PRELIMINARY DATA
- Date of visit: 1/12/18
- PATIENTS NAME: Mrs. D.D
- AGE: 29 Years /Female
- STATUS: Married
- RELIGION: Hindu
- OCCUPATION: House wife
- ADDRESS: Lotoulim, Goa
PRESENTING COMPLAINTS
- ℅ weight gain during pregnancy
- ℅ Easy breaking of nails since 1.5 months after delivery
- ℅ Pain in Right knee since 1.5 yrs
- ℅ Pain in lower back since last 10 yrs
DETAILS OF PRESENTING COMPLAINTS
℅ weight gain during pregnancy ( from 59kg to 73kg at time of delivery) Was put on Tab. Thyroxine 75mg , 1/OD
℅ Easy breaking of fingernails and toenails as she has stopped T.thyroxine 1.5 months after delivery.
℅ Pain in Right knee since delivery
Pain < while standing from sitting position
Stiffness of joints present when she sits for long to wash clothes
Range of B/L knee joint is normal, no swelling, No warmth.
℅ Pain in lower back since last 10 yrs
Sensation: As if weight present
Pain < bending, cannot rise from bending (it’s difficult)
Lumbago < during menses – during flow pain is more
< 1 to 2 days prior.
O/E (Local): tenderness present over L4 –L5 vertebrae.
PAST HISTORY – Nothing significant
PHYSICAL CHARACTERISTICS
Build- obese
Hair- Hair Fall +, No dandruff, No greying
Nails- No pallor, No Paronychia, brittle nails
Face – Symmetrical and expressive
Appetite- good
Diet- Mixed
Craving – Sweets +3
Aversion- NS
Thirst- 4 lit/day, warm water, Drinks as habit.
| Stool | 2 time /day | semisolid | satisfactory | Non offensive |
| Perspiration | Localised on scalp +3 | Odour + | Non Staining | |
| Urine | 5-6 times/day | Pale yellow | Can control | No dysuria |
MENSTRUAL FUNCTION
| Menarche-10 yrs | |
| LMP- 21.10.18 | |
| Menses:
Duration- 3 days , colour: dark maroon Cycle-regular Flow- heavy Clots – present, small Odour- No peculiar odour |
Concomitant: Before- Pain in back 1- 2days prior
During: Pain increases on 1st day After-pain present in hypogastrium |
| Leucorrhoea : present 4-5 days after menses | |
PREGNANCY, LABOUR, PUERPERIUM
| G1 P1 L1 A0 | |
| Male | 1.5 yrs |
LIFE SPACE
Patient stays in a nuclear family. Husband, son and herself.
Fear of dark.
Gets angry easily but does not do anything during anger and remains silent.
She studied till graduation, wanted to do work but couldn’t, do due to her child.
THERMAL STATE- Hot patient
| COVERING | Summer- No covering | winter-thin | Rainy- thin |
| BATH | Summer- Cold | Winter- Warm | Rainy- Warm |
| FAN | summer-Fast | winter-fast | Rainy- medium |
GENERAL EXAMINATION
Eyes- No pallor, No ictrus
Tongue- Clean
Nails- No pallor, no deformities
Neck: No restricted movements in cervical spine .
Oedema- No periorbital swelling, No pedal oedema.
VITALS : T: 98 F Pulse- 82b/m RR- 17 resp/m BP- 130/80 mmHg
SYSTEMIC EXAMINATION
RS – No Rales, No Ronchi.
CVS- S1, S2 rhythmically heard, No murmurs
GIT- No tenderness, No organomegaly.
GUT- No tenderness, Kidneys not palpable.
