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MODULE FOR STUDENTS Thyroid Disease

Modul 10 & 11 Modul 12 Modul 13 Modul 14 Modul 15 Anatomy and physiology Thyroid hormone formation (synthesis, metabolism, and a tion! "#aluation of patients $ith thyroid disease (physi al e%amination, ordering and interpretating of thyroid fun tion test, imaging of thyroid gland, &'A(! )yperthyroid and hypothyroid (diagnosis, treatment, and e#aluation! "mergen y in thyroid disease *odine defi ien y

FACULTY OF MEDICINE BRAWIJAYA UNIVERSITY MALANG 2012

MODUL

10 & 11

THYROID DISEASE ANATOMY AND PHYSIOLOGY THYROID HORMONE FORMATION

Overv e!

The thyroid gland is the body's largest single organ specialized for endocrine hormone production. Its function is to secrete an appropriate amount of the thyroid hormones, primarily 3,5,3',5'-l-tetraiodothyronine (thyroxine, T !, and a lesser "uantity of 3,5,3'-l-triiodothyronine (T3!, #hich arises mainly from the subse"uent extrathyroidal deiodination of T . In target tissues, T3 interacts #ith nuclear T3 receptors that are, in turn, bound to special nucleotide se"uences in the promoter regions of genes that are positi$ely or negati$ely regulated by thyroid hormone. %mong their life-sustaining actions, the thyroid hormones promote normal fetal and childhood gro#th and de$elopment& regulate heart rate and myocardial contractility& affect gastrointestinal motility and renal #ater clearance& and modulate the body's energy expenditure, heat generation, and #eight. To understand the structure and synthesis of thyroid hormone, and hypothalamus-pituitary-thyroid axis. 'xplain the physiological effects of thyroid hormone on organ systems. %fter completion of this module, you should be able to ( ). *nderstand structure and synthesis of thyroid hormone. +. 'xplain about hypothalamus-pituitary-thyroid axis. 3. 'xplain the physiological effects of thyroid hormone.

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%cti$e learning #ith module tas,, group discussion, and expert lecture. -ecture ( ) hours 'xamination or assignment

) . The Thyroid .land. In ( .reenspan/s 0asic 1 2linical 'ndocrinology, 3th 'd. 4igital 'dition (+556!& 2hapter 3. +. 4isorders of The Thyroid .land. In ( 7arrison/s 8rinciples of Internal 9edicine, )6th 'd. 4igital 'dition (+553!& 2hapter 335.

A'( v (1 121 *nderstanding the mechanism of thyroid hormone synthesis and physiological effect of thyroid hormone in the organ system. %im ( This acti$ity #ill help you to define the mechanism of thyroid hormone synthesis and physiological effect of thyroid hormone in the organ system.

). %ccording to the picture, explain about thyroid biosynthesis .

+. :hat is the main function of hypothalamus, pituitary, thyroid gland, thyroxine (T !, and triiodothyronine (T3! in the regulation of thyroid hormone synthesis ; 'xplain your ans#er.

3. 2haracteristic of 2irculating T and T3.

. :hat is the physiological effect of thyroid hormone on ( a. <etal de$elopment b. =xygen consumption, heat production, and free radical formation c. 2ardio$ascular system d. >ympathetic ner$ous system e. 8ulmonary system f. 7ematopoetic system

g. .astrointestinal syste h. >,eletal system i. @. ?euromuscular system -ipid and carbohydrate metabolism

MODUL

12

THYROID DISEASE EVALUATION OF PATIENT WITH THYROID DISEASE

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Thyroid disorder is a general term representing se$eral different diseases in$ol$ing thyroid hormones and the thyroid gland. Thyroid disorders are commonly separated into t#o ma@or categories, hyperthyroidism and hypothyroidism, depending on #hether serum thyroid hormone le$els (T and T3! are increased or decreased, respecti$ely. The diagnosis of thyroid disease can be particularly challenging. The issue of routine screening is contro$ersial because cost-effecti$eness has not been clearly pro$en. %lthough it may not be economically feasible or necessary to test all patients for thyroid dysfunction, there are instances #hen thyroid screening is appropriate. To pro$ide the opportunity of memorizing the different cutoff $alues of thyroid function test for diagnosis of thyroid disease. It #ill also familiarize you #ith clinical differentiation of thyroid disease (hyperAhypothyroid!. %fter completion of this module, you should be able to ( ). *nderstanding typical presentation (hyperAhypothyroid! in a case. of thyroid disease

