1. diagnostic decision
1.1. down syndrom with ventricular defect with congestive heart failure
2. step 1: identify and difficult words
2.1. difficult words
2.1.1. Sluggish: slow
2.2. kews
2.2.1. newborn baby
2.2.2. trouple in feeding
2.2.3. diagnosed with down syndrom
2.2.4. 8 week age
2.2.5. breastfeeding difficulty
2.2.6. slow weight gain
2.2.7. sweating and shortness of breath ( about 5 - 10 min) and spend 1 hour during feeding
3. step3: hypothesis generation
3.1. Down syndrome ( congenital problem)
3.2. problem on swallowing or gi ( digestion is affected)
3.3. intolerance of milk
3.4. people with down syndrome will have many conginetal heart problems and also macroglossa
3.5. disease related to blood for example acute megaloblastic leukemia
3.6. breathlessness because he is using neck muscle to respirate
3.7. slow weight gain because he is taking enough milk
3.8. cystic fibrosis
3.9. cyanosis in right to left shunt
3.10. he spends very much effort when breastfeeding that why he is sweaty and takes time to feed.
3.11. tetralogy of fallot ( congenital heart defect)
3.12. patent ductus arteriosus
3.13. av septal defect
3.14. down syndrom patient will have mental retardation
3.15. dudental atresia
4. step4: hypothesis organization
4.1. GI
4.2. cardiopulmonary system
5. step5: learning objectives
5.1. 1- to define down syndrome, genetic basis, manifestation, risk factors, and complication( gi and cvs).
5.2. 2- to describe the normal process of breastfeeding and abnormalities related to down syndrome.
5.3. 3- to know the normal developmetl structure of the heart.
6. step2: problem formulation
6.1. an 8 week newborn male with down syndrome presented to the doctor after his mother noticed that he has trouble that is breastfeeding is associated with sweating, shortness of breath and gaining weight.
7. Step 6 Review of Last Session
7.1. dwon syndrom patient
7.1.1. Long duration of feeding
7.1.2. extra effort for breastfeeding
7.2. heart development
7.2.1. develop in cardiogenic area
7.2.2. placental circulation
7.2.2.1. two art and one vein the blood eighter come from svc or from an area to join to the the ivc
7.3. step6
7.3.1. difintion:
7.3.1.1. most common genetic problem with a problem in chromosome 21
7.3.2. cause
7.3.2.1. translocation to other chromosom
7.3.2.2. problem in the chromosome
7.3.3. charactersitics
7.3.3.1. amternal myotic dysfuntion: problem in the second stage.
7.3.3.2. most of the problem in the mental retardation
7.3.4. clinical prsentation
7.3.4.1. congenital heart disease
7.3.4.1.1. Atrioventricular defect
7.3.4.2. tetralogy of falop
7.3.4.3. gi problem
7.3.4.3.1. dudenal atresia
7.3.4.3.2. vomoting
7.3.4.4. dysmorphic feature
7.3.4.4.1. flat face
7.3.4.4.2. slant palpaular fissure
7.3.4.4.3. ear and eye proble
7.3.4.4.4. short neck
7.3.4.4.5. problem in the extremeties
7.3.4.5. neurological defect
7.3.4.5.1. alzahaimar disease
7.3.4.5.2. speach difficulty
7.3.4.5.3. loss of hear
7.3.4.5.4. vision problem
7.3.4.6. hematological
7.3.4.6.1. anemia
7.3.4.7. psychiatric
7.3.4.7.1. autism
7.4. breast feeding problem
7.4.1. duration of 20 to 35
7.4.2. frequency is 8 of 12 a day
7.4.3. improves the immunity
8. Step 7 Inquiry Plan
8.1. history
8.1.1. problem in feeding
8.1.2. any baby has previous problem
8.1.3. pregnancy is normal
8.1.4. us: no abnormality detected
8.1.5. vaginal delivery
8.1.6. weight:
8.1.7. family history
8.1.8. parents: no smoking
8.2. physical examination
8.2.1. wt; 3.5
8.2.2. pulse: 140
8.2.3. bp: 90 \ 60
8.2.4. respirtory rate
8.2.4.1. 42
9. Step 9 REview
10. Step 10 Management
10.1. GOAL
10.1.1. TO increase theheart.
10.2. medication
10.2.1. to keep the heart rater in nomral rat
10.2.1.1. digixon
10.2.1.2. ace
10.2.1.3. dirutics
10.2.1.3.1. increase the na+ and water lose in the body
10.2.1.4. gaba receptor
10.2.1.4.1. Improve learning
10.2.1.5. antioxidant
10.2.1.5.1. zinc
10.3. surgery
10.3.1. goal
10.3.1.1. pulmonary vascular resistance
10.3.1.1.1. assement
10.3.1.2. refractory congestive heart failure
10.3.1.3. failure to thrive
10.3.1.3.1. we give them calori
10.3.2. dependant on the size
10.3.2.1. open heart surgery
10.3.2.1.1. it is the best
10.3.2.2. cathetarization
10.3.2.2.1. through femoral artery
10.3.2.2.2. ventricles
10.3.3. be careful from the infection
10.3.3.1. give antibiotic eve
10.3.4. vsd
10.3.4.1. sometime benefatial
10.3.4.1.1. Preventing the closure
10.4. guidlines
10.4.1. diurtic and ace ( low doses)
10.4.2. beta blocker
10.4.2.1. contraindication
10.4.2.1.1. if it decrease the heart rate more than the normal
10.5. non drug related
10.5.1. education of the family
10.5.2. family support
10.6. refer him
10.6.1. pediatric cardiologist
10.6.1.1. avoid cyanosis
10.6.1.2. and murmar
11. Step Feedack
11.1. resource
11.1.1. uptodate
11.1.2. e-mdecine
11.1.3. medicine.net
11.1.4. WHO
11.1.5. medscape
11.1.6. divitson
11.1.7. cdc
11.1.8. american heart association