Specimen Case 1

Describe all your present complaints, first the most troublesome ones, then others. As far as possible, try to provide the following details about each complaint with date of its start, if possible:

i. Nature of the complaint

ii. Seat of the complaint

iii. Conditions and circumstances which cause increase, decrease or relief of the complaint

iv. At what time of the day or night is the complaint worse?

v. Any cause for this particular complaint?

Food allergies- small red rashes appear as an insect bite from underneath the skin as soon as certain foods are ingested. (foods include milk, butter, yogurt, cheeses (any kind), yeasty breads (and anything with bread crumbs and yeast, anything fermented), sugar (any simple sugar and fruit sugars), and whole wheat flour).  Appear mainly on the upper legs and arms sometimes, and now they’ve started to appear on my face a little bit.  Appear in about 10-30 minutes after ingesting those foods.

• Pus filled painful boils when I eat sugar or sweets- appear on my lower back and buttocks). Appear within an hour or so.
• Small blister-type pus filled boils when I eat yeast related foods (appear on my shoulders and back) or especially yogurt (appears on my vaginal area when I eat yogurt). I was told that this is a recurring staph infection.  It’s as if I get this after I eat any cultured foods, i.e. cheese, yogurt, yeast.  (This is in addition to the rashes when I eat these foods).  Appear within 10-30 minutes of ingesting these foods.
• Diarrhea when I eat really fatty foods, such as really oily/buttery/heavy foods. Have diarrhea right after eating those foods.  Also have really bad stomach growling and loud noises when fatty foods are ingested.
• Really dry skin and scalp no matter how much vitamin E or oily foods I eat. It is as if I have a real problem of fat/carbohydrate absorption/digestion.

a: Nature of the complaint (e.g. pain, soreness, coldness, heat, numbness, burning, uneasiness, emptiness, swelling, etc.);

• I start to itch as soon as those rashes appear on my skin. With boils, I tend to have a lot of pain, especially if it’s not fully on the skin and is still developing underneath the skin.  With small blisters, I feel itch and pain, somtimes soreness.  With diarrhea, I feel really sick in the stomach, no pain, but just growling noises and diarrhea right away.  

b: Seat of the complaint (e.g. head, chest, foot, kidney, heart, etc.);

• Mostly skin, rashes and boils/blisters. Diarrhea, I feel it’s my intestines/stomach digestive problem.

c: Conditions and circumstances which cause increase, decrease or relief of the complaint (e.g. rest, movement, heat, cold, open air, when in room, light, noise, odours, touch, pressure, standing, sitting, lying, weather, season, in company, when alone, eating, drinking, urination, defaecation, certain food items, emotions, mental exertion, physical exertion, conversation, perspiration, occupation (the state of being busy), etc.);

• I sometimes get small bumps on my skin and similar itching when my arms/legs are exposed to cold weather (similar to hives).

d: When is the complaint worse? (Morning, forenoon, noon, afternoon, evening, night, midnight);

• There’s no timing for the complaints, it’s mostly a reaction after I eat those foods, and it can be whenever I eat them, whatever time.

e: Any cause for this particular complaint?

