Scenario : Bolang Bolang, 2-year--old boy was referred for failure to thrive .

He is pink with vital signs and pulses normal.There is a slightly increased precordial bulding with a systolic thrill at the lower sternal border. The lung are clear. S and S2 are obscured by a !"# high-fre$uency, harsh holosystolic murmur heard all over the chest, but best at the lower left sternal border. There is a 2"# middiastolic murmur at the ape% . The abdomen is soft and there is no organomegaly. The result of his chest-& ray' (ardiothoracic ratio )*+, downward ape%, increase pulmonary vascular markings The result of ,(-' sinus rhythm, normal a%is, left ventricle hypertrophy .uestions' . /hat lesion is this e%amination classic for 0 2. /hat cause of the holosystolic murmur 0 1. /hat is the tools to confirm diagnosis 0 !. /hat is the best management0 2343 ' S(56, ' 274 ' 4inimum re$uirement 3TT7T9:, . -reeting 2. 7ntroduction 1. 8urpose !. 3cknowledgement"e%cusing T,64S (;367<7(3T752 . <ailure to thrive 2. Holosystolic murmur 1. (T6 = cardiothoracic ratio> 865B;,4 7:,2T7<7(3T752 . Bolang refer for failure to thrive 2. Holosystolic murmur 1. Systolic thrill, middiastolic murmur !. 3bnormal chest %- ray, abnormal ,(865B;,4 323;?S7S . /hy was Bolang failure to thrive 2. How is about the hemodynamic of this disease 1. /hat is the sign and symptoms of this disease !. /hat is the chest % ray of this disease ). /hat is the ,(- of this disease #. /hat is the association of failure to thrive and the disease *. How is the treatment A. How is the prognosis of this disease H?85TH,S7S' Bolang, 2-year old boy, suffer from large BS: S?2TH,S7S 8oint ) 2 1 Score s

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. ;arge BS: -----large the left to right shunt ---- decreased flow to systemic ---- the volume overwork done by left ventricle ---- left ventricle dilated. Because the shunt of BS: occurs mainly during systole when the right ventricle also contracts, the shunted blood goes directly to the pulmonary artery rather than remaining in the right ventricle cavity. Therefore, there is no significant volume overload to the right ventricle, and right ventricle remains relatively normal in size. 2. ;arge BS: ---large the left to right shunt --- overflow blood to pulmonal ---- increase in pulmonary vascular markings 1. The heart murmur in BS: is produced by the left to right shunt. 7ncreased blood flow through the mitral valve produces a relative stenosis of this valve and diastolic murmur at the mitral valve area !. Systolic thrill is vibratory sensations that represent palpable manifestations of loud, harsh murmurs. Thrills in the lower left sterna border are characteristic of a BS: ). <ailure to thrive can be associated with heart disease when lesions cause increased caloric e%penditure resulting from increased work of breathing, and decreased caloric intake resulting from respiratory distress and feeding difficulties #. :iagnosis 3namnesis ' failure to thrive 8hysical e%amination ' holosystolic murmur ;aboratory' (hest %-ray, ,(*. Treatment Surgical A. 8rognosis :efet closed' good prognosis 2ot close' congestive heart failure, pulmonary hypertension, subacute bacterial endocarditis, cerebrovascular accident 8,6<56432(, . Systematic"logical 2. :ressing 1. 8resentation skill

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Scenario' 46S. <3TT? B,63 4rs. <atty Bera, )# years old, body weight *A kg, height )! cm, admitted to the hospital with severe dyspnea.

3ctually, 2 weeks ago, he got headache and sometime nausea and vertigo. She went to polyclinic doctor and got medicine Cust to relief her complaint. Two =2> hours before admitted she got dyspnea after she heard that her husband walked with a beautiful woman. 8hysical e%amination' B8 2 @" !@ mmHg, pulse rateDheart rate 2!%"minute, pulmonary rales =E> ;aboratory finding' Hemoglobin ! g+F initial serum troponine is normal, as is (G-4B (hest %Hray showed cardiomegaly and pulmonary edema ,(- ' Tachycardia and ;eft Bentricular Hypertrophy. .uestion' . 2. 1. !. 2ama 274 ' Minimum re uirement 3TT7T9:,S' . -reeting 2. 7ntroducing 1. 8urpose !. 3cknowledgement"e%cusing T,64 (;367<7(3T752' . Severe dyspnea 2. Headache 1. Bertigo !. 2ausea ). 8ulmonary rales #. 8ulmonary edema I (ardiomegaly *. Tachycardia A. left ventricular hypertrophy 865B;,4 7:,2T7<7(3T752' . 4rs. <atty Bera, body weight *A kg, height )! cm. 2. 3ctually, 2 weeks ago, he got headache and sometime nausea and vertigo. 1. Two =2> hours before admitted she got dyspnea after she heard !. B8 2 @" !@ mmHg, pulse rateDheart rate 2!%"minute, pulmonary rales =E> ). Hemoglobin ! g+F initial serum troponine is normal, as is (G-4B #. (hest %Hray showed cardiomegaly and pulmonary edema *. Tachycardia I ;eft ventricular hypertrophy 865B;,4 323;?S7S' . 7s there any correlation between obesity and this disease0 2. /hy does she got severe dyspnea0 1. /hy does she got headache, vertigo, and nausea 0 !. How is the correlation high blood pressure and these complain0 ' S(56, ' !oin t ) 2 A Scor e /hat is the most likely diagnosis0 How the patophysiology of this disease0 /hat is the best therapy for this case0 /hat is the ne%t step in care of this patient0