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+. *nderstanding the use of different diagnostic tools for thyroid disease. 3. *nderstanding thyroid disease (hyperAhypothyroid! and cut off $alues of thyroid function test for diagnosis of hyperAhypothyroid. Te#'* +, )(r#(e, e) S-,,e)(e. ( /e Ev#$-#( "+ "0 $e#r+ +, Re0ere+'e) %cti$e learning #ith module tas,, group discussion, and expert lecture. -ecture( ) hours 'xamination or assignment

) . The Thyroid .land. In ( .reenspan/s 0asic 1 2linical 'ndocrinology, 3th 'd. 4igital 'dition (+556!& 2hapter 3. +. 4isorders of The Thyroid .land. In ( 7arrison/s 8rinciples of Internal 9edicine, )6th 'd. 4igital 'dition (+553!& 2hapter 335.

A'( v (1 221 *nderstanding the typical presentation of patient #ith hyperAhypothyroid disease. %im ( This acti$ity #ill help you to understand the typical presentation of patient #ith hyperAhypothyroid disease by a case study. ). 7o# do you examine the thyroid gland ; +. :hat do you ,no# about ?e# 2astle/s Index ; 3. 2ase % ( % +) yo #hite female has a-3 month history of #eight loss ()5 ,g!, increased ner$ousness, ta$hycardia, and heat intolerance. >he has noticed that her eyes are bigger and are occasionally dry. 7er family has noticed that she is more irritable than usual, and the "uality of her school#or, has declined significantly. 8hysical examination demonstates ob$ious exopthalmus, #ith no extraocular impairment. 7er thyroid gland is approximately three time normal size, #ith a soft bruit auscultated o$er the gland. :rite do#n presenting features of hyperthyroid of the patient (based on anamnesis and physical examination!. BBBBBBBBBBBBBBBBBBBBBB BBBBBBBBBBBBBBBBBBBBBB BBBBBBBBBBBBBBBBBBBBBB BBBBBBBBBBBBBBBBBBBBBB . 2ase 0 ( % +3 yo #hite female has a +- year history of galactorrhea, cold intolerance, fati"ue, and amenorrhea. >he has gained o$er +55 pounds in the last 3 years. 7er family has noticed that her speech is extremely slo# and coarse. The family history is remar,able for obesity. 8hysical examination demonstrates a morbidly obese female, blood pressure )+5A65 mm7g, pulse 55. >he has puffy facies and pedal edema. >,in and hair $ery coarse& there are no striae. >he spea,s in a deep, coarse, Cgra$ellyD $oice #ith extremely slo# phonation. BBBBBBBBBBBBBBBBBBBBBBBB BBBBBBBBBBBBBBBBBBBBBBBB BBBBBBBBBBBBBBBBBBBBBBBB BBBBBBBBBBBBBBBBBBBBBBBB

:rite do#n presenting features of hypothyroid of the patient (based on anamnesis and physical examination!. BBBBBBBBBBBBBBBBBBBBBB BBBBBBBBBBBBBBBBBBBBBB BBBBBBBBBBBBBBBBBBBBBB BBBBBBBBBBBBBBBBBBBBBB A'( v (1 222 4iagnostic tools used for thyroid disease. %im ( This acti$ity #ill ma,e you understand #hich of the diagnostic tests are to be used for determining thyroid disease in a person. In the left hand column, there is a statement regarding a particular tool& in the right hand column, #rite do#n the appropriate figure(s! if you agree #ith the statement. 4etermining a T>7 le$el alone is often a 4o you agree #ith the statement ; sufficient indication of thyroid function. If Eyes/ #rite do#n the $alue abo$e #hich a person is hyperthyroid. 9any years ago, physicians did not realize that acti$e form, and so they made errors in diagnosing hyperand hypo-thyroid states 4o you agree #ith the statement ; based on total thyroid hormone le$els in serum. <or the patient #ho presents #ith a thyroid measurement of the serum thyrotropin le$el and a fine-needle aspiration, preferably guided by ultrasonography. A'( v (1 223 *nderstanding cutoff $alues for hyperAhypothyroid disease. %im ( This acti$ity #ill help you practice understanding ho# laboratory $alues of thyroid function test are interpreted to label a person as a normalAhyperAhypothyroid patient. TSH Ser-/ T4 Free T4 Ser-/ T3 I+(er5re(#( "+ BBBBBBBBBBBBBBBBBB mI*Am4o you agree #ith the statement ; BBBBBBB to BBBBBBBB FgAdBBBBBBBBBBBBBBBBBBBBBBBB BBBBBBBBBBBBBBBBBBBBBBBB BBBBBBBBBBBBBBBBBBBBBBBB BBBBBBBBBBBBBBBBBBBBBBBB

