Specimen Case 2

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?

Complaint No. 1   Vision problem

Nature of the complaint: Gradual loss of vision over the last ten years. Side vision has been decreasing. Cannot make out colours clearly (e.g. when a white object is placed on a white table top, I cannot see it. If there is a pothole in the road, I cannot see it and will tumble in it. I cannot make out the edge of the stairs and have to feel it with my feet). There is a yellow smokescreen in front of my eyes which means that whatever I see is not very clear and sharp.

Seat of the complaint: Eyes

Conditions and circumstances which cause increase, decrease or relief of the complaint: In darkness, I just cannot see anything. Low light also affects visibility. Reading is difficult when lying down.

When is the complaint worse? At night because of dark.

Any cause for this particular complaint?     Was diagnosed as being genetic. There are others  in the family with similar problem.

Complaint No. 2:   Dry eyes

Nature of the complaint: The eyes feel dry, itchy, heavy and prickly

Seat of the complaint: Eyes

Conditions and circumstances which cause increase, decrease: Get relief when I use eye drops

When is the complaint worse?  In morning

Any cause for this particular complaint? Came on after my cataract surgery

After cataract surgery

Complaint No 3:  Incontinence and urinary infection

Nature of the complaint: The bladder feels full at very short intervals. Cannot hold urine for long.  Sometimes I leak just when I am going to the bathroom. The urinary infection has cleared up but recurs at time causing burning sensation in abdomen.

Seat of the complaint: Not sure – maybe bladder

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

When I drink a lot of tea and coffee the problem is aggravated. It is worse when I am nervous. When worried about some problem, it becomes worst.

When is the complaint worse?  In the morning

Any cause for this particular complaint?  Began after menopause.

Other complaints:  High blood pressure (being treated and well managed) – for 10 years

High cholesterol (being treated and under control). Cholesterol is high when I don’t take medication.

Memory loss

Have become forgetful of late. Forget appointments or other marrers.

 

  1. What do you think is the cause of your present complaints?  Can’t see any reason except genetic
  2. What medicines have been taken so far?                                                                        Vitalux – multivitamins, Genteal eye gel, Blink Fresh eye drops, Detrusitol, Furosil, Augmentin, Hyzaar, Norvask, Ascard-75Lipitor

 

  1. How do changes in temperature, of weather and season affect you?  No visible impact
  2. What tests have been done so far? Give a summary of their findings.

Eye tests to measure range of vision

Ultrasound of bladder and kidney. Normal. Urine test. Infection

 

  1. Personal History:

 

Live by myself. Am comfortable and contented. Try to be careful about my diet. Particular about physical exercise (morning walk for 1 hour) Sleep soundly about 6  hours at night. No special loss  or gain in weight. No addiction.

 

  1. Miscellaneous:

Average thirst (about 6 glasses of water in a day. Snacking between meals. Craving for sweet things. No special aversion. Nothing extraordinary about the above mentioned things.

 

  1. Past History:

The only skin disease is dry palms and fingers when under stress. Had BCG and small pox vaccination in childhood. Have had mumps, chicken pox, diphtheria, have chronic sinus problem. In my childhood had a number of surgeries on foot.

 

  1. Family History:

My parents had heart disease, cancer, high blood pressure