PRELIMINARY DATA
Date of visit: 17/8/18
Patients Name: Mrs. M.S
Age: 30 Years /Female
Status: Married
Religion: Hindu
Occupation: House wife
PRESENTING COMPLAINTS
℅ Headache (Vertex) since last 9 yrs
℅ Small swelling over chin bilaterally (1 on each side ) since last 4-5 years
℅ puffiness of face and swelling of full body x last 4-5 years
℅ Numbness of both hands, even after working a little since last 4-5 years
DETAILS OF PRESENTING COMPLAINTS
℅ Headache (Vertex) since last 9 yrs
H/o Fall from bike- sustained injury to occiput
Sensation – as if heat is coming out of vertex the last few years
Headache > applying Oil, Vicks
< stress
No nausea, no vomiting, no photophobia. No aura (visual/Sensory) before
headache.
℅ Small swelling over chin bilaterally (1 on each side) since last 4-5 years, size: 2 x 1cms / each side), No tenderness.
hard swelling (+) Left side of chin, Not movable.
hard swelling (+) Right side of chin, movable.
Previously same complaints were present – was excised (sample -sent for
histopathological examination – reported as benign swelling).
℅ Puffiness of face and swelling of full body since last 4-5 years, Puffiness
throughout the day.
℅ Numbness of both hands, even after working a little since last 4-5 years
Swelling of inter phalangeal joints of both hands, Non tender.
No modalities
No tenderness, no warmth, no restriction of movements.
PAST HISTORY
| Sr. No | Age | condition | Treatment taken |
| 1. | 25 yrs | Umbilical Hernia | Repaired |
| 2. | 26 yrs | Nodular swellings over Chin | Excised |
PHYSICAL CHARACTERISTICS
Build- obese
Hair- Hair loss + , No dandruff, No greying
Nails – No pallor, No Paronychia
Face – Symmetrical and expressive, puffiness
Appetite- good
Diet- Mixed
Craving – Nothing significant
Aversion- Nothing significant
Thirst- 2 lit/day
| Stool | once /day | semisolid | satisfactory | Non offensive |
| Perspiration | Localised on neck | No peculiar odour | Non-Staining | |
| Urine | 4-5 times/day | Pale yellow | Can control | No dysuria |
MENSTRUAL FUNCTION
| Menarche-12 yrs | |
| LMP- 12.8.18 | |
| Menses:
Duration- 3-4 days Cycle-regular Flow- moderate Clots – Absent Odour- No peculiar odour |
Concomitant: Before- Pain in lower
abdomen During: Pain present After- No complaints |
| Leucorrhoea : Before menses, thin albuminous, for 2-3 day | |
PREGNANCY, LABOUR, PUERPERIUM
| G2 P2 L2 A0 | |
| Male | 11yrs |
| Male | 6 yrs |
LIFE SPACE
Patient lives in a nuclear family. Patient doesn’t want to share her feeling with anyone, will share only with her husband. Doesn’t want to mix easily, doesn’t talk much, since childhood. Doesn’t want to go out of house, wants to stay at home. Needs company of husband whenever she goes out of the house. Speed of her household work is slow, but she does it perfectly and systematically and completes it on time. Wants to do only routine work; if she does any extra work she feels exhausted.
The last 2-3 years she cannot remember things; forgets where she has kept things; remembers only after 2-3 hours.
Patient studied till VIII std. Before marriage used to work in a shop where she did calculations, but now she finds it difficult to calculate. She wants to teach her children, but cannot do so. She says her mind doesn’t work, cannot understand.
Dreams: of Snakes in forest, going on its own way, but becomes fearful by looking at them; gets up frightened from sleep.
Fear: To go out of the house when it’s dark.
THERMAL STATE- Chilly patient
| COVERING | Summer- thin | winter-thick | Rainy- thick |
| BATH | Summer- Cold | Winter- Warm | Rainy- Warm |
| FAN | summer-Fast | winter-slow | Rainy- slow |
GENERAL EXAMINATION
Eyes- No pallor, No icterus
Tongue- Clean , Macroglossia
Nails- No pallor
Lymph node- submandibular, submental, pre and post auricular, cervical lymph nodes not palpable
Neck: No restricted movements in cervical spine. Lhermitte sign- negative
Oedema- No periorbital swelling, Non pitting pedal oedema.
VITALS : T: 98 F Pulse- 73b/m RR- 15 resp/m BP- 120/84 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
DIAGNOSIS
Subclinical hypothyroidism (Homeopathy for Hypothyroidism)
TOTALITY OF SYMPTOMS
- Doesn’t want to share her feelings.
- Doesn’t want to talk much.
- Desires Company of husband.
- Weakness of memory.
- Exhausted feeling.
- Cannot understand.
- Fear of dark.
- Swelling over chin.
- Puffiness of face.
- Swelling of whole body.
- Numbness of both hands.
- Swelling of inter phalangeal joints.
- Headache –vertex .
- Chilly patient.
REPORTORIAL RESULT
REMEDY/PRESCRIPTION (date: 17/8/18)
- Calc carb 200 3 pills / TDS
- Rubrum 3—3—-3 x 15 days
FIRST FOLLOW UP: 19.09.2018
Investigation Done By Patient In Morning Before Starting First Prescription : 18.08.2018
| TEST | RESULT | REFERENCE RANGE |
| FBSL | 102 mg/dl | (70-105 mg/dl) |
| Hb | 13.7 gm/dl | Male :13.5-17.5gmm/dl
Female: 12.0-15.5 gm/dl |
| Serum creatinine | 0.8 mg/dl | 0.5 – 1.1 mg/dl |
| Blood urea | 24 mg/dl | (14 – 40 mg/dl) |
| TSH | 30.43 uIU/ml | (0.3– 5.5 uIU/ml ) |
| T3 | 80 ng/dl | (60 — 200 ng/dl) |
| T4 | 5.4ug/dl | (4.5-12 ug/dl) |
Repertorisation after seeing investigation Report during first follow-up
FIRST FOLLOW UP: 19.09.2018
| SYMPTOMS | INTERPRETATION | PRESCRIPTION |
| ℅ small swelling over chin bilaterally | SQ | 1. Calc carb 0/1
1 tbsp / OD x 15 Days
After 15 days
2. Calc carb 0/2 1 tbsp / OD x 15 days |
| Puffiness of face and swelling of full body | >> | |
| Numbness of both hands, even after doing little work | Increased | |
| Swelling of interphalangeal joints of both hands | > 100% | |
| Headache (Vertex)
Sensation – as if heat is coming out of vertex Headache > Applying Oil , Vicks |
> 20% | |
| App – Good
Thirst- 2 litre/day Urine, Stools – No complaints |
||
| LOCAL EXAMINATION – CHIN
Inspection: post surgical scar present over chin palpation : hard swelling (+) Left side of chin Non movable, non tender. hard swelling (+) Right side of chin Movable, non tender. |
Second Follow up: 02.11.2018
| SYMPTOMS | INTERPRETATION | PRESCRIPTION |
| ℅