Scenario 4-a:

Scenario 4-a:

Melati, 28 years old, visited to a doctor with chief complain of mentally sluggish (slowed thinking). She also felt fatigue and intolerance to cold. She had irregularity menstrual periods and constipation.On physical examination: the skin is cold, dry and rough. The heart sounds are quiet and the pulse rate is 50x/min. There is an enlargement of thyroid gland. The result of the laboratory: TSH increased, FT4 was lowQuestion:

1. What is the most likely diagnosis?2. How is pathophysiology of this disease?3. What is the best therapy?

4. What is the next step in care of this patient?

NAMA :

NIM : SCORE :

Minimum requirementPointScores

ATTITUDES:5

1. Greeting

2. Introducing

3. Purpose

4. Acknowledgement/excusing1

1

2

1

TERMS CLARIFICATION:3

1. Enlargement in her neck area.

2. mentally sluggish, etc

3. TSH increased, FT4 was low

1

1

1

PROBLEM IDENTIFICATION:12

1. Melati with enlargement in her neck area 2. She also Fatigue , Feeling cold, Dry skin and hair, Heavy menstrual periods, Constipation, Slowed thinking

3. The result of the laboratory: TSH increased, FT4 was low

444

PROBLEM ANALYSIS:10

1. What is the association between enlargement of thyroid gland and all the symptom and signs2. What is the cause enlargement of thyroid gland 3. Whats the function of thyroid gland

4. How is about the pathophysiology of this disease

5. How to make the diagnosis

6. How to manage

7. What are the prognosis and complication1112221

HYPOTHESIS :10

Melati suffered from primary hypothyroidism

SYNTHESIS:55

1. Fatigue or lack of energy, feeling cold, dry skin , heavy menstrual periods, constipation, and slowed thinking are the signs and symptoms of hypothyroid 2. Function of thyroid gland : influence of growth, metabolism and development

3. Abnormalities of thyroid function ( hypothyroid :

In adults ( myxedema

In infants ( cretinism and mental retardation4. Pathogenesis :

Inadequate thyroid hormone ( TSH hyper secretion ( goiter; if compensatory physiological response is insufficient ( goitrous hypothyroidism Cause : most common Hashimotos disease5. DD: simple goiter

6. Diagnosis : Anamnesis : fatigue or lack of energy, cold intolerance, dry skin and hair, irregularity menstrual periods, constipation, slowed thinking physical examinations: bradycardia, hypotension, hypothermia, goiter, hypotonia, delayed relaxation of reflexes, myxedemia, a hoarse voice laboratory test: TSH, FT4 or T4 7. Treatment :

HRT : L-Thyroxin per-oral

8. Prognosis :

Without complication and with adequate therapy prognosis good Complication of excessive administration thyroid hormone replacement therapy

Complication of hypothyroidism : myxedemia, hypercholesteromia, arteriosclerosis

555

205555

PERFORMANCE :5

1. Systematic/logical

2. Dressing

3. Presentation skill2

1

2

TOTAL100

Palembang, januari 2008

Penguji 1 ( )

Penguji 2 ( )

Scenario 4-b:

Parents bring their 6-month-old baby (Dinda) to your clinic because she has constipation and delayed motor development. The baby can not roll her body. The history: their baby was born full term and large in size (> 4 kg) and has experienced prolonged physiologic jaundice.

Physical examination: there are dull facies, an umbilical hernia, mottle (cutis mammorata), macroglossi and dry skin, slow in linier growth with no weight loss

The result of the laboratory: TSH increased, FT4 was low Question:

1. What is the most likely diagnosis?2. How is the pathophysiology of this disease?3. What is the best therapy?

4. What is the next step in care of this patient?

NAMA :

NIM : SCORE :

Minimum requirementPointScores

ATTITUDES:5

1. Greeting

2. Introducing

3. Purpose

4. Acknowledgement/excusing1

1

2

1

TERMS CLARIFICATION:3

1. prolonged physiologic jaundice

2. motoric and developmental delayed 3. macroglossi, mottle4. TSH increased, FT4 was low

1

1

1

1

PROBLEM IDENTIFICATION:12

1. motoric and developmental delayed

2. full term and large in size (> 4 kg) and prolonged physiologic jaundice. dull facies, an umbilical hernia, mottling, macrogloss and dry skin, slow in linier growth with no weight loss