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). /hat is the precipitating factor in this case0 #. /hat is the diagnosis this case *. How is the treatment0 A. How is the prognosis0 H?85TH,S7S' 4rs. <3TT? B,63 )2 years old suffer from congestive heart failure =as complication of Hypertension trigger by stress> S?2TH,S7S' . 5besity hyperinsulinemia--Jstructural hypertrophy increasing peripheral atrial resistancehypertension 2. Hypertensionmyocardial hypertrophy"ventricular remodelingdecreased left ventricular compliance and abnormal diastolic rela%ationincreased left ventricular end diastolic pressure reflected backpulmonary edema 1. 8hysical stress' sympathetic nervous activityincreased cardiac contractility and peripheral -resistancehypertension !. :iagnosis' 3namnesis' :yspnea, treatment history for headache, vertigo and nausea 8hysical e%amination' B8 2 @" !@Fpulse rateDheart rates 2!&"menF pulmonary rales=E> ;aboratory' not significant &-ray ' cardiomegali pulmonary edema ). Treatment' 2on pharmacologic 8harmacology ' :iuretic F 8arenteral anti hypertensive agent #. 8rognosis' - /ithout complication and with ade$uate therapy' good - (omplication' StrokeF 6enal failure' poor 8,6<56432(,' . Systematical"logical 2. :ressing 1. 8resentation skill TOTAL <ebruari 2@@A

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8enguCi 2 Scenario ' 4r. Sarif

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4r. Sarif, ) years old, came to hospital because of shortness of breath, starting @ days ago and become worse since 1 days ago. He had a history of severe chest pain a year ago. The doctor suggested for regularmedical control. But, he visited his doctor if he got complain like easy tired.

On "hysical e#amination' blood pressure @@"#@ mmHg, pulse rate # %"min, respiratory rate 1# %"min. Kugular venous pressure )E2 mmH2@, basal rales and wheeLing, liver palpable ! fingers below costal arch and bilateral ankle edema. $hest %&ray ' cardiomegaly, butterfly appearance at hillus region. 'lectrocardiogram' corresponding to anteroseptal old myocardial infarction.

(uestion' 1. ,. /. 1. 2AMA 23M )hat is the most li*ely diagnosis+ -o. is "atho"hysiology of this disease+ )hat is the 0est thera"y+ )hat is the ne#t ste" in care of this "atient+ : : S$O4' :

Minimum re uirement ATT3T56'S: . -reeting 2. 7ntroducing 1. 8urpose !. 3cknowledgement"e%cusing T'4MS $LA4383$AT3O2: . shortness of breath 2. The history of severe chest apin a year ago 1. anteroseptal old myocardial infarction !4OBL'M 36'2T383$AT3O2: . He suffered shortness of breath with the history of severe chest pain. 2. Signs of congestive heart failure 1. (hest %-ray showed cardiomegaly and butterfly appearance at hillus region. !. ,(- corresponding to anterior 547 !4OBL'M A2AL9S3S: . /hat is the association between shortness of breath and the history of severe chest pain 2. /hat is the cause of this actual condition of this patient 1. How is about the pathophysiology of this disease !. How to make the diagnosis ). How to manage #. /hat are the prognosis and complication -9!OT-'S3S : (ongestive heart failure caused by coronary artery disease. S92T-'S3S: . Heart failure due to low cardiac output. (oronary artery disease might caused impairment of cardiac pumping depends on the e%tend of lesion. 2. 3nterior wall of left ventricle is the important part of left ventricle pumping.

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:isorder of this part will decrease the pump capability. 1. 8athogenesis ' 8revious coronary artery disease =anteroseptal wall> decrease the ;B pumping capability systolic dysfunction longer and longer, ;B chamber enlarged systolic failure and also diastolic dysfunction congestive heart failure. !. :iagnosis ' 3namnesis ' shortness of breath, the history of severe chest pain a year ago, uncontrolled hypertension. physical e%aminations' orthopnoe, B8 @@"#@ mmHg, KB8 increased, congestive liver and ankle edema. (hest %-ray' cardiomegaly, butterfly appearance at hillus region. '$: : anteroseptal old myocardial infarction ). Treatment ' 7((9' o%ygen :iuretics, digitalis, 3(, inhibitors, aspirin 8lanning ' echocardiography and or coronary arteriography #. 8rognosis ' /ithout complication and with ade$uate therapy prognosis good 7f ;eft ventricle function still good =,< J !)+> , cardia intervention can help. !'48O4MA2$' : . Systematic"logical 2. :ressing 1. 8resentation skill T5T3; 8alembang, 8enguCi = A <ebruary 2@@A >

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