• Food allergies, weak digestive system.
• What do you think is the cause of your present complaints? (e.g. shock, fear, worry, stress, dietary errors, unhealthy living, overexertion (mental and/or physical), injury, exposure to cold, heat, wetting, etc.)
• The real cause of these allergies started when had taken several weeks (about 3 months) of antibiotics from 4-5 different doctors, due to a really bad cold that I had. My cold never got cured from those antibiotics, however, I took some herbal teas and I was cured from this stubborn cold.  After that, I had attracted a staph aureus infection, for which I took really strong antibiotics such as clyndamycin, several different times they recurred and each time it was some infection from the staph family, but something different.  My doctor didn’t want me to keep on taking more antibiotics, because he didn’t want me to become  resistant and get Methycillan Resistant Staph Aureus (MRSA). 
• What medicines have been taken so far and with what result? If you do not remember all, just name the last one.
• Lots of antibiotics, tetracylcine and augmentin, mostly antibiotics from the penicillan family. I don’t remember all of them.  Clyndamycin was my last one and I’ve taken this several times for my staph infection.  Clyndamycin would clear up my staph infection, but it has been recurring every twice or so a year with certain foods and also from shaving/hair removal products (I’ve also been told it’s called Staph folliculitis (hair follicle infection when it infects the pores of my skin where hair grows.  I can’t use razors on my skin anymore, I get staph infections/rashes. 
• How do changes in temperature, of weather and season affect you? ( warm, cold, winter, summer, extreme heat or cold, wet, etc)
• I am a spring/fall person. I feel normal in those seasons.  In summer, I feel extremely hot, however, I don’t like using fans/AC.  In winter, I always catch a cold/flu/cough.  I also have recurring coughs whenever I eat/drink cold foods.  I normally dress up completely even if it’s not to cold, just to avoid catching a cold since my cold/coughs/flu are really terrible/stubborn.   
• What tests have been done so far? Give a summary of their findings.
• I have been tested for diabetes several times (empty stomach and after eating) and it’s been negative each time. I’ve been tested for thyroid, and it was normal.  About 3 years ago, I had a little high platelets count, and my doctor had suggested an MRI of my head, which was normal.  I had a staph infection which I’ve mentioned earlier about 2.5 years ago.  I was told to avoid foods which I’m allergic to and then try eating lots of that allergic food at once to see the reaction and that’s how I’ve figured out my allergies, mostly experience and noticing my diet and changes.   About two months ago, I had a blood test where my sedation rate  of the blood cells was really high.  After that I was tested for Lupus, negative.  I had an upper endoscopy of my intestines to check for celiac disease, that was normal.  I also had a colonscopy, and I was told I had microscopic colitis, which is a very low form of colitis.  I also had a skin biopsy for celiac disease, which came out negative, but sometimes it comes out negative although the patient may surely feel that they get those rashes when they eat wheat.  I told my doctor it was more of yeast in the wheat, but American medicine doesn’t believe in Candida problems, although Europeans/Asian doctors are much more aware of nutrition and preventive medicine and they do believe that candida exists (yeast related allergies when your beneficial bacteria is wiped out. 
• Personal History:

a: mode of living, habits, activities, social and domestic relations, any accident or event which you think may have something to do with your present troubles.

• I used to be a very active person, very lively and happy person. Now I feel really low of energy easily.  I get tired very easily.  I’m not active anymore the way I used to be about 2-2.5 years ago.  I used to feel happy and didn’t have mood swings/depression at times.  Now I get angry really easily and sometimes have mood swings.   

b: any difficulty or problem in discharging your day-to-day domestic or occupational obligations?

• I have trouble studying/working concentrating continuously on my school work/career goals.  I don’t have the energy to do those things.  My diet is really limited and I’m not getting proper nutrition from past two years.  I don’t eat any sweets and don‘t feel energized to stay up working/studying for long.  I have lost about 22 pounds from the past 2 or 2.5 years.  I’m underweight according to my height/age.

c: any irregularity in daily routine life e.g. meals, rest, sleep, etc?

• I’m afraid to eat many foods now, especially since I get those reactions right away and they cause so much discomfort/irritation in me. I used to love eating everything and I used to eat lots of different foods, and used to use up my calories by working out, used to love eating outside halal foods, but even those are limited for me now.  I don’t work out anymore, because I loose a lot of weight, even by just toning up myself and I get tired very easily.  I tend to skip meals now, and I know I’m not getting proper nutrition, not enough calcium, not enough carbohydrates/fats.  And even the days when I do eat properly, I will not gain weight.  Most of my food is easily passed thru, I really feel my digestion is not proper.  My diet mostly consists of meats/vegetables and some breads (rotis), not much yeasty breads. 

d: any addiction?

e: colour, height, weight. Howmany pounds (or kilos) have you lost or gained since the beginning of the present illness?

• Medium to fair skin, 5 feet 4 inches, 100 pounds now, small bone frame. I used to be 122 pounds about 2.5 years ago.  I was 110 in January of 2007, but have lost all those pounds after my Mom passed away in January of this year.

f: anything else?

• Married last year in July. Monthly cycle is normal. 
• Miscellaneous:

i) Tell about your thirst (how much and how often you drink) and appetite (voracious, normal, wanting, easy satiety, cannot bear hunger, etc.);

• I feel really thirsty and drink lots of water. I urinate  a lot too.  I’ve tried to cut down on my drinking water habit so I can urinate less frequently.

