Curriculum Vitae

Nama

: Prof. Dr. H. Djanggan Sargowo, dr., SpPD., SpJP(K),

FIHA, FACC, FESC, FCAPC, FASCC
Tempat/Tgl lahir : Sragen, 21 September 1947
Alamat
: Wilis Indah E-10 Malang, Telp. 0341-552395
Pendidikan
:
1.
Lulus Dokter dari UGM, tahun 1974
2.
Lulus Cardiologist dari Univ. Indonesia, tahun 1983
3.
Lulus Internist dari Univ. Airlangga, tahun 1986
4.
Lulus Doktor, Univ. Airlangga, tahun 1996
5.
Advanced Cardiology Course, Univ. Hongkong, tahun 1984
6.
Senior Visiting Program, Institut Jantung Negara, Kualalumpur, 1996
7.
Fellow American College of Cardiology (FACC), September 2006.
8.
Fellow Collage Asia Pacific Society of Cardiology (FCAPC), Desember
2007
9.
Fellow European Sociaty of Cardiology (FESC), 2008
10.
Fellow Asean Collage of Cardiology (FASCC), 2008
Jabatan :
1.
Dosen Pengajar Program Pascasarjana Universitas Brawijaya
2.
Ketua MKEK Ikatan Dokter Indonesia Cabang Malang Raya
3.
Ketua PERKI Cabang Malang Raya
4.
Anggota Kolegium Kardiovaskuler Indonesia
5.
Dekan Fak. Kedokteran Univ. Wijaya Kusuma Surabaya1
Page 1
6.
Ketua Dewan Pengawas Rumah Sakit Pendidikan

CAPITA SELECTA

Djanggan Sargowo

FAKULTAS KEDOKTERAN UNIVERSITAS WIJAYA KUSUMA

Page 2

Doctor-Patient relationship:
Empathy : the ability to recognize and to some extent share the emotions and
states of mind of another and to understand the meaning and significance of
that person's behavior.
Empathy is different from sympathy in that to be empathetic one
understands how the person feels rather than actually experiencing those
feelings, as in sympathy.
Patient: human being

mimics
feelings
Appreciate or honor each other
honest may be positive / Negative

Page 3

Doctor-Patient Relationship
Interaction
My feelings
affect my
behaviour

Patients behaviour
affect my feelings

My behaviours
affect patients
feelings

Patients feelings
affect their
diseases

Page 4

Examination of patient the central point needs scientific background

Phase I :

- Anamnesis
- Physical notes
- Data recording
Needs patience, discipline, sensitive, curious

Phase II :

- Data analysis
- Integrating data
Diagnosis, Prognosis, Process, Diagnosis

Phase III :

-M anagement
- Treatment
Consideration, experience, advice

Primum Non Nocere

Do No Harm (=Pertama jangan melakukan tindakan yang merugikan).
Page 5

The Cardiovascular Data Base

1.
2.
3.
4.
5.
6.

Patient history
Physical examination
Electrocardiogram
Chest X-ray
Routine blood exams
Additional Tests:
1. Two-dimensional echocardiography with Doppler studies
2. Exercise treadmil ECG test
3. Ambulatory Holter Monitoring
4. Nuclear imaging
5. Cardiac catheterization

Page 6

Classification of Common Heart Disease

(according to the causes)
Cardiovascular malformations (congenital heart
disease)
Involving the valve, heart structure, and other large vessels,
etc.

Acquired heart disease

Artery thrombosis disease : leading to ischemia or infarction,
such as coronary heart disease
Rheumatic heart disease: heart inflammation, valvular
disease

Hypertension: primary, hypertensive heart disease

Page 7

Classification of Common Heart Disease

(according to the causes)
Acquired heart disease
pulmonary and pulmonary-vascular heart
disease: pulmonary heart disease, pulmonary
hypertension, pulmonary embolism, etc.

Infection: bacteria, viruses invade the heart

Diseases of other systems involve the
heart: hyperthyroidism, anemia, malnutrition,
immune abnormalities, physical and chemical
damage, mental factors, etc.

Page 8

Classification of Common Heart Disease

(according to pathology )
Endocardial disease
Endocarditis, valvular disease, etc.

Myocardial disease
Inflammation, ischemia or necrosis, hypertrophy,
fibrosis, damage, etc.

Great vascular diseases

Atherosclerosis, dissection, inflammation, thrombosis,
angioma, embolism, etc.

Pericardium disease
Inflammation, plot (gas, water, blood, pus, etc),
coarctation, etc.