it's only the free thyroid hormone that is the If Eyes/ #rite do#n the range of freeT .

nodule, the initial e$aluation should include 'xplain your ans#er.

6/IU7/L8 5.5 5.5) G.5

69,7.L8 6.5 ++.5 +.5

69,7.L8 ).+ .3 5.+

69,7.L8 )+5 +55 65 >ubclinical hyperthyroid >ubclinical hypothyroid

MODUL

13

THYROID DISEASE HYPERTHYROID AND HYPOTHYROID

Overv e!

Thyroid disorder is a general term representing se$eral different diseases in$ol$ing thyroid hormones and the thyroid gland. Thyroid disorders are commonly separated into t#o ma@or categories, hyperthyroidism and hypothyroidism, depending on #hether serum thyroid hormone le$els (T and T3! are increased or decreased, respecti$ely. The diagnosis of thyroid disease can be particularly challenging. The issue of routine screening is contro$ersial because cost-effecti$eness has not been clearly pro$en. %lthough it may not be economically feasible or necessary to test all patients for thyroid dysfunction, there are instances #hen thyroid screening is appropriate. To identify the etiologies of hyperAhypothyroid and understand the principles management of thyroid disease . %fter completion of this module, you should be able to ( ). 4efine the etiologies of hyperAhypothyroid +. *nderstand the principles (hyperAhypothyroid!. management of thyroid disease

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%cti$e learning #ith module tas,, group discussion, and expert lecture. ). +. 3. The Thyroid .land. In ( .reenspan/s 0asic 1 2linical 'ndocrinology, 3th 'd. 4igital 'dition (+556!& 2hapter 3. 4isorders of The Thyroid .land. In ( 7arrison/s 8rinciples of Internal 9edicine, )6th 'd. 4igital 'dition (+553!& 2hapter 335. Thyroid and %ntithyroid 4rugs. In .oodman 1 .ilman/s The 8harmacological 0asis of Therapeutics. 4igital 'dition (+553!& >ection HII

A'( v (1 321 *nderstanding the etiologies of patient #ith hyperAhypothyroid disease. A / ( This acti$ity #ill help you to understand the etiologies of patient #ith hyperAhypothyroid disease by a case study. CASE 1 % +6 yo male has a history of #ea,ness and ner$ousness for approximately 3 months. 4espite increasing her caloric inta,e, her #eight has gone about )5 ,g. 7e complains of

excessi$e s#eating and a bad disposition. 7is #or, is of lesser "uality than usual and sho#s extreme disorganization. 7er primary physician noted a large right sided nodule, #hich by history has been present for approximately I months. It has gro#n in size. >erum T>7 is undectable (J5.53 mI*Am-!& fT is I.5 FgAd-. 8hysical examination demonstrates a thin, hyper,inetic males, height )I5 cm, #eight 53 ,g, blood pressure )++AI5, pulse )+5. % fine resting tremor of hand and bilateral exopthalmus are noted. The remainder examination is normal. ). 4oes this man ha$e hyperthyroidism or hypothyroidism;

+. :hat are the causes of hyperAhypothyroidism in this patient ;

