotropin acts on TSH receptors located on the thyroid gland. Serum thyroid hormones
levothyroxine and triiodothyronine feed back to the pituitary, regulating TSH production. Interference with this
TRH-TSH thyroid hormone axis causes changes in the function and structure of the thyroid gland. Stimulation
of the TSH receptors of the thyroid by TSH, TSH-receptor antibodies, or TSH receptor agonists, such as
chorionic gonadotropin, may result in a diffuse goiter. When a small group of thyroid cells, inflammatory cells,
or malignant cells metastatic to the thyroid is involved, a thyroid nodule may develop.
A deficiency in thyroid hormone synthesis or intake leads to increased TSH production. Increased TSH causes
increased cellularity and hyperplasia of the thyroid gland in an attempt to normalize thyroid hormone levels. If
this process is sustained, a goiter is established. Causes of thyroid hormone deficiency include inborn errors
of thyroid hormone synthesis, iodine deficiency,[1] and goitrogens.
A goiter may result from a number of TSH receptor agonists. TSH receptor stimulators include TSH receptor
antibodies, pituitary resistance to thyroid hormone, adenomas of the hypothalamus or pituitary gland, and
tumors producing human chorionic gonadotropin.
http://emedicine.medscape.com/article/120034-overview#a0104
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Goiter, on Medscape
Trapping I
Tiroglobulin
hipertiroid