Female Aged 45 years old
Past history :
Uterus Removed on July 2012
Complaints since December 2015
Pain in upper abdomen
Pain in right leg
Doesn’t like to eat or drink anything
Tongue – no sense of taste
Endoscopy showed duodenitis
Blood Sugar – normal
Renal Function – normal
USG showed fatty infiltration of liver
P: Allopathic Medicines were taken bit they gave slight relief and then it started again. Doctor you can see my all reports are normal.
D: Tell me about your pain.
P- Pain is very severe in upper abdomen on both sides. Vomiting tendency always. Pain is unbearable and is burning.
D: Since when you are having this?
P – Since December 2015 I’m getting this pain I have visited many doctors , visited priests , pandits everyone who can relive me from this pain but still no hope. The pain subsides and then it comes back
Please help me. I got your reference from my uncle. You are the only hope please tell me the actual problem why am I suffering from this ?
D: You have issues with your stomach, liver and pancreas and that’s why you are having this severe pain
P : Doctor There is strong burning in my stomach with heaviness in chest and the pain radiates.
D: Anything else you have besides this?
P: I have severe migraine since 7-8 years pain is always one sided. It’s so uncontrolled that I had to take allopathic medicine for head pain for relieving the pain. Ok this is not important doctor but my abdomen pain is very painful. Please give me medicine for that.
D: I asked you to do lipase test
P- Yes I did and its very high according to reports. but still I don’t understand why the other hospital I visited did not do this test.
D: Its okay what ever happened it’s past now. Tell me what do you do for relieving the pain?
P: Nothing, I take pain killers but still after 2-3 hours pain come back .
D: Tell me about the burning of stomach
P: Chest is burning, my stomach is burning, sometimes I throw up the water which I drink.
D: Dtop all oily food intake . Eat very simple food .
P: Doctor one thing I want to tell you my pain radiates to right side of the back always whenever I get pain . My appetite is good but due to pain I avoid the food. My general living has been affected badly due to this pain.
D : Do you have any fear ?
P: I have fear of high places I cannot look downward from high places
D: What do you prefer to eat ?
P: Mostly sweets.
D: Do you have vomiting during the headache ?
P: No I don’t, sometimes very rare.
D: Mostly which side is all your pain on?
P: Right side. My pain is very severe on right side along with burning in chest.
D: I’m giving you the medicine and after 10 days get the lipase test done then report to me.
Prescription : 2nd July 2016
Phosphorus 30 BD for 10 days
Lipase Report on 2nd July 2016
10th July 2016
Lipase Report 10th July 2016
D: Tell me how are you feeling now?
P: Pain is much better and feeling relieved 70% . Back pain was shooted up one night and after ½ hour it was a relief and good sleep. After that till 7 am there was heaviness in head, then I was relived after few hours after sleep. Motion was normal and no more tendency to vomit.
D: Okay continue the medicine and report to me after 15 days.
Follow up : 21st July 2016
D: Now tell me about your pain.
P: I’m much much relived now as you can see also my reports have improved a lot I did twice and the results are very much improving. I’m better from the condition I was suffering .Thank you so much. I’m really happy to see my reports.
D: How is the headache you had ?
P: My headache has been improved much and now I don’t get so much pain as I used to .
D: I’m giving to another medicine please report after 1 month.
Prescription 21st July :
Rx Sac Lac 30 One dose daily for one month
Follow up :
22 August 2016
D- How are you feeling?
P- I’m much better free from pain I have suffered so much from, pain I cannot even describe.
P- Doctor how long do I need to take medicine ?
D- At least 2 months more
Sac Lac 1 month daily one tablet
Follow up : 27th September , 2016
D- How are you feeling now ?
P- I’m better doctor. I think I should stop medicine as there is no complaint at all.
D- There is no harm so you can stop it.
P- Still doctor please advise what shall I do now as my headache is better too. In between I got few mouth ulcers but that gradually disappeared .
Prescription : NIL .
Followup : 27Th October 2016
D- How are you feeling now ?
P- I m feeling good there has been no pain at all thank you.
D- Earlier you mentioned about your headache how is that?
P- It’s better now
D- Any relapses in headache or pain in abdomen?
P- I didn’t get any as such.
D- Okay, that’s good to know .
Prescription : NIL