10/09/03
Chief Complaint: She is always tired, has eruptions in the scalp, gets ulcers in her mouth, her glands get swollen often. She has had chronic and recurrent ear infections with high fevers; has had miringotomies twice, and an adenoidectomy in 1994.
Past Medical History:
Chickenpox, and seasonal allergies. Has had a Steven-Johnson’s reaction to Sulpha drugs.
Family Medical History:
Her mother also suffers from seasonal allergies; the father suffers from irritable bowel syndrome.
Review of Systems:
She has an intense sensitivity to smells, particularly smoke and sharp odors.
Her face has a red discoloration often.
She tends to eat a lot; craves colas, chocolate, cookies and ice cream. There are many foods she doesn’t like, especially spinach, grilled vegetables, and spicy foods.
She has intense skin sensitivity, particularly to touch, fabrics, tags and her scalp is sensitive to hair brushing.
She has vaginal discharges yellow or white, without burning or itching.
Feet sweat a lot.
She has pain in the dorsal and lumbar spine, mostly in the morning on waking.
Sleep is not good; she may wake up at 5:00 am and will not be able to get back to sleep. She often has bad dreams and wakes up from them; wakes up feeling nervous. The dreams are of people dying or of violence.
She also complains of having anxiety and palpitations with the anxiety.
She tends to be shy, worries, has persistent and intrusive thoughts and feels inadequate socially. She feels better when she talks about her feelings. She often feels moody, cranky, at times she feels hyper, and has been told she has mild ADD. Her attention may drift in school. She has tried stimulants but it made her irritable and angry.
She has had some difficulty with fine motor skills.
Physical Examination:
Unremarkable.
Assessment:
Sum of symptoms (sort:deg) – Sum of symptoms (sort:deg) – Intensity is considered
| 1 | 1234 | 4 | GENERALS – WEAKNESS – exertion – agg. – slight exertion | 86 |
| 2 | 1234 | 4 | EAR – INFLAMMATION | 54 |
| 3 | 1234 | 4 | EAR – INFLAMMATION – Media | 67 |
| 4 | 1234 | 4 | GENERALS – HISTORY; personal – ear – inflammation – Internal; of recurrent | 7 |
| 5 | 1234 | 4 | HEAD – ERUPTIONS – Scalp | 13 |
| 6 | 1234 | 4 | MOUTH – ULCERS | 129 |
| 7 | 1234 | 4 | FACE – INFLAMMATION – Submaxillary glands | 54 |
| 8 | 1234 | 4 | NOSE – SMELL – acute | 134 |
| 9 | 1234 | 4 | FACE – DISCOLORATION – red | 375 |
| 10 | 1234 | 4 | GENERALS – FOOD and DRINKS – sweets – desire | 207 |
| 11 | 1234 | 4 | GENERALS – FOOD and DRINKS – vegetables – aversion | 36 |
| 12 | 1234 | 4 | SKIN – SENSITIVENESS – touch; to | 30 |
| 13 | 1234 | 4 | GENERALS – CLOTHING – intolerance of | 67 |
| 14 | 1234 | 4 | MIND – SENSITIVE – touch, to | 36 |
| 15 | 1234 | 4 | FEMALE GENITALIA/SEX – LEUKORRHEA – white | 113 |
| 16 | 1234 | 4 | FEMALE GENITALIA/SEX – LEUKORRHEA – yellow | 138 |
| 17 | 1234 | 4 | BACK – PAIN – morning – waking; on | 30 |
| 18 | 1234 | 2 | BACK – PAIN – Dorsal region – morning – waking; on | 1 |
| 19 | 1234 | 4 | BACK – PAIN – Lumbar region – morning – waking; on | 4 |
| 20 | 1234 | 4 | BACK – PAIN – Lumbar region – waking; on | 40 |
| 21 | 1234 | 4 | SLEEP – SLEEPLESSNESS – waking agg.; after | 94 |
| 22 | 1234 | 4 | CHEST – PALPITATION of heart – anxiety – with | 144 |
| 23 | 1234 | 4 | MIND – THOUGHTS – persistent | 125 |
| 24 | 1234 | 4 | MIND – CARES, full of | 74 |
| 25 | 1234 | 4 | MIND – MOOD – changeable | 204 |
| calc. | merc. | sulph. | sil. | phos. | psor. | kali-c. | ars. | puls. | nat-m. | |
| 76/148 | 72/136 | 72/136 | 72/100 | 68/124 | 68/104 | 68/84 | 64/136 | 64/132 | 64/124 | |
| 1 | 3 | 2 | 2 | 1 | 3 | 2 | 1 | 3 | – | 2 |
| 2 | 2 | 3 | 1 | 1 | 1 | – | 1 | – | 3 | – |
| 3 | 3 | 3 | 3 | 3 | 1 | 2 | 2 | – | 3 | 2 |
| 4 | 1 | 2 | – | 1 | – | 1 | – | – | – | – |
| 5 | 2 | 1 | 2 | – | – | – | – | 3 | – | – |
| 6 | 1 | 2 | – | 1 | 2 | 2 | 1 | 3 | – | 2 |
| 7 | 1 | 3 | 2 | 2 | – | 2 | 1 | 1 | 2 | 1 |
