Aycocho, Ann Myrthel de G.

3NU02; Group 2

Biographic Data

 Patient’s Name : Ino, Kyle

 Age: 2 years old and 5 Months
 Address: Anonas Extension Antipolo Hills, Antipolo City
 Birthdate: March 17, 2008
 Position in the Family: Youngest son
 Religion: Roman Catholic

Parents

 Mother: Emily Ino

 Father: Roxel Cortez
o Not Married
 No. of Child: 4

History of present Illness

 The night prior to admission, there is positive leaking in the fluid-filled sac in the head at the
occipital area.
 Few hours prior to admission, there is an increase in fluid discharge. Afebrile.
 On August 19, patient was admitted first time in the ward at 11 am via wheel chair.

Assessment:

 Wt: 9 kgs
 Bp: 40/60
 HC: 48 cm
 CC: 44 cm
 AC: 44 cm

Drugs given:

 Ceftazidine 450 mg q8 IV
 Amikacin 45 mg q8 IV

Past Health History

 NSD delivery at home assisted by the TBA after 5 hours of labor and delivered at birth with small
sac and increases in size as the patient grows older.
 Mother: No prenatal Visits, No illness during pregnancy, No exposure to teratogens.
 Breastfeed until now
 Immunization: (+) BCG, incomplete
 No consultation done.

Family History

 Mother side: No known History

 Father side: Cleft lip
o 1st Child: with Cleft lip