Page 9

Classification of Common Heart Disease

(according to pathophysiology )
Heart Failure

Left heart, right heart; acute, chronic; systolic,

diastolic
Shock
Dysfunction of coronary circulation
Papillary muscle dysfunction
Arrhythmia
Cardiac tamponade
Others: high or low blood pressure (of systemic or
pulmonary vascular), shunt, etc.
Page 10

Format of Heart Disease Diagnosis

Etiological diagnosis
Such as rheumatic heart disease, coronary
artery disease

Pathological or anatomical diagnosis

Such as mitral stenosis

Pathophysiology diagnosis
Such as heart failure, atrial fibrillation,
pulmonary hypertension

Page 11

Methods of Cardiovascular Disease

Diagnosis
Patient history
present history, past history, personal history,
the history of surgery, vaccination history,
marriage and procreation, family history, etc.

Physical examination
Symptoms and signs

Laboratory examination
Blood, urine, faeces, serous effusions (from
pericardial effusion), sputum, biopsy, etc.

Equipment inspection
X-ray, ultrasound (echocardiography),
electrocardigraphy, radionuclide, angiography,
etc.
Page 12

Evaluation of the Methods in

Cardiovascular Disease Diagnosis
History and physical examination
basic skills, first-hand information, many
diseases can be diagnosed through this

Laboratory examination
Most supportive, but some can be used to make
a definite diagnosis, such as myocardial
necrosis marker, BNP, etc.

Page 13

Evaluation of the Methods in

Cardiovascular Disease Diagnosis
Equipment inspection
Major method for cardiovascular disease diagnosis,
Divided into invasive and non-invasive method.
non-invasive method can easily be accepted by patients,
and is safe, however, the information may be limited
(eg. ECG, echocardiography)
Invasive method: the opposite to non-invasive ones (eg.
Cardiac catheterization)
Semi-invasive examination such as those via the
esophagus (eg. Trans-esophageal echocardiography)

Page 14

Basic skill
Inspection:

Skin, mucosae, movement of

chest wall
Palpation : - Sensitivity of the hands/fingers
- Muscle tone
- Tumor
Percussion
: Sonor, dulness, timpanic
Auscultation
: Sounds/Voices
- Breath
- Friction
- Heart sounds
- Additional sounds: gallop, murmurs
Page 15

Problem Oriented Medical Record

POMR is oriented to problem
1.Baseline data
2.Problem list
3.Problem oriented medical record
4.Summary of problem

Page 16

Common symptoms and signs related to

Cardiovascular problem
1.
2.
3.
4.
5.
6.
7.
8.

Chest pain
Dyspnea
Syncope
Palpitations
Lower extremity edema
Heart murmur
Hypertension
Fever associated with cardiac symptoms and
signs

Page 17

Chest Pain

Page 18

Differential diagnosis of chest pain

System involved

Pathology

Cardiac

Myocardial infarction
Angina pectoris
Pericarditis
Prolapse of the mitral valve
Tamponade

Vascular

Aortic dissection

Respiratory (all tend to give rise to

pleuritic pain)

Pulmonary embolus
Pneumonia
Pneumothorax
Pulmonary neoplasm

Gastrointestinal

Esophagitis due to gastric reflux

Esophageal tear
Peptic ulcer
Biliary disease
Pancreatitis

Page 19

Differential diagnosis of chest pain

System involved

Pathology

Musculoskeletal

Cervical nerve root compression by

cervical disc
Costocandritis
Fractured rib

Neurological

Herpes zoster

Respiratory (all tend to give rise to

pleuritic pain)

Pulmonary embolus
Pneumonia
Pneumothorax
Pulmonary neoplasm

Psychogenic

Anxiety
Panic disorder
Conversion disorder
Malingering

Page 20

Dyspnea

Page 21

Differential diagnosis of dyspnea:

System involved

Pathology

Cardiac

Cardiac failure
Coronary artery disease
Valvular heart disease aortic
stenosis, aortic regurgitation. Mitral
stenosis/regurgitation, pulmonary
stenosis
Cardiac arrhythmias

Respiratory

Pulmonary embolus
Airway obstruction-COPD, asthma
Pneumothorax
Pulmonary parenchymal disease (eg.
Pneumonia, interstitial lung disease,
lung neoplasm)
Pleural effusion
Chest wall limitation-myopathy,
neuropathy (eg Guillain-Barre
disease), rib fracture,
kyphoscoliosis
Page 22

Differential diagnosis of dyspnea:

System involved

Pathology

Other

Obesity (limiting chest wall movement

or sleep apnea)
Anemia
Psychogenic hyperventilation, panic
attack, anxiety.
Acidosis (eg aspirin overdose,
diabetic ketoacidosis)

Page 23

Syncope

Page 24

Differential diagnosis of syncope :

