INFORMANT: CASTRO, Rica

RELIABILITY: 95%
GENERAL DATA
NAME: CASTRO, Enrico Resuello

SEX: Male

AGE: 12 days old

BIRTHPLACE: Macarena St. Malabon City

DATE OF BIRTH: October 31, 2014

ADDRESS: 3-Y Araneta Village Malabon City

NUMBER OF ADMISSION: 1

DATE AND TIME OF ADMISSION: November 1, 2014

CHIEF COMPLAINT:
Sobrang naninilaw ang baby ko
HISTORY OF PRESENT ILLNESS:
14 hours prior to admission after being born to a lying in clinic. Patient was noticed to have a
yellow discoloration of the skin and poor appetite. In the lying in clinic he was exposed to phototherapy
and there was no medication given to him. Patient was then rushed to MCU-FDTMF hospital.
PAST MEDICAL HISTORY:
Since its the first time that the patient was hospitalized there was no previous illness was
noted. There were no operations, accidents and no known allergies.
FAMILY HISTORY:
Mother of the patient Rica Castro is a 30 year old in good mental health. Rica, 10 years ago
underwent peritoneal dialysis for 1 month because of drug overdosed. Rica is a single parent and no
information about the father of the patient. Enrico is the only child of Rica.
No miscarriage and abortion happened before Enrico.
SOCIAL HISTORY:
Mother of the patient finished a 2 year degree course of Caregiver. She is now currently working
as a Package checker in a gulaman factory. They live in their own house in Araneta Village, Malabon City.
She is living with her parents, siblings, nephews and nieces. They are 13 in the house. She shares her
room with her younger sister. She has a good relationship with her family. Water supply was from
Nawasa. There is a two comfort room. Garbage is collected every morning. Colds and cough are
prevalent in their neighbourhood.

PERSONAL HISTORY:
Prenatal History:
According to the mother of the patient, she just knew that she was pregnant on her 4th month of
pregnancy. During the 1st trimester she had toothache and took pain reliever. She continued working up
to her 3rd trimester and just took a leave of absence 2 weeks before her delivery. She had fever and
cough for 3 days 1 week before giving birth. She did not consult her doctor and no medication was taken
except for calamansi juice. She also took ferrous sulphate and CLusivol during her pregnancy. No folic
acid was taken. There was no known exposure to infectious agent, complications and teratogens.
Natal History:
Enrico was born 5 days after the expected date of delivery. He was expected to be delivered on
October 26, 2014 but came out October 31 2014. He was born on a normal delivery