Any problem after eating or drinking?

• My stomach bloats  after I drink water after eating. 
• ii) Name the items you like the most (sweety, salty, spicy, sour, coffea, tea, cold drinks, fats, fruits, milk, meat, tea, vegetables, ice etc.);
• I love all foods but since those allergies, I eat very limited foods.

ii) Could your liking for a certain thing be called a craving (i.e. a very impassioned desire – (its equivalent in Urdu is shadeed khahish – nehari  mujhay diwangi ki had tak pasand hai! Children crave toffees, ice creams);

• I love eating specialty foods, outside Pakistani/Afghani/Arabic foods, but I only try to eat the foods which I think I’m not allergic to. I’ll eat lots of those foods which I can, when I can but I’m not crazy about anything where I will call something a craving, sitting somewhere’s and will have a desire to eat that right away.  

iii) Name the food items you dislike and, if possible, also give reasons why you dislike them.  Is your disliking for a certain food item so intense as to be termed an aversion? (In Urdu it can be: sakht napasand, chir, nafrat);

• I love foods, mashallah, it’s a blessing to be able to eat everything Allah has created (halal) for us to eat in this world.
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• iv) Condition of tongue (e.g. coated, clean, dirty etc.)
• Most of the time, my tongue is white, but I try to brush my tongue whenever I brush my teeth. However, my mom used to say that I sometimes had a bad breath and she used to tell me that it has something related to my stomach.  I feel that it’s because my food is not digested properly.  My teeth are clean and I brush regularly.
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• v) Condition of nails (any cracks, spots etc.)
• They used to grow very quickly and they used to be medium hard. Now they grow very slowly, which I think is due to lack of calcium absorption/deficiency.  Sometimes, I have white spots on my nails.
•  
• vi) Any warts, moles or growths? Where?
• I had a medium-sized mole on my lower back, right on the top of my buttocks, but my doctor had me removed thru surgery when I was very young. 

vii) Stool, urine, sweat: Any thing remarkable ?

• Stool is normal most of the times, except when I eat fatty foods, in which case I get diarrhea. Urine is clear most of the times, except when I take some vitamins.  I’ve had my urine tested several times, and I was told that I had some blood in my urine.  I never re-tested.  I don’t sweat and don’t have any body odor. 

viii) Sleep and dreams: Any thing remarkable?

• Sleep is normal mashallah. Dream frequently, sometimes good, sometimes very strange/negative.  Sometimes I see snakes, sometimes I see my Mom in my dreams and sometimes nothing related, just very strange. 
• Past History:

a: Describe all or as many episodes as you can remember of the skin diseases you have had since birth with their treatment and results. Also mention dates if possible;

• No skin diseases since birth, Allah ka shukar hai, except for chicken pox, two or so times when I was very young. 

b: Any kind of venereal disease with treatment and results;

c: Vaccination/inoculation, etc., since birth. Any ill-effects after any of them?

• I don’t remember any vaccinations, but I’ve had all the required vaccinations since birth, just recently had my tetnus shot because I had fallen down on dirt and had scraped my knee really badly. 

d: What illnesses have you had since birth? If possible, describe in chronological order. I am particularly interested in knowing about mumps, measles, pox, whooping cough, throat troubles, pneumonia, malaria, typhoid, etc.

• Haven’t had any illnesses since birth, except for chicken pox and coughs.
• Family History:
• Mother- started off with arthritis, took medicines which affected her kidneys, couldn’t eat salt, ate everything sweet and fatty, got heart problems and diabetes.  Last 2-3 years ago, was diagnosed with lupus. 
• Father- Diabetes and now heart problems. Had collapsed about 6 years ago and broken his hip bone, now he is retired/disabled.

Presence of any of the following diseases in your blood relations (both paternal and maternal):  asthma, biliary colic, cancer, diabetes, epilepsy, fistula, high blood pressure, insanity, peptic ulcer, piles, renal colic, rheumatism, tuberculosis, etc.

Please let me know if you have any additional questions, I’ve tried to be as detailed as I could’ve been.  Thank you.