A'( v (1 322 : M#+#,e/e+( "0 (*1r" . . )e#)e A / : To understand the principle management of thyroid disease CASE 1 % +6 yo male has a history of #ea,ness and ner$ousness for approximately 3 months. 4espite increasing her caloric inta,e, her #eight has gone about )5 ,g. 7e complains of excessi$e s#eating and a bad disposition. 7is #or, is of lesser "uality than usual and sho#s extreme disorganization. 7er primary physician noted a large right sided nodule, #hich by history has been present for approximately I months. It has gro#n in size. >erum T>7 is undectable (J5.53 mI*Am-!& fT is I.5 FgAd-. 8hysical examination demonstrates a thin, hyper,inetic males, height )I5 cm, #eight 53 ,g, blood pressure )++AI5, pulse )+5. % fine resting tremor of hand and bilateral exopthalmus are noted. The remainder examination is normal.

:hat are the accepted treatments for this disorder ; :hat are the ad$antages and disad$antages of each ;

T*e . 00ere+( #( "+ %e(!ee+ 5r"51$(* "-r#' $ #+. /e(* /#:"$e Pr"51$(* "-r#' $ 8lasma protein binding 8lasma t)A+ Kolume of distribution 2oncentrated in thyroid 9etabolism of drug during illness >e$ere li$er disease >e$ere ,idney disease 4osing fre"uency Transplacental passage -e$els in breast mil, CASE 2 % +3 yo #hite female has a +- year history of galactorrhea, cold intolerance, fati"ue, and amenorrhea. >he has gained o$er +55 pounds in the last 3 years. 7er family has noticed that her speech is extremely slo# and coarse. The family history is remar,able for obesity. Me(* /#:"$e

8hysical examination demonstrates a morbidly obese female, blood pressure )+5A65 mm7g, pulse 55. >he has puffy facies and pedal edema. >,in and hair $ery coarse& there are no striae. >he spea,s in a deep, coarse, Cgra$ellyD $oice #ith extremely slo# phonation. ). :hat laboratory studies should be ordered ;

+. 7o# #ould you manage this patient ;

MODUL

14

THYROID DISEASE EMERGENCY IN THYROID DISEASE

Overv e!

Thyroid crisis is an acute, life threatening, hypermetabolic state induced by excessi$e release of thyroid hormone in indi$iduals of thyrotoxicosis. 4iagnosis is primarily clinical, and no specific laboratory test are a$ailable. >e$eral facrors may precipitate the progression of thyrotoxicosis to thyroid crisis. 0ecause thyroid storm is almost in$ariably fatal if left untreated, rapid diagnosis and aggressi$e treatment are critical. To define the precipitating factors do thyroid crisis, ma,e the diagnosis of thyroid crisis and ho# to pre$ent it. %fter completion of this module, you should be able to ( ). 4efine the precipitating factors of thyroid crisis +. 4iagnose case of thyroid crisis and teach the patient ho# to pre$ent it.

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%cti$e learning #ith module tas,, group discussion, and expert lecture. ). +. 3. The Thyroid .land. In ( .reenspan/s 0asic 1 2linical 'ndocrinology, 3th 'd. 4igital 'dition (+556!& 2hapter 3. 4isorders of The Thyroid .land. In ( 7arrison/s 8rinciples of Internal 9edicine, )6th 'd. 4igital 'dition (+553!& 2hapter 335. Thyroid and %ntithyroid 4rugs. In .oodman 1 .ilman/s The 8harmacological 0asis of Therapeutics. 4igital 'dition (+553!& >ection HII

A'( v (1 421 A / ( This acti$ity #ill help you to diagnose patient #ith thyroid crisis and define the precipitating factors of thyroid crisis by a case study. CASE 1 % +6 yo #hite male #as in good health until I months ago, #hen he began noticing increased ner$ousness, irritability, appetite, and heat intolerance. 7e has lost )5 ,g during that periode, and his symptoms ha$e #orsened. 7e has been able to #or,, but lesser "uality than usual. 7e sleeps only + hours at night& he #ould li,e to sleep more because he is fati"ued but Ccan/t because I/m too ner$ous.D 4espite eating constantly, he has lost

