Acne; Pollen allergy

Dear Doctor,
I am 25 years old, male.
I have: Acne since 2008, Decreased Iron level in January and September, 2019, Pollen allergy since 2004, Mild subclinical hypothyroidism since January 2019.

I would like you to help me.

Thank you very much!

I am sending you my history.


_A. K/C/O : [Duration is important. e.g. HTN since 2 yrs. etc.] Acne since 2008, Decreased Iron level since 2019, Pollen allergy since 2004, mild subclinical hypothyroidism since 2019
B. Investigations :
Date : ,6.01. 2019 Haemogram / Blood Report/ Urine Report/ CT scan/ MRI/USG Abdomen & Pelvis/ Thyroid Function Test, etc;,; Complete blood count – normal; Fe – 9.66 /11-36/ Thyroid-stimulating hormone 5.00; TAT, MAT – normal; D – normal, 63.06 /50-120/,
Date : ,17.09. 2019 Haemogram / Blood Report/ Urine Report/ CT scan/ MRI/USG Abdomen & Pelvis/ Thyroid Function Test, etc;,; Complete blood count – normal; Fe – 7.60 /11-36/ Thyroid-stimulating hormone 4.430; FT4 – normal;
Date : ,19.12.2019 Thyroid Function Test, etc;,; Complete blood count – normal; Fe – 15.64 /11-36/ Hgb – 166 /135-180/
C. Chief C/O: Write the complaints with sides & duration.
Give them separate nos. [e.g. 1] Abdominal pain(Rt. side)Since 8 days. Etc.
1. Acne since 2008, currently on my neck and on the temples of face
2. Pollen allergy since 2004 – in May and June, from blooming trees, in a mild form
3. Decreased Iron level since 2019
4. Mild subclinical hypothyroidism since 2019

Please start with History of C/C : How complaints started?
H/o C/C : Write every complaint individually with-
1. Onset, decline, causation
• Side. Left and right
• Location & Extension – neck and on the temples
• Character of Pain. none
• Duration of Pain. none
• Sensation. none
• Modalities : Movements/ Positions/ Thermals/ Food Habits/ Seasonal/
Time

2. • Onset, decline, causation.
• Side –
• Location & Extension – eyes - tearing, nose – running nose
• Character of Pain.
Sensation. irritation

3. Duration of Pain.
• Sensation. Character of Pain. none
• Duration of Pain. none
• Sensation. None
4. • Sensation. Character of Pain. none
• Duration of Pain. none
• Sensation. None
• Modalities : Movements/ Positions/ Thermals/ Food Habits/ Seasonal/
Time
¾ Concomitant.

D. Ask for any recurrent complaint. Ex. Fever, Cold, Coryza.
runny nose,
red pimples and scars

E. Past H/o : Any major illness (along with side if present) e.g. H/o Typhoid/ Malaria /
None
And H/o Vaccination – Hepatitis B / Dog bite Vaccination, etc.
Blood Group O+

F. Family H/o
G. Physical Generals :
• Habit : Alcohol / Drugs/ Smoking/ Tobacco, etc. (Since how many tears?) No
• Diet : Veg./ Mixed.
Mixed
• Appetite : Any alteration? No