3. The result of the laboratory: TSH increased, FT4 low4

4

4

PROBLEM ANALYSIS:10

1. What is the relationship between the sign and symptom and motoric-development delay

2. What is the relationship between motoric-development delay and this disease

3. Whats the function of thyroid gland

4. How is about the pathophysiology of this disease

5. How to make the diagnosis

6. How to manage 7. What are the prognosis and complication1

12

21

1

2

HYPOTHESIS :10

Dinda suffered primary congenital hypothyroid

SYNTHESIS:55

1. full term and large in size (> 4 kg) and prolonged physiologic jaundice. dull facies, an umbilical hernia, mottling, a large tongue and dry skin, slowing in linier growth with no weight loss are the signs and symptoms of hypothyroid congenital2. Function of thyroid gland : influence of growth, metabolism and development (CNS and body)3. Abnormalities of thyroid function ( hypothyroid :

a. In adults ( myxedema

b. In infants ( cretinism and mental retardation4. Pathogenesis :

Dysgenesis thyroid gland (Inadequate thyroid hormone ( TSH hypersecretion

The most cause of hypothyroid congenital dysgenesis thyroid gland ( agenesis/hypoplasia)5. Diagnosis : Anamnesis: full term and large in size (> 4 kg) and prolonged physiologic jaundice. dull facies, an umbilical hernia, mottling, a large tongue and dry skin, slowing in linier growth with no weight loss, developmental delay, motoric delay physical examinations : hypothermia, bradycardia, hypotonia, motoric and developmental delay, delayed relaxation of reflexes, myxedemia, a hoarse voice laboratory test :TSH, FT4 or T4 Bone age: retarded/ delay6. Treatment :

a. HRT : Thyroxin per-oral ( long life )7. Prognosis :

a. Without complication and with adequate therapy prognosis good for the motoric delayedb. Permanent mental retardation ( because of late treatment - after 3 weeks old )

5

5

5

20105

5

PERFORMANCE :5

4. Systematic/logical

5. Dressing

6. Presentation skill2

1

2

TOTAL100

Palembang, januari 2008

Penguji 1 ( )

Penguji 2 ( )

Scenario 4-c:

Mrs. Elok, a 42-year-old woman was admitted to hospital complaining of abdominal pain. She stated that she had felt poorly for the past year, having been bothered by constipation, loss of appetite, lethargy and intolerance of cold. Her blood pressure was 100/70 mmHg, pulse was 66 beats/min; body temperature was 36, 8 C.

The result of the laboratory: TSH increased, FT4 was low

Question:What is the most likely diagnosis?

What is laboratory test should be ordered?

What is the treatment for Mrs. Elok?

Minimum RequirementPointsScore

ATTITUDE5

1. Greeting

2. Introducing

3. Purpose

4. Acknowledgement/excuse1

1

2

1

Terms Clarification3

1.Constipation,loss of appetite, lethargy

2.Intolerance to cold

3.Blood pressure 100/60 mmHg, pulse 66 x/ minute1

1

1

Problem Identification12

1. Mrs. Elok, 42 years, complaining abdominal pain

2. Felt poorly for the past year, constipation, loss of appetite, lethargy, intolerance to cold, bradycardia (pulse 66x/min), temperature 36,8 C

3. TSH increased, FT4 was low

444

Problem Analysis10

1. Why did she complain of abdominal pain? What is the cause?

2. What is the common cause of her symptoms for the past year?

3. What is/are other symptoms, signs, and laboratory test to determine the disease?

4. How is the pathophysiology?

5. What is the DD?

6. What is the diagnosis?

7. What is the treatment?

8. What is the complication?

9. What is the prognosis?1

21

1

1

1

1

1

1

1

Hypothesis10

Mrs.Elok, 42 years old, suffered abdominal pain or chronic constipation due to primary hypothyroidism

Synthesis55

1. Thyroid hormone decreased ( GI tract motility decreased ( constipation ( accumulation of feces in colon ( abdominal pain

2. The action/effect of thyroid hormone on : CNS ( lethargy, loss of appetite, BMR ( intolerance to cold, Cardiovascular system ( hypotension, bradycardia

3. Clinical approach :

a. Anamnesis : - daily diet, -drug consumption, - toilet habit, fatigue or lack of energy, cold intolerance, dry skin and hair, irregularity menstrual periods, constipation, slowed thinkingb. Physical examination:-abdomen area: mass? tenderness, peristaltic sound, rectal examination, enlargement of thyroid gland, bradycardia, hypotension, hypothermia, hypotonia, delayed relaxation of reflexes, myxedemia, a hoarse voicec. Laboratory : TSH, FT4 or T44. DD : simple goiter5. Diagnosis : primary hypothyroidism6. Treatment :

evacuate impacted fecal mass

HRT :L- Thyroxin

7. Prognosis : usually good Complication : megacolon

hyperlipidemia/ hypercholesteromia arteriosclerosis

myxedema excessive administration thyroid hormone replacement therapy

7

151355

5

5

Performance5

1. Systematic/ logical

2. Dressing

3. Presentation skills2

1

2

TOTAL100

Palembang, januari 2008

Penguji 1 ( )

Penguji 2 ( )