1. Step 6
1.1. Review session 1
1.2. Report new knowledge
1.2.1. embryological heart development
1.2.1.1. picture 1
1.2.1.2. picture 2
1.2.1.3. picture 3
1.2.1.4. picture 4
1.2.1.5. Foramen Ovale
1.2.1.6. Septum primume
1.2.1.7. Septum secundum
1.2.1.8. Development of the ventricles
1.2.1.9. Fetal circulation
1.2.1.10. Defects
1.2.1.10.1. Septum premum defect
1.2.1.10.2. Septal defects
1.2.1.10.3. Patent ductus artiriosis
1.2.2. down's syndrome
1.2.2.1. risk factors
1.2.2.1.1. Graph 1
1.2.2.2. pathophysiology
1.2.2.3. complication
1.2.2.3.1. CVS?
1.2.2.3.2. hypotonia?
1.2.2.4. clinical features and diagnosis
1.2.2.4.1. Picture 1
1.2.2.4.2. Picture 2
1.2.2.4.3. Picture 3
1.2.2.4.4. Picture 4
1.2.2.4.5. Picture 5
1.3. 30 minutes
1.3.1. The scribe does not have to write in this step!
2. Step 8
2.1. Diagnostic decision
2.1.1. CHF as a complication of down syndrome (VSD)
2.1.1.1. How to cope with a down syndrome baby?
2.2. Mechanism
2.2.1. maternal age
2.2.2. CVS complication after getting down syndrome
2.2.3. VSD left to right (no cyanosis)
2.2.4. leading to RVH
2.3. Presentation
2.3.1. sluggish feeding
2.3.2. slow growth
2.3.3. tachypnea
2.3.4. beathlessness
2.4. Supporting data
2.4.1. CXR, ECG
2.5. 10 minutes
3. Step 7
3.1. Inquiry plan and info gathering
3.1.1. History of presenting complain
3.1.1.1. having poor weight gain, sweaty, SOB
3.1.1.2. during feeding start to stop after 5-10 min
3.1.1.2.1. duration for 1 hour
3.1.1.3. the mother is anxious
3.1.1.4. diagnosed at day 2 by DS due to clinical features
3.1.1.5. normal prenatal visit results
3.1.1.5.1. US at 18
3.1.1.5.2. refused the amniocentesis that has been ordered
3.1.1.5.3. term delivery
3.1.1.6. 3.1 kg after delivery
3.1.2. Previous medical / surgical history
3.1.3. Drug history / allergy
3.1.4. Family history
3.1.4.1. mother age 39
3.1.4.2. they have another normal girl
3.1.4.2.1. 2 y
3.1.4.3. no relatives with DS
3.1.4.4. no hx of congenital CVS
3.1.4.5. granfather died from IHD
3.1.4.6. father 41 yo
3.1.4.6.1. works as a manager
3.1.5. Social / occupational history
3.1.5.1. parents don't smoke
3.1.6. Systemic review
3.1.7. Physical examination
3.1.7.1. vital signs
3.1.7.1.1. weight 3.5 kg
3.1.7.1.2. hight 60 cm
3.1.7.1.3. head cercumflux 40 cm
3.1.7.1.4. PB 90/60
3.1.7.1.5. HR 140
3.1.7.1.6. RR 32
3.1.7.2. inspection
3.1.7.2.1. slightly tachypenic
3.1.7.2.2. afebrile
3.1.7.2.3. no cyanosis
3.1.7.2.4. 5 features of the DS
3.1.7.3. CVS
3.1.7.3.1. BF pulse equal
3.1.7.3.2. apex beat diplaced laterly
3.1.7.3.3. auscultation
3.1.7.4. respiratory
3.1.7.4.1. normal
3.1.7.5. GIT
3.1.7.5.1. liver palbale 3 cm below CM
3.1.7.5.2. spleen is normal
3.1.7.6. Neurological
3.1.7.6.1. slightly decrease mm. tone
3.1.8. tests results
3.1.8.1. CBC
3.1.8.1.1. HB 110
3.1.8.1.2. WBC 5
3.1.8.1.3. PLT 270
3.1.8.2. ECG
3.1.8.2.1. right ventricular hypertrophy
3.1.8.3. CXR
3.1.8.3.1. cardiomegaly (RV)
3.1.9. graph