System involved

Pathology

Cardiac

Tachyarrhyhtmias- supraventricular or ventricular

Bradyarrhythmia- sinus bradycardia, complete or
second-degree heart block, sinus arrest
Stokes-Adam attack- syncope due to transient asystole
Left ventricular outflow tract obstruction- aortic
stenosis, HOCM (hypertrophic obstructive
cardiomypathy)
Pulmonary hypertension

Vasovagal

After carotid sinus massage and also precipitated by

pain (simple faint), micturition, anxiety; these result in
hyperstimulation by vagus nerve, which leads to AV
node block (and therefore bradycardia, hypotension
and syncope)

Page 25

Differential diagnosis of syncope :

System involved

Patology

Circulatory

Postural hypotension usually due to antihypertensive

drugs or diuretics; also caused by autonomic
neuropathy as in diabetes
Pulmonary embolus may or may not preceded by
chest pain
Septic shock severe peripheral vasodilatation results
in hypotension

Cerebravascular

Transient ischemic attack

Vertebrobasilar attack

Neurological

Epilepsy

Metabolic

Hypoglycemia

Page 26

Palpitations
Page 27

Palpitations :
Palpitations may be caused by any disorder
causing a change in cardiac rhythm or rate
and any disorder causing increased stroke
volume

Page 28

Palpitations :
Rapid Palpitations:
1.Regular palpitations may be a sign of:
1. Sinus tachycardia
2. Atrial flutter
3. Atrial tachycardia
4. Supraventricular re-entry tachycardia
2.Irregularly irregular palpitations may indicate:
1. Atrial fibrillation
2. Multiple atrial or ventricular ectopic beats
3. Multifocal atrial tachycardia (MAT): usually found in
patients with lung pathology

Page 29

Palpitations:
Slow palpitations: patients often describe these as missed
beats or forceful beats (after a pause the next beat is often
more forceful due to a long filling time and therefore a
higher stroke volume).
Causes of slow palpitations:
1.Sick sinus syndrome
2.Atrioventricular block
3.Occasional ectopics with compensatory pauses

Page 30

Normal ECG

Rate
Regularity
P waves
PR interval
QRS duration
Interpretation?

90-95 bpm
regular
normal
0.12 s
0.08 s

Normal Sinus Rhythm

Page 31

Sinus Tachycardia
Etiology: SA node is depolarizing faster
than normal, impulse is conducted
normally.
Remember: sinus tachycardia is a
response to physical or psychological
stress, not a primary arrhythmia.

Page 32

Atrial Fibrillation
Deviation from NSR
No organized atrial depolarization, so no
normal P waves (impulses are not
originating from the sinus node).
Atrial activity is chaotic (resulting in an
irregularly irregular rate).
Common, affects 2-4%, up to 5-10% if >
80 years old
Page 33

Atrial Flutter

Deviation from NSR

No P waves. Instead flutter waves
(note sawtooth pattern) are formed at
a rate of 250 - 350 bpm.
Only some impulses conduct through
the AV node (usually every other
impulse).
Page 34

Lower Extremity Edema

Page 35

Differential diagnosis of lower

extremity edema
Pathology

Cause

Congestive heart
failure

Myocardial infarction, recurrent tachyarrhythmias

(particularly atrial fibrillation), hypertensive
heart disease, myocarditis, cardiomyopathy due
to drugs and toxins, mitral, aortic or pulmonary
valve disease

Right heart failure

secondary to
pulmonary
hypertension (cor
pulmonale)

Chronic lung disease, primary pulmonary

hypertension

Hypoalbuminemia

Excessive protein loss (due to nephritic

syndrome, extensive burns, protein losing
enteropathy), reduced protein production (due
to liver failure), or inadequate protein intake (due
to protein-energy malnutrition)
Page 36

Differential diagnosis of lower

extremity edema
Pathology

Cause

Renal disease

Any cause of renal impairment ( e.g. hypertension,

diabetes mellitus, autoimmune disease, infection)

Liver cirrhosis

Alcohol, hepatitis A, B, C, etc, autoimmune

chronic active hepatitis, biliary cirrhosis, Wilsons
disease, hemochromatosis, drugs

Idiopathic

Premenstrual edema

Arteriolar dilatation
Dihydropyridine calcium channel blockers ( e.g.
(exposing the
nifedipine, amlodipine)
capillaries to high
pressure, thus
increasing
intravascular
hydrostatic pressure)

Page 37

Differential diagnosis of lower

extremity edema
Pathology

Cause

Sodium retentio

Cushings disease resulting in excessive

mineralocorticoid activity, corticosteroids

Local causes

Cellulitis, venous thrombosis, lymphedema

Page 38

Heart Murmur

Page 39

Differential Diagnosis of Heart Murmur

Phase
of
cardiac
cycle

Nature of
murmur

Valve lesion

Cause of valve lesion

Systolic

Ejection
systolic

Aortic stenosis

Valvular stenosis,
congenital valvular
abnormality, rheumatic
fever, supravalvular
stenosis, senile valvular
calcification