CNS- Well oriented in time and space
INVESTIGATION : 24.3.2018
24.3.2018
| TSH | 6.69 uIU/ml | (0.3– 5.5 uIU/ml) |
DIAGNOSIS
Hypothyroidism
- TOTALITY OF SYMPTOMS
- Remains quiet when angry
- Fear of dark
- Craving- sweets +3
- Perspiration- scalp +3
- Menses heavy
- Hot patient
- Pain in Right knee < Rising from sitting
- Lumbago < rising from sitting
- Lumbago < menses during
REPORTORIAL RESULT
REMEDY/PRESCRIPTION (date: 1/12/18)
- Pulsatilla 200 3 pills / TDS x 3 days
- Rubrum 3—3—-3 x 15 days
FIRST FOLLOW UP: 28.12.2018
| SYMPTOMS | INTERPRETATION | PRESCRIPTION |
| ℅ weight gain, today’s weight: 68kg | SQ | 1. Pulsatilla 200
3 pills/TDS x 3 days
2. Rubrum 3—3–3 x 15 days |
| ℅ Easy breaking of fingernails and toenails | SQ | |
| ℅ Pain in Right knee x delivery
Pain < while standing from sitting position Stiffness of joints present when she sits for long |
>50% |
|
| ℅ Pain in lower back
Sensation: As if weight present Pain < bending, cannot rise from bending (it’s difficult) |
>30% | |
| C/o Nasal blockade, right sided, constant x 15 days
Discharges thin. Itching of throat- present |
||
| App – Good
Perspiration- scalp +, offensive Thirst- 2 litre/day Urine, Stools – No complaints O/E: Nose: Right turbinate enlarged Throat: No tonsillitis, No congestion Vitals: P: 79b/m , BP: 110/70mmHg , RR: 16 resp/Min |
SECOND FOLLOW UP: 12.01.2019
| SYMPTOMS | INTERPRETATION | PRESCRIPTION |
| ℅ weight gain , today’s weight: 68kg | SQ | 1. Pulsatilla 200
3 pills / TDS x 3 days
2. Rubrum 3—3—3 x 1 month |
| ℅ Easy breaking of fingernails and toenails | >> | |
| ℅ Pain in Right knee x delivery
Pain < while standing from sitting position Stiffness of joints present when she sits for long |
>50% |
|
| ℅ Pain in lower back
Sensation: As if weight present Pain < bending, cannot rise from bending (it’s difficult) |
>60% | |
| C/o Nasal blockade, right sided, constant x 15 days
Discharges thin. Itching of throat- present |
>20% |
THIRD FOLLOW UP: 12.05.2019
| SYMPTOMS | INTERPRETATION | PRESCRIPTION |
| ℅ weight gain | SQ | 1. Calc Sulph 200
3 pills / TDS x 3 days
2. Rubrum 3—3—-3 x 1 month |
| ℅ Easy breaking of fingernails and toenails | >>> | |
| ℅ Pain in Right knee
Pain < while standing from sitting position Stiffness of joints present when she sits for long |
>60% |
|
| ℅ Pain in lower back
Sensation: As if weight present Pain < bending, cannot rise from bending (it’s difficult) |
SQ | |
| C/o Nasal blockade, right sided,< Night, sneezing < Night
Discharges thin. |
>50% | |
| C/o itching in ears; has to put in ear bud to scratch
Itching < night, early morning No otorrhoea |
||
| App – Good
Thirst- 2-3 litre/day Urine, Stools – No complaints Weight: 67kg |
FOURTH FOLLOW UP: 13.7.2019
| SYMPTOMS | INTERPRETATION | PRESCRIPTION |
| ℅ weight gain, reduced by 1 kg | >> | 1. Calc Sulph 200
3 pills / TDS x 3 days
2. Rubrum 3—3—3 x 1 month |
| ℅ Pain in Right knee
Pain < while standing from sitting position Stiffness of joints present when she sits for long |
>60% |
|
| ℅ Pain in lower back
Sensation: As if weight present Pain < bending, cannot rise from bending (it’s difficult) |
> | |
| C/o Nasal blockade, right sided,< Night, sneezing < Night
Discharges thin. |
>70% | |
| C/o itching in ears , has to put ear bud to scratch
Itching < night, early morning |
>50% | |
| App – Good
Thirst- 2-3 litre/day Urine, Stools – No complaints Weight: 67kg |
FIFTH FOLLOW UP: 18.8.2019
| SYMPTOMS | INTERPRETATION | PRESCRIPTION |
| ℅ weight gain , reduced by 1 kg | >> | 1. Calc Sulph 1M
3 pills / TDS x 1 days
2. Rubrum 3—3—-3 x 1 month |
| ℅ Pain in Right knee
Pain < while standing from sitting position Stiffness of joints present when she sits for long |
>70% |
|
| ℅ Pain in Hypogastrium < during menses, 1st day
Cramping pain , pain last for 2-3 hrs Nausea with pain Sensation of passing stools during menses |
||
| C/o itching in ears | >90% | |
| App – Good
Thirst- 2-3 litre/day Urine, Stools – No complaints Weight: 67kg |
SIXTH FOLLOW UP: 3.11.2019
| SYMPTOMS | INTERPRETATION | PRESCRIPTION |
| ℅ weight reduced | >> | 1. Calc Sulph 1M
3 pills / TDS x 1 days
2. Rubrum 3—3—-3 x 1 month |
| ℅ Pain in Right knee
Pain < while standing from sitting position Stiffness of joints present when she sits for long |
>90% |
|
| ℅ Dysmenorrhoea
LMP- 19.10.2019, pain was mild No sensation of passing stools during menses |
>> | |
| C/o itching in ears | >, Now occasional | |
| App – Good
Thirst- 2-3 litre/day Urine, Stools – No complaints Weight: 67kg |
THYROID REPORT: NORMAL: DONE ON : 3.10.2019
Case by Dr. Reetesh Ratnakar Shet, under the guidance of Prof.(Dr). Jyothi Vijaykumar, MD(Hom.)
HOD, Dept of Practice of Medicine, A.M Shaikh Homoeopathic Medical College PG Research Centre and Hospital, Belagavi
REFRENCES
1. Munjal YP, API Textbook of Medicine; 9th edition; Jaypee Brother Medical Publishers Pvt. Ltd; New Delhi; 2012; p425
2. Boericke William, Pocket Manual of homoeopathic Materia Medica & Repertory; B. Jain Publishers Pvt Ltd, new Delhi; 52nd Impression: 2012
3. https://emedicine.medscape.com/article/122393-overview
