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 low
Question:
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 requirement
ATTITUDES:
1. Greeting
2. Introducing
3. Purpose
4. Acknowledgement/excusing
TERMS CLARIFICATION:
1. Enlargement in her neck area.
2. mentally sluggish, etc
3. TSH increased, FT4 was low

Point
5
1
1
2
1
3
1
1
1

PROBLEM IDENTIFICATION:
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

12
4
4

PROBLEM ANALYSIS:
1. What is the association between enlargement of thyroid
gland and all the symptom and signs
2. What is the cause enlargement of thyroid gland
3. Whats the function of thyroid gland
4. How is about the pathophysiology of this disease

10
1

1
1
2

Scores

5. How to make the diagnosis

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

2
2
1

HYPOTHESIS :
Melati suffered from primary hypothyroidism
SYNTHESIS:
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 retardation
4. Pathogenesis :
Inadequate thyroid hormone TSH hyper secretion
goiter; if compensatory physiological response is
insufficient goitrous hypothyroidism
Cause : most common Hashimotos disease
5. 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

10

PERFORMANCE :
1. Systematic/logical
2. Dressing

5
2
1

55
5
5
5
20

5
5
5
5

3. Presentation skill

2
100

TOTAL
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 requirement

ATTITUDES:
1. Greeting
2. Introducing
3. Purpose
4. Acknowledgement/excusing
TERMS CLARIFICATION:
1. prolonged physiologic jaundice
2. motoric and developmental delayed
3. macroglossi, mottle
4. TSH increased, FT4 was low

PROBLEM IDENTIFICATION:

Point
5
1
1
2
1
3
1
1
1
1

12

Scores

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
low
PROBLEM ANALYSIS:
1. What is the relationship between the sign and
symptom and motoric-development delay
2. What is the relationship between motoricdevelopment 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 complication

HYPOTHESIS :
Dinda suffered primary congenital hypothyroid
SYNTHESIS:
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 congenital
2. 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 retardation
4. 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,

4
4
4

10
1
1
2
2
1
1
2

10
55
5

5
5
20

10

bradycardia, hypotonia, motoric and

developmental delay, delayed relaxation of
reflexes, myxedemia, a hoarse voice
laboratory test :TSH, FT4 or T4
Bone age: retarded/ delay
6. Treatment :
a. HRT : Thyroxin per-oral ( long life )
7. Prognosis :
a. Without complication and with adequate therapy
prognosis good for the motoric delayed
b. Permanent mental retardation ( because of late
treatment - after 3 weeks old )
PERFORMANCE :
4. Systematic/logical
5. Dressing
6. Presentation skill
TOTAL

5
5

5
2
1
2
100

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 Requirement
ATTITUDE
1. Greeting
2. Introducing
3. Purpose
4. Acknowledgement/excuse

Points
5
1
1
2
1

Score

Terms Clarification
1.Constipation,loss of appetite, lethargy
2.Intolerance to cold
3.Blood pressure 100/60 mmHg, pulse 66 x/ minute
Problem Identification
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

3
1
1
1
12
4

Problem Analysis
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?
Hypothesis
Mrs.Elok, 42 years old, suffered abdominal pain or chronic
constipation due to primary hypothyroidism
Synthesis
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 thinking
b. 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 voice
c. Laboratory : TSH, FT4 or T4
4. DD : simple goiter
5. Diagnosis : primary hypothyroidism

10
1
2
1
1
1
1
1
1
1
1
10

4
4

55
7
15
13

5
5

6. Treatment :
evacuate impacted fecal mass
HRT :L- Thyroxin
7. Prognosis : usually good
o Complication :
megacolon
hyperlipidemia/ hypercholesteromia
arteriosclerosis
myxedema
excessive administration thyroid hormone
replacement therapy
Performance
1. Systematic/ logical
2. Dressing
3. Presentation skills

5
5

5
2
1
2

TOTAL

100
Palembang, januari 2008

Penguji 1

Penguji 2