TOOBA HUSSAIN

3RD YEAR DIMC

GROUP B

HISTORY# 1:
Biodata:
Nargis wife of Muhammad Anwar, 47 years old, married, muslim, female and
housewife is a resident of malir. She has had a known case of epilepsy and
asthma for 2 years and now presented to OPD on 22nd of August 2023.

Presenting Complain:
Shortness of breath for 1 month
Chest pain for 1 month

History of Presenting Complain:

According to the patient she was in her usual state of health 1 month back when
she started developing shortness of breath which was gradual in onset, moderate
in intensity, and having seasonal variations.
It was progressive in nature, aggravated by lying flat and relieved by taking an
inhaler.
It was associated with a cough for 15 days which was sudden in onset,
progressive and dry in nature aggravated by talking and relieved by taking
hydraline syrup with no diurnal variation.
After that she developed both sided chest pain which was sudden in onset,
moderate in intensity radiating to the posterior chest wall, non shifting and non
referred.
The pain was progressive and heavy in nature aggravated by sitting and relieved
by taking nuberol forte.
It was associated with fever for 1 month which was gradual in onset, low grade
associated with rigors and chills undocumented being high in the evening and
associated with night sweats.
It was also associated with vomiting for 2 days which was sudden in onset and
non-projectile with a frequency of 2-3 episodes per day.
The amount of vomitus per episode was almost half a cup.It was yellow in color
with non foul smelling and contained only food particles.

Past Medical History and Surgical History:

Patient is non diabetic non hypertensive and has no history of ischemic heart
disease tuberculosis or arthritis.
There is no history of blood transfusion.
There is no history of recent hospitalisation.
There is a recent history of travel to Hyderabad.

Personal history:
There’s no history of blood transfusions and denies the use of alcohol, tobacco, or any
illicit drug use.

Family History:
There is no family history of similar complaints in the past.
Her father in law had a history of tuberculosis.
Her family is non diabetic non hypertensive and has no history of ischemic heart disease
asthma or arthritis.

Drug history:
Patient does not have any history of prolonged drug intake except Tamlev - 500mg for
epilepsy and inhaler for asthma.
There is a history of use of tablets similar to rice for asthma due to which her condition
became worse than before but she has no idea about the name and dosage of the drug.
There is no history of hakeem medications, steroids or kushta intakes.
There is no history of drug allergy as well.

SYSTEMIC REVIEW:
On systemic inquiry, the patient complaints of weakness, headache, back pain,
numbness of the left side of body, diarrhea, palpitations on walking, dark colored
urine and undocumented weight loss in last 6 months with poor appetite.
There is no other abnormality seen in rest of the systemic inquiry.

Social History:
Patient belongs to a lower socioeconomic class.
HISTORY#2

Biodata:
My patient Akhtar Rasheed son of Irshad Hussain is a 40 years old married
muslim male bykea rider by profession resident of Gulshan e Iqbal came to opd
on 19th of August 2023.

Presenting Complain:
Cough for 20 days.
Chest pain for 20 days.

History of Presenting Complain:

According to the patient, he was in his usual state of health 20 days back when
he started developing cough which was sudden in onset, progressive and
productive in nature, non aggravating and non relieving with no diurnal variation.
It was associated with sputum with frequency of 10-15 episodes per day.
The amount of sputum per episode was almost 1 glass.
It was initially green in color and later it became brown with foul smelling and
contained fresh blood for a once which was of short duration.
It was also associated with grade 3 shortness of breath.

After that he developed both sides chest pain which was sudden in onset,
moderate in intensity non radiating non shifting and non referred.
The pain was progressive and pricking and nature aggravated by movements
with no relieving factors.
It was associated with vomiting which was sudden in onset and non projectile
with frequency of 3-4 episodes per day.
The amount of vomitus per episode was almost 2 glass.
It was yellow in color, non foul smelling and contained only food which he eat.
It was also associated with fever which was gradual in onset, low grade
associated with rigors and chills documented 101F being high in the evening.

Past Medical History and Surgical History:

Patient is non diabetic non hypertensive and has no history of ischemic heart
disease, asthma or arthritis.
Patient has history of pulmonary tuberculosis in 2019 and in 2020 again for
which he got treatment of 6 months and got resolved.
There is no history of blood transfusion.
There is no history of recent hospitalisation and travelling as well.

Personal history:
There’s no history of blood transfusions and denies the use of alcohol, tobacco, or any
illicit drug use.

Family History:
There is no family history of similar complaint in the past.
His mother is diabetic and hypertensive with good compliance and good control.
There is no family history of ischemic heart disease tuberculosis asthma or arthritis.

Drug history:
Patient is not having any history of prolonged drug intake for any recent or past
problem.
There is no history of hakeem medications steroids or kushta intakes.
There is no history of drug allergy as well.

Personal History:
Patient is non smoker and has no history of smoking or any other addictions.
He has normal bowel and bladder habits.
There is no history of any kind of allergy.

SYSTEMIC REVIEW:
On systemic inquiry the patient complaints of weakness, headache, red coloured
urine, dysphagia, constipation and weight loss of about 4 kg with poor appetite in
last 6 months. There is no other abnormality seen in rest of the systemic inquiry.

Social History:
Patient belongs to middle socioeconomic class.
HISTORY#3

Biodata:
My patient Shoaib son of Muhammad Saleem is 38 year old married Muslim
male Air conditioner operator by profession resident of korangi came to opd on
19th of July 2023.

Presenting Complaint:
Pain in RLQ for 2 months.
Cough for 1 month.

History of Presenting Complaint:

According to the patient, he was in his usual state of health 2 months back when
he started developing pain in the RLQ which was sudden in onset, severe in
intensity, non radiating, non shifting and non referred.
The pain was progressive and colicky in nature aggravated by lying down and
relieved by taking IV medications from local hospital.
It was associated with fever which was acute in onset, high grade associated
with rigors and chills documented 104F being high in the evening.
It was not associated with nausea or vomiting.
After one month, he developed cough which was gradual in onset, progressive
and productive in nature, non aggravating and non relieving.
It was associated with chest pain which was sudden in onset, moderate in
intensity, non radiating, non shifting and non referred.
The pain was progressive and heavy in nature aggravated by coughing with no
relieving factors.
Cough was also associated with sputum with frequency of 3-4 episodes per day.
The amount of sputum per episode was almost one spoon.
It was green in color with foul smelling and contained blood for a once about 6
days ago.The amount of blood was almost less than a spoon.
Past Medical History and Surgical History:
He is non hypertensive but has history of tuberculosis in the age of 10 years.
There is no history of ischemic heart disease, asthma or arthritis.
There is no history of blood transfusion.
There is no history of recent hospitalisation and travelling as well.

Personal history:
There’s no history of blood transfusions and denies the use of alcohol, tobacco, or any
illicit drug use.

Family History:
His whole family is diabetic except his children's.
There is no family history of hypertension.
His mother and uncle has history of tuberculosis.
His mother got treatment for 6 months and got resolved but his uncle died due to tuberculosis
according to him.
There is no family history of ischemic heart disease, asthma or arthritis.

Drug History:
Patient is diabetic from 5 from 5 years for which he's taking insulin with good
compliance and good control.

Personal History:
Patient is non smoker and ha no history of any other addictions except maya.
He has normal bowel and bladder habits.
There is no history of any kind of allergy.

SYSTEMIC REVIEW:
On systemic inquiry, the patient complaints of weakness, headache, dysphagia
and weight loss of about 6kg with poor appetite in last 6 months.
There is no other abnormality seen in rest of the systemic inquiry.

Social History:
Patient belongs to a lower socioeconomic class.