| 8 | 2 | 1 | 2 | 1 | 3 | 1 | 1 | 2 | 1 | – |
| 9 | 1 | 2 | 2 | 2 | 3 | 1 | 1 | 2 | 2 | 2 |
| 10 | 2 | 2 | 3 | 1 | 2 | 1 | 2 | 1 | 2 | 1 |
| 11 | 1 | – | 1 | – | 2 | 1 | – | 1 | – | 2 |
| 12 | – | – | – | – | – | – | – | – | 1 | – |
| 13 | 3 | 1 | 1 | – | 2 | – | 1 | – | 2 | 2 |
| 14 | – | – | – | 1 | 1 | – | 1 | 1 | – | – |
| 15 | 2 | 2 | 1 | 1 | 1 | 2 | 1 | 2 | 2 | 3 |
| 16 | 3 | 2 | 3 | 1 | 1 | 1 | 1 | 3 | 2 | 1 |
| 17 | – | – | – | – | – | – | – | – | – | 1 |
| 18 | – | – | – | – | – | – | – | – | – | – |
| 19 | – | – | – | – | – | – | – | – | – | – |
| 20 | – | 1 | 1 | 1 | – | 1 | – | – | 1 | – |
| 21 | 1 | 2 | 2 | 3 | 2 | 1 | 1 | 3 | 1 | 3 |
| 22 | 3 | 2 | 3 | 1 | 3 | 2 | 2 | 3 | 3 | 3 |
| 23 | 2 | 1 | 2 | 2 | 1 | 2 | 1 | 2 | 2 | 3 |
| 24 | 2 | – | 2 | 1 | 1 | 2 | 1 | 2 | 3 | 2 |
| 25 | 2 | 2 | 1 | 1 | 2 | 2 | 2 | 2 | 3 | 1 |
Considering her increased sensitivities and recurrent acute infections, I will start treatment with Sulphur in order to clarify the constitutional symptoms.
Plan:
Sulphur 6X once per day.
11/14/2003
Has felt better since she started the Sulphur; she still feels fatigue and is moody. Her face is better; is not as red. Her scalp continues to be sensitive. Ulcers in the mouth are better.
Plan:
Continue with Sulphur. Natrum Carbonicum 30 C, one dose.
1/02/2004
She has continued feeling tired. She is not eating as much; has been able to cut out some of the foods that are not good for her. Has had a little cold.
Has felt moody and irritable and feels that the family doesn’t love her.
She had a period of some pain in muscles and joints, flu like symptoms, with stringy mucus. She is feeling better now.
She had her first menstrual period; had a lot of flatulence the day before the menses.
She has been able to sleep through the night. She has felt warmer than normal.
Feels isolated and unloved by her friends; feels the school is very crowded; too many people she doesn’t feel she can connect with. People see her as weird because of the way she relates to people. She feels more comfortable feeling unique.
Plan: Pulsatilla 200C, one dose.
01/23/2004
She is a very deep thinker; identifies herself with peers. She throws things when she is angry. She puts heavy demands on herself to act like an adult. She is ready to be more independent publicly and wants to test the waters.
She is afraid of being along for long periods of time; has a hard time making decisions. At times she gets really nervous and afraid of something bad is going to happen. She tends to have a vivid imagination.
Plan: no remedy
02/09/2004
Still has pain the arm when she writes for a long time. Her concentration is better. She has pain in her upper back when she bends forward. Her skin eruptions are better. During the first day of her period she was achy and fatigued. Her scalp has been feeling sore. Emotionally she has been feeling better. Feels angry at people who she sees as annoying.
Plan Calcarea Carbonica 200C, in water, 1 TBS for three days.
04/16/2004
One of her classmates committed suicide; even though she was not close to the student is was hard for her. She has recurring images of the memorial service.
Her feet are very sweaty. Her left knee hurts when walking. (she fractured her left tibia when she was 2 yrs old).
At times she feels she’s not smart enough.
She had another period; she got flatulence and cramping.
Plan: Silicea 200C, one dose.
06/03/2004
She has been having runny nose for 2 weeks. She has a beautiful singing voice but is very uncomfortable singing is someone is watching her. She is afraid she will make a mistake of forget her lines when she is in a play. She will put a lot of pressure on herself to things perfectly the first time she practices.
She tends to have a limited range of emotions, and tends to be serious. She is starting to allow herself to be more expressive, particularly of happy feelings. She feels weakness and irritability before menses.
