**THE CASE OF HEARTY KAPUSO**

**Patient Overview:**
- Name: Hearty Kapuso
- Age: 10 months
- Gender: Female
- Religion: Catholic
- Weight: 7.4 kg
- Blood Type: B+
- Allergies: None
- Address: 30 Pinagpusuan St., Kamahalan City, Manila
- Date of Birth: August 18, 2020
- Date of Admission: June 19, 2021, at 9:20 am
- Hospital Number: 2020-183019

**Vital Signs:**
- Temperature: 38.9°C
- Pulse Rate: 122 bpm
- Respiratory Rate: 38 cpm
- Capillary Refill: 138 bpm
- Blood Pressure: 90/60 mmHg
- Oxygen Saturation: 90%

**Current Medical Condition:**
Hearty Kapuso was admitted to the Pediatric ICU Bed 4 at Corazon Memorial Medical Center with central cyanosis, respiratory distress, and oxygen saturation of 90%. She is on high back rest with difficulty breathing and has a capillary refill time of 3 seconds.

**Treatment and Medication:**
- IV Fluid: D5LR 500ml at 120cc/hr
- Oxygen Therapy: 6 liters/minute via facemask
- Intubation: Standby with a 3.5mm uncuffed endotracheal tube
- Foley Catheter: Draining 110 cc of amber yellow urine
- Medications:
- Cefuroxime 180 mg TIV ANST q12h (Stock: 500 mg diluted to 5 ml)
- Propranolol 1 mg PO OD (Stock: 2 mg/tab)
- Paracetamol 85 mg IV PRN (Stock: 150 mg/2 ml for temp ≥ 39.5°C)
- Ancillary Tests: CBC, UA, pending ABG, serum electrolytes, and Chest X-ray

**Feeding:**
- Mixed feeding with strict aspiration precaution

**Diagnosis:**
- Congenital heart defect cyanotic type, rule out Tetralogy of Fallot

**Physical Examination:**
- Dark skin complexion with evenly distributed hair
- Dry, warm skin with clubbing of fingernails and bluish nail beds
- Round scars on both legs
- Normocephalic head, symmetrical eyes, and ears
- Bluish discoloration of lips, dry mucous membranes, and dry tongue
- Slightly barrel chest, right side enlarged with clear breath sounds using accessory muscles
- Heart murmur along the left sternal border
- Flat abdomen with normo-active bowel sounds
- No lesions noted

**Familial Health History:**
- Paternal grandfather has a heart problem; grandmother has no hereditary disease.
- Family history of hypertension and asthma.
- Both parents are negative for the disease; the mother is a non-smoker but drinks alcohol.

**Medical Health History:**
- **Perinatal (Mother):** Prenatal check-up started in the 4th month of pregnancy, Tetanus toxoid 1 given, febrile episode during the 3rd month, no physician consultation or medication.
- **OB Score:** G2P1 (1-0-1-1)
- **Past Medical Illness:** At 4 months, syncope, cough for 2 weeks, admitted and diagnosed with CHD, advised for surgical management which was refused due to financial constraints, poor compliance to Propranolol medication.

**Present Illness:**
- The client became restless and cyanotic after defecating, leading to admission at CMMC as advised by Dr. Mea Amor for further medical management.

**Task:**
1. Review the system sheet and expound on the familial and medical history of the client on the back of this form.