Mr.

HT, a 59 year old farmer, comes to Mohammad Hoesin Hospital because of shortness of breath
since 8 hours ago. In the last 4 weeks he became easily tired in daily activites. He also complains about
having night cough, nausea.

Post medical history : untreated long standing hypertension, heavy smoker.

Family history : no history of premature coronary disease.

Physical exam :

General Consideration:

Conscious, compos mentis, Orthopneu, BP 140/90, PR 109 x/min, regular, RR 32x/min, height 160 cm,
body weight 59kg.

Specific Consideration

JVP (5+2) cmH20, HR 109x/min, regular, murmur (-), S3 gallop (+), basal rales (+), wheezing (-), liver :
palpable 2cm below the costal arch, ankle edema (+)

Laboratory results :

Hemoglobin : 10,7 g/dl, WBC : 6800/mm3, Platelet : 190.000/mm3

Total cholesterol 209 mg/dl, LDL 135 mg/dl, HDL 29 mg/dl, Triglyceride 130 mg/dl, fasting blood glucose
98 mg/dl, Ureum 40 mg/dl, Creatinine 1,0 mg/dl. Sodium 135 mmol/L, Potassium 4,2 mmol/L

Urinalysis : normal findings.

Additional examinations :

ECG: Sinus rhythm, LAD, HR 120x/min, slow progression of R wave, LV strain (+)

Chest X-Ray : CTR 65% boot-shaped cardiac, Karley’s B line (+), signs of cephalization (+)

II. Klarifikasi Istilah :

1. Shortness of breath : Pernapasan yang sukar atau sesak (Dorland)

2. Night cough : manifestasi proses redistribusi cairan dari sirkulasi splanknik
dan ekstremitas bawah ke sirkulasi sentral selama berbaring, yang menyebabkan peningkatan
tekanan kapiler pulmonal. (Harrison)
3. Premature coronary disease :
4. Orthopneu : Form of dyspniea in which the person can breathe
comofortably pnly when standing or sitting erect; associated with asthma and emphysema and
angina pectoris (Farlex)
5. JVP : Blood pressure in the jugular vein, which reflects the volume
and pressure of venous blood (Farlex)
6. S3 gallop : The heart sound Cardiology The Heart sound that coincides
with the onset of a low frequency diastolic wave generated by rapid fillinh ; the SG is best heard
at the apex of the left lateral decubitus position’ the SG indicates ↓ ventricular compliance, and
is characteristic of CHF ; ‘physiologic’ SGs occur in children and young adults (Farlex)
7. Ankle edema : An abnormal infiltration and excess accumulation of serous
fluid in connective tissue or ina serous cavity especially ankle (Merriam Webster)
8. Karley’s B line : Any several fine horizontal lines a few centimeters above the
angle in the chest x-ray that is made by the recess between the ribs and the lateral most portion
od the diaphgram (Farlex)

9. Signs of cephalization : The antigravitational redistribution of pulmonary blood flow

that occurs with heart failure, caused by increased vascular resistance in the dependent part of
the lung, a consequence of pulmonary venous hypertension usually described on the basis of
relative vascular size on chest radiography

III. Identifikasi Masalah

Masalah Prioritas
1.Mr. HT, a 59 year old farmer, comes to VV
Mohammad Hoesin Hospital because of
shortness of breath since 8 hours ago. In the
last 4 weeks he became easily tired in daily
activites. He also complains about having
night cough, nausea.
Post medical history : untreated long standing
hypertension, heavy smoker.
Family history : no history of premature
coronary disease.

2.Physical exam : V
General Consideration:
Conscious, compos mentis, Orthopneu, BP
140/90, PR 109 x/min, regular, RR 32x/min,
height 160 cm, body weight 59kg.
Specific Consideration
JVP (5+2) cmH20, HR 109x/min, regular,
murmur (-), S3 gallop (+), basal rales (+),
wheezing (-), liver : palpable 2cm below the
costal arch, ankle edema (+)

3. Laboratory results : V
Hemoglobin : 10,7 g/dl, WBC : 6800/mm3,
Platelet : 190.000/mm3
Total cholesterol 209 mg/dl, LDL 135 mg/dl,
HDL 29 mg/dl, Triglyceride 130 mg/dl, fasting
blood glucose 98 mg/dl, Ureum 40 mg/dl,
Creatinine 1,0 mg/dl. Sodium 135 mmol/L,
Potassium 4,2 mmol/L
Urinalysis : normal findings.
 4.Additional examinations : V
ECG: Sinus rhythm, LAD, HR 120x/min, slow
progression of R wave, LV strain (+)
Chest X-Ray : CTR 65% boot-shaped cardiac,
Karley’s B line (+), signs of cephalization (+)