Plan: Natrum Muriaticum 200C one dose.
06/07/2004
Pain her knees are on/off occasionally; they are achy. Her period tends to be intermittent and last 7-8 years. She has white leucorrhea. She gets crampy, fatigued and irritable.
She is frustrated in school; she feels her peers are very picky. She has learned to deal with the teachers well. She has needed to work on being more tolerant and patient.
Plan: Pulsatilla, 1M, in water, one TBS Q 4-6 hours.
07/26/2004
She banged her fingernail and it is swollen, red and painful. The nail is black and blue.
Plan” Ledum 200C, in water, 1 TBS every 4-6 hours.
08/09/2004
She has felt a little crampy and has been eating poorly. Abdominal pain from being constipated. Didn’t get a lot of sleep the night before. Her period in June was late for two weeks. It seems to be coming every six weeks. It is lastin 6-7 days. She was fatigued, weepy and irritable. She has been sensitive to reprimands and reproaches. The period was very light.
She has found 3 warts on the sole of the left foot, and one in the left. She has slightly swollen glands.
Plan: Thuja 1M, one dose.
10/11/2004
She has felt alright. Her lower back has been hurting. She has been swimming 4-6 hours per week. Her hamstrings have been feeling tight. The pain is mostly in her lower dorsal and upper lower spine. She is concentrating better. At times she feels absent minded, absorbed in thoughts. Forgetful of what she needs to do.
Plan: Natrum Muriaticum 1M.
10/14/2004
She has an upset stomach, feels flushed, her body aches, is feeling irritable. Symptoms started suddenly at night.
Plan: Belladona, 30C, in water Q 4-6 hours.
11/03/2004
Her symptoms improved after a couple of dosages of Belladona. In the last couple of days she has had swelling of her tonsils, has felt flushed and irritable.
Plan: Belladona 30C, in water, one tbs every 4-6 hours.
01/21/2005
She has had a lesser tendency to get easily flushed. She has continued being distractible. At times feels overwhelmed. She has been tired physically and mentally. She complains of muscle aches and stiffness. She has had pain in her ankles and the soles of her feet. Her sleep has been good, has not been waking up in the middle of the night. Her scalp has been sensitive. She tends to have trouble with transitions.
Plan: Selenium 1M, one dose; Kali phos. 30C , one globule per day, PRN.
03/08/2005
Her energy has been fair. She has been active physically, playing tennis and swimming. Her stamina has been much better. Her concentration has been better. She has not had as much pain in the ankles and feet. Sometimes she feels really hot. She tends to get colds when exposed to the cold weather; her sinuses tend to act out.
She doesn’t like winter and cloudy weather. She still tends to feel overwhelmed. She has been more consistent in her ability to deal with difficult situations.
Plan: Sepia 1M, one dose; Ferrum Metallicum 12C, once per week.
03/14/2005
She has swollen tonsils. Eyes are looking glossy and her checks are rosy colored.
Plan: Apis Mell. 12C , Q 4-6 hours.
03/15/2005
Tired; throat is hurting, particularly on the right side. The pain is going up into the ear. Her hips are hurting.
Plan: Lycopodium 12C, Q 4-6 hours.
04/20/2005
She has been doing alright. Her throat is doing better. Her knees and back are hurting after she plays sports. She has been feeling tired, physically and mentally. She feels better after she goes out for a walk. There has been a lot of stress at school. A lot of social stress having to deal with different groups of peers and not knowing which she is part. Pressing pain in her frontal part of the head. She has a constant song playing in her head.
Plan: Thuja 10M one dose.
04/26/2005
Swollen glands. Her tonsils have been swollen. Has been feeling warm.
Plan: Lachesis 30 C, in water, 1 tbs Q 4-6 hours.
04/28/05
She has a fever, as measured in her ear, 100 degrees. Also has a headache, especially over the right eye. Yesterday had a stinging feeling in the nose. Has a dry cough. Has been feeling emotional.
Plan: Pulsatilla 30 C, in water, 1 TBS Q 4-6 hours.
05/05/2005
She has been feeling much better. She still has some cough and runny nose. Symptoms disturb her sleep.
Plan: Sulphur 30C, in water, 1TBS Q 4-6 hours.
The patient continued improvement in her emotional difficulties, cognitive functioning and menstrual symptoms. She was able to feel more comfortable being on stage and has gotten important roles to perform in school plays, which includes vocal performances.
The homeopathic treatment continued using the remedies indicated, particularly the ones we have used. However, she would continue to have acute symptoms a few days after a higher potency remedy was given. Therefore, decided to start remedies in the LM potency. Since using the LM potencies she has been able to respond to the remedy without subsequent manifestation of acute symptomatology. The predominant remedy used has been Calcarea Carbonica 1LM.
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