Whether patient can tolerate hunger? No
• Desire : With reference to taste and not any particular food item. e.g. Sweet, Pungent, Spicy,
Sour, Fatty(Oily, ghee), Non- veg, milk, milk products, tea, coffee, Vegetables, Fruits, Ice Cream, Cold Drinks etc. is important. Also ask for any desire for indigestible food items.
Sweet, milk products, Fruits, meats, bread
• Aversion : Main taste e.g. Sweet, Sour, Fatty, Non-veg etc. is also important.
• Food :sour
• Head :
• Eyes : lower eyelid formation
• Ears :
• Nose : running nose
• Mouth : any odour , No
• Tongue : Dry/Moist/ Coating/ Cracked/ Fissured/ Imprints of teeth
• Thirst : Thirsty/ S.Q.S.I./L.Q.S.I./
• Teeth :
• Gums :.
• Taste :
• Throat :
• Chest :
• Stomach/ Abdomen
• Bowel : Character of stool is important. Dry/ Hard/ Soft/ Loose. Color, Smell, Straining or not - sometimes? Etc.
• Bladder:
• Skin : scars on the face
• Chest & Back : scars and pimpls
• Extremities:
o Upper Extremities:
o Lower Extremities :
• Perspiration : normal
o Scanty/ Profuse. On which part of the body? normal
o Stain /Odour. none
o Hot/ Cold sweating. none
• Sleep : normal
o Time : Daytime any sleeping habit / Night time sleep hrs. –8 hours
o Sound/ Natural normal
o Refreshing/ Unrefreshing normal
o Startles/ Snoring – I used to have snoring
o Position : Whether lies on back / sides-which side ? sides
o Covering – normal
o Bed+ Pillow normal
o Talking/ Walking sleep during? none
o Eyes open / closed sleep during.
• Dreams :
• Female:
o Menstrual History
i. Menarche
ii. Duration of cycle
iii. Color of discharge/ Any clots, etc.
iv. Smell
v. Any pain Before / During etc.
• In General Discharges : Color/ Smell/ Quantity –scanty/ profuse etc. (very important)
H. Mind :
• Education : higher education
• Occupation : (Working / Retired) Studying
• Childhood at which place? City/ Town - City
• Marital Status : Married / Unmarried - Unmarried

Childhood :
o Family : Joint / Separate - Separate
o Financial Condition : Sound/ Poor/ Rich etc. . Normal
o About Study: excellent
o Nature : Obstinate/ Mild/ Pampered/ Short Tempered/ Irritable. - Irritable
o Desires Company or Not? Not
o Close to? mother
o Fear of the dark/ Stage courage – Yes/No
o Playful/ Studious. - Playful/ Studious
o Any impactful/ disturbing incidence in childhood. - No
o Angry when? How is it expressed ? Angry when irritated
o Timid / Daring. - Timid
o Ambition. – Yes

After Marriage. Unmarried
(Suppression injustice and relation with inlaws, Adjustment)
• NOW :
o Specially ask about main feelings : Anger, Sadness, Hypocrisy, Jealousy, etc. (Please, write in Rubric form)
o Family: Joint / Separate
o Financial Condition : Sound / Poor/ Rich etc.
o Mild/ Short Tempered
o Angry when ? How is it expressed?
o Talkative/ Less talkative.
o Jolly- Jesting/ Submissive
o Affectionate / Reserved/ Censorious.
o Reaction to Jesting
o Reaction to Criticism.
o Reaction to Reprimand
o Reaction to Mortification
o Any major conflicts - No
o Sympathy about ? - No
o Helping nature? - No
o Desires Company? - No
o About Cleanliness. - I keep the cleanliness and hygien
• About Time Punctuality. – Yes, very punctual
• o About Religiousness. - No
o Reaction to Lie & Injustice. -
o Fears ? (Being alone, Dark, Water, Height, Quarrel, Exam, Robbers, Animals, Downward Motion) - Dark
o Sensitive (Physically & Emotionally) – no
o Happy When? When I am at home
o Sad when?
o Weeps when? When I am sad
• o Consolation.
o Hobbies? Video Games
• o About Social Activities. No
• o Lazy/ Workaholic. Normal
o Industrious ? No
o Duty Bound? No
o Relation with others :
¾ Husband/ Wife -
• ¾ Son / Daughter.
¾ In-laws.
¾ Friends. No
¾ Colleagues, etc. No
• A/F :
o Anxiety about what ?
Loan, Court case, Money, Future, Health, Disease, Death, Job, Settlement, Children. - Yes
o Any Anticipatory Anxiety
o Death of Relatives : Yes,
Reaction : Grief, Sad, Forsaken, Helpless, Weeping.- Grief
o Any Insecurity - No
o Perfectionism. good workability and time management - good workability and good planning
o Fall/ Accident/ Injury/ Fracture/ Sprain/ Loss of fluid. - No
o Overexertion. No
• o Brooding. No
o Suppression of anger.- Yes
o Any major setback in life. - No

Your Observation(Physical Appearance/Dressing).
Thermals :
Summer Winter
Bathing Hot / Cold / Luke Warm Luke warm Hot / Cold / Luke Warm - Hot
Fanning requires or not? Yes requires or not? No
Covering Thick / Thin? (1 or 2,etc) Thin Thick / Thin? (1 or 2,etc) Thick

• Open air : desires or not Yes
• Require Sweater in Winter ? no
• Chills begin from which part? Hands