IV. Analisis Masalah

1. Mr. HT, a 59 year old farmer, comes to Mohammad Hoesin Hospital because of shortness
of breath since 8 hours ago. In the last 4 weeks he became easily tired in daily activites. He
also complains about having night cough, nausea.
Post medical history : untreated long standing hypertension, heavy smoker.
Family history : no history of premature coronary disease.
a. Bagaimana hubungan umur, jenis kelamin, dan pekerjaan Tuan HT terhadap keluhan
yang dialaminya?
b. Bagaimana mekanisme napas pendek pada kasus?
c. Bagaimana mekanisme batuk pada malam hari pada kasus?
d. Bagaimana mekanisme mual pada kasus?
e. Mengapa Tuan HT mudah lelah ketika melakukan aktivitas sehari-hari?
f. Bagaimana hubungan hipertensi lama dan merokok terhadap keluhan yang dialami?
g. Apa makna klinis tidak ada riwayat premature coronary disease?

2. Physical exam :
General Consideration:
Conscious, compos mentis, Orthopneu, BP 140/90, PR 109 x/min, regular, RR 32x/min, height
160 cm, body weight 59kg.
Specific Consideration
JVP (5+2) cmH20, HR 109x/min, regular, murmur (-), S3 gallop (+), basal rales (+), wheezing (-),
liver : palpable 2cm below the costal arch, ankle edema (+)
a. Bagaimana interpretasi pemeriksaan fisik?
b. Bagaimana mekanisme abnormal hasil pemeriksaan fisik? (mekanisme orhtopneu,
mekanisme basal rales, mekanisme liver teraba, mekanisme ankle edema)
c. Bagaimana prosedur pemeriksaan JVP?
d. Bagaimana bunyi jantung pada kasus (S3 gallop)?
 3.Laboratory results :
Hemoglobin : 10,7 g/dl, WBC : 6800/mm3, Platelet : 190.000/mm3
Total cholesterol 209 mg/dl, LDL 135 mg/dl, HDL 29 mg/dl, Triglyceride 130 mg/dl, fasting
blood glucose 98 mg/dl, Ureum 40 mg/dl, Creatinine 1,0 mg/dl. Sodium 135 mmol/L,
Potassium 4,2 mmol/L
Urinalysis : normal findings.
a. Bagaimana interpretasi pemeriksaan laboratorium?
b. Bagaimana mekanisme abnormal hasil pemeriksaan lab?
c. Mengapa dilakukan pemeriksaan urin?
d. Apakah ada pemeriksaan lain yang diperlukan? (biomarker)

4.Additional examinations :

ECG: Sinus rhythm, LAD, HR 120x/min, slow progression of R wave, LV strain (+)

Chest X-Ray : CTR 65% boot-shaped cardiac, Karley’s B line (+), signs of cephalization (+)
a. Bagaimana interpretasi pemeriksaan tambahan?
b. Bagaimana mekanisme abnormal pada pemeriksaan tambahan? (gambar CTR 65% boot-
shaped cardiac, Karley’s B line (+), signs of cephalization (+))
c. Mengapa terdapat perbedaan HR pada pemeriksaan fisik dan tambahan?

5.Berdasarkan anamnesis, pemeriksaan fisik, pemeriksaan laboratorium, dan pemeriksaan

tambahan, maka :

a. Apa diagnosis terhadap keluhan pada kasus?

b. Epidemiologi
c. Etiologi
d. Faktor resiko
e. Patofisiologi, patogenesis
f. Diagnosis banding
g. Algoritma penegakan diagnosis
h. Tata laksana
i. Komplikasi
j. Prognosis
k. Edukasi
l. SKDI

LI

1.Gagal jantung

a.Anatomi-Fisiologi + Diagnosis banding, Algoritma penegakan diagnosis, Tata laksana, Komplikasi,

Prognosis Edukasi SKDI
b.Hipertensi + Epidemiologi, Etiologi, Faktor resiko, Patofisiologi pathogenesis

2.Pemeriksaan fisik

3.Pemeriksaan lab

4.Pemeriksaan tambahan

5.Bunyi jantung