Aortic sclerosis
(murmur that
does not radiate
to the carotids)

Aortic valve roughing

HOCM

Left ventricular outflow

tract (sub aortic) stenosis

Increased flow
across normal
valve

High output states (eg

anemia, fever, pregnancy,
thyrotoxicosis)
Page 40

Differential Diagnosis of Heart Murmur

Phase
of
cardiac
cycle

Nature of
murmur

Valve lesion

Cause of valve lesion

Systolic

Holosystolic

Mitral
regurgitation
(MR)

Functional MR due to
dilatation of mitral valve
annulus
Valvular MR: rheumatic
fever, infective
endocarditis, mitral valve
prolapse, chordal rupture,
papillary muscle infarct

Tricuspid
regurgitation
(TR)

Functional TR
Valvular TR : rheumatic
fever, infective
endocarditis

VSD with left-to- Congenital, septal infarct

right shunt
(acquired)
Page 41

Differential Diagnosis of Heart Murmur

Phase
of
cardiac
cycle

Nature of
murmur

Valve lesion

Diastolic

Early diastolic

Aortic
Functional AR: dilatation of
regurgitation (AR)
valve ring, aortic dissection,
cystic medial necrosis
(Marfan syndrome)
Valvular AR: rheumatic fever,
infective endocarditis,
bicuspid aortic valve
Pulmonary
regurgitation

Cause of valve lesion

Functional PR: dilatation of

valve ring, Marfan
syndrome, pulmonary
hypertension
Valvular PR: rheumatic fever,
carcinoid, tetralogy of Fallot

Page 42

Differential Diagnosis of Heart Murmur

Phase of
cardiac
cycle

Nature of
murmur

Valve lesion

Cause of valve lesion

Diastolic

Mid
diastolic

Mitral stenosis
(MS)

Rheumatic fever, congenital

Tricuspid
stenosis (TS)

Rheumatic fever

Left and right

atrial myxomas

Tumor obstruction of valve

orifice in diastole

PDA
Arteriovenous
fistula
Cervical venous
hum

Congenital

Continuous

Page 43

Hypertension

Page 44

Differential diagnosis of
hypertension

Systemic hypertension may be classified

as:
Primary (essential) hypertension, for which
there is no identified cause. This accounts for
95% of cases.
Secondary hypertension, for which there is a
clear cause

Page 45

Blood Pressure Classification

BP Classification

SBP mmHg

DBP mmHg

Normal

<120

and

<80

Prehypertension

120139

or

8089

Stage 1 Hypertension

140159

or

9099

Stage 2 Hypertension

>160

or

>100

JNC VII
Page 46

Causes of secondary hypertension

Mechanism

Pathology

Renal

Renal parenchymal disease (e.g.

chronic atrophic pyelonephritis,
chronic glomerulonephritis), renal
artery stenosis, renin-producing
tumors, primary sodium retention

Endocrine

Acromegaly, hypo- and

hyperthyroidism, hypercalcemia,
adrenal cortex disorders (e.g
Cushings disease, Conns
syndrome, congenital adrenal
hyperplasia), adrenal medulla
disorders (e.g pheochromocytoma)

Vascular disease

Coarctation of the aorta

Other

Hypertension of pregnancy

Page 47

Causes of secondary hypertension

Mechanism

Pathology

Increased intravascular volume

Polycythemia (primary or
secondary)

Drugs

Alcohol, oral contraceptives,

monoamine oxidase inhibitor,
glucocorticoids

Psychogenic

Stress

Neurological

Increased intracranial pressure

Page 48

Fever associated with a

cardiac symptom or sign

Page 49

Differential diagnosis of fever

Infective endocarditis (bacterial or fungal infection
within the heart)
Myocarditis (involvement of the myocardum in an
inflammatory proess, which is usually viral)
Pericarditis (inflammation of the pericardium which
may be infective, postmyocardial infarction or
autoimmune)
Other rare conditions such as cardiac myxoma

Page 50

Summary
1. Clinical diagnosis for patient with
cardiovascular disease needs
comprehensive approach.
2. Cardiovascular data base includes
patient history, physical examination,
electrocardiogram, chest X-ray, Routine
blood exams and additional tests

Page 51

Summary
3. Components of a complete cardiac
diagnosis include etiologic diagnosis,
pathologic or anatomical diagnosis, and
pathophysiologic diagnosis.
4. Many of symptoms and signs may lead to
differential diagnosis.

Page 52

Thank You

53

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