#eight. 7er family finally brought him to the emergency room because he has gotten much #orse. 8hysical examination re$eals thin male, height )I5 cm, #eight 55 ,g, 08 ) +AG5, pulse )II, temperature 3G.5L2. 7e is extremely hyper,inetic and agitated. 7e is ob$iously disoriented and is unable to carry on a coherent con$ersation. 7e has moderate exopthalmus bilaterally. The thyroid gland is only minimally enlarged, #ithout bruit. 7e has a resting tremor of the hands. ;-e)( "+) ). :hat disorder does this man most li,ely ha$e ; 'xplain your ans#er

+. :hat do you ,no# about 0urch 1 :artofs,y Index ; 7o# is the scoring index of this patient;

3. :hat is the precipitating factors of thyroid crisis ;

CASE 2 % +6-year-old #oman #as referred for e$aluation of thyroid disease. >he had a 3-month history of intermittent heat intolerance, s#eats, tremor, tachycardia, and muscle #ea,ness. >he had lost #eight in spite of a mar,ed increase in appetite. >he denied ta,ing any medications before seeing her family physician. >he had been ta,ing iodide drops since

seeing her doctor and initially noted a decrease in symptoms. <or the past month, ho#e$er, they had #orsened. 8hysical examination re$ealed blood pressure )35AG5 mm 7g, heart rate ))5Amin, minimal proptosis, and an enlarged thyroid gland. -aboratory tests sho#ed ele$ated thyroxine, resin T3 upta,e, radioacti$e iodine upta,e, and antimicrosomal antibodies. % diagnosis of hyperimmune hyperthyroidism (.ra$es' disease! #as made. ;-e)( "+): a. :hat therapeutic measures should be considered in this case; :hy did the iodide drops the patient #as ta,ing reduce symptoms at first and then lose their effecti$eness;

b. :hat are the benefits and hazards of pharmacologic therapy in hyperthyroidism;

c. :hat therapy should be considered if thyrotoxic crisis (thyroid storm! occurs;

MODUL

1<

: THYROID DISEASE IODINE DEFICIENCY DISORDERS 6IDD8

Overv e!

Iodine is a chemical element. It is found in trace amounts in the human body, in #hich its only ,no#n function is in the synthesis of thyroid hormones. >e$ere iodine deficiency results in impaired thyroid hormone synthesis andAor thyroid enlargement (goiter!. 8opulation effects of se$ere iodine deficiency, termed iodine deficiency disorders (I44s!, include endemic goiter, hypothyroidism, cretinism, decreased fertility rate, increased infant mortality, and mental retardation. To ,no# the pre$alence of I44 in the #orld#ide and define the iodine metabolism, also the characteristic and conse"uences of I44 in human life.. %fter completion of this module, you should be able to ( ). Mno# the pre$alence of I44 in the #orld#ide especially in Indonesia +. 4efine the iodine metabolism. 3. 4efine the characteristic of iodine deficiency and the conse"uences of I44 in human life.

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%cti$e learning #ith module tas,, group discussion, and expert lecture. ). The Thyroid .land. In ( .reenspan/s 0asic 1 2linical 'ndocrinology, 3th 'd. 4igital 'dition (+556!& 2hapter 3. +. 4isorders of The Thyroid .land. In ( 7arrison/s 8rinciples of Internal 9edicine, )6th 'd. 4igital 'dition (+553!& 2hapter 335.

A'( v (1 <21 %im ( To ,no# the pre$alence of I44 in the #orld#ide especially in Indonesia. I44 has been ,no#n in Indonesia for many years. 8re$alence of I44 in a #orld#ide #asBBBBBBBBBBN. 8re$alence of goiter in Indonesia #asBBBBBBBBBBN. A'( v (1 <22 A / ( To define the iodine metabolism and the pathophysiology of I44 #ith all the conse"uences. Could you explain about the iodine metabolism and pathophysiology of hypothyroid due to IDD with all the consequences.

A'( v (1 <23 A / ( To define the characteristic of iodine deficiency and to understand the conse"uences of I44 in human life.
I". +e De0 ' e+'1 9edian urine iodine, mcgA.oiter pre$alence N"+e O)55 J5N M $. M".er#(e Severe

?eonatal thyroid stimulating hormone (T>7!, O5 I*Am- #hole blood 2retinism

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