Name : Othman Alagha Uni.

NO. : 120160802

Case History

Personal details :
Mr.Mohammed Ahmed Asfour, a 28 year old male patient from Khanyonis, he is
married, work as management employee at Ministry of Health, he is non
smoker.

He was admitted via emergency department to male internal medical ward at

Nasser Medical complex.

This history was taken by Othman Atef Alagha from the patient himself on
Wednesday 17/07/2019 at 10.00 A.M.

Chief complain :
chest pain for 1 week.

Present illness :
The patient was doing well until the last week when he started complaining of
retrosternal chest pain . The pain starts suddenly, it is burning in nature, well-
localized and not radiate to any site. It aggravated by exertion and relieved by
rest and after receiving Deoclofin and Decort injection. The pain is severe that it
awak the patient from sleep .The pain severity increases at the morning.

The pain was associated with productive cough, the sputum was green to
yellow. The cough presented mostly at the morning, the amount is mild. There
is no blood in cough.

There is an epigastric pain associated with chest pain and with every cough
episode, starting gradually, localized and there is no radiation. The pain is
burning in nature. It was aggravated by cough and relieved by rest. The pain
was severe. There was a bilateral lower limb edema.

There was an intermittent fever and occasional night sweats.

There is no dyspnea, wheeze, hoarseness or nasal symptoms.

The course of symptoms was stationary constant.

No weight loss or anorexia..

Past history :
The patient hadn't has any previous similar condition. He hadn't has any chronic
disease. His previous hospitalization was in 2013. No recent vaccination
received.

He didn't undergo any previous surgical operation. No blood transfusion done

before.

Drug history :
The patient takes Ventolin aerosol and Azithromycin but the dose not knwon.

He also takes Deoclofin and Decort injection to relieve the pain and IV Rocephin
when he got recurrent infections.

He didn't take anticoagulants or corticosteroids.

He hasn't any drug or food allergy.

Family history :
There was no similar condition in his family. There was no chronic diseases in
his relatives. There was no inherited diseases in his relatives. The couples aren't
relatives. There was no sudden death in the family.

Family pedigree :

Social history :
The family type is nuclear, he lives in a concrete house in the ground floor, he
finished bachelor degree.

His financial state is good and he has a medical insurance.

He works as management employee in the Ministry of Health, he didn't do

exercises.

He is non smoker. No recent travel. No animal contact. No contact with ill

people. No specific diet is followed.

He has no children although he is married since 2 years and his wife aborted an
embryo in her 6th month of pregnancy.

Systemic review :

Nervous:

No headache, no dizziness, no visual disturbances

Musculoskeletal :

There was a bilateral arthalgia which develops gradually.

GIT :

There was no mouth pain, ulcer, dental desiase, no vomiting or nausea, no

dysphagia or odynophagia , no diarrhea , no constipation, no change in stool
color.

CVS :

There was no palpitation, no tachycardia, no cyanosis, no claudication.

Endocrine :

Normal appetite , normal sleep , no heat or cold intolerance, no excessive

drinking or eating.

Urinary :

There was no dysuria , no frequency or urgency , no flank pain, no hematuria.

Hematological system
No bleeding, no bruising.

Skin:

Pigmented spots on skin, large to medium size nodules, hump on back, no signs
for skin

infection or irritation, no skin rash.