Angelina

Birth weight: 3450 Height: 40 cm

Diagnosis: Main illness: Down Syndrome   Q90
Second illness: Congenitial heart failure: atrioventicularspataldefect Q 21.2
Cardiopulmonal insufficiency level I   P 29.1

Anamnesis and clinical findings: IV pregnancy/ II labor a new-born on scheduled time, has a phenotype of the Down syndrome, was brought to hospital for the elaboration of the heart failure, state was stable. A light cardiac insufficiency is developing (hypervolemia in the lungs, the veins of the liver are filled), diuretical treatment started on 20.02. Overall condition is satisfactory. Coloration subcritelical, acrotyanosis. Eats Tuttel well from the pacifier, 370-400ml a day; diuresis before diureticum 4,6 ml/kg/die. No heart murmur, fr 140-150x‘, abdomen meteoristic, liver + 1,5 cm. Muscle hypotonia.

Was sent to the local childrens hospital for further treatment and maintenance (the parents will decide if they will give up the child or raise her themselves).

Aftercare and recommendations: Furosemid 2mgx2; Verospiron 1/8 of a 25-milligrab pill x1; Multitabs 1mlx1, to raise the amount of furosemid if necessary.

Date: 21.02

Down Syndrome                          Q.90
Defectus septi atrioventicularis     Q21.2
Rachitis acuta                            E55.0
Rota virus infection(19.03.03)    A08.0

The reason for hospitalization: treatment and maintenance - Anamnesis: IV pregnancy, trisomia with 21 syndrome, the child has an inborn heart failure. The child was at the Tartu Children’s Hospital for treatment and maintenance, from where she was brought to our hospital. The mother has not yet decided if she wants to take the child home or give her up (01.04.03). It was announced via telephone that the genetic research proved the diagnosis of trisomia 21.

Objective find:
Typical phenotype of the Down syndrome. At first there was no heart murmur, later was heard a 2-2,5*  coarse systolical murmur with an epicenter of III iCS, fr 134-138xmin. The child developed rachitis from what she is now recovering. Psyhomotorical development: does react to speech with a searching-movement of the eyes, at times makes a short sound as a reply to speech. Does not lift her head while on stomach. Weight: 3660g, height 52 cm, measurement of the head 34,5 cm.

Treatment recommendations:
A consultation of a cardiologist is necessary. Developing activities. Furosemid 2,5mg x2  day. Verospiron 3mg die. D2 vitamines until 13.04.03 1600ü pro die, from the on 400ü a day.Eats Nan I about 500-600ml a day.

Date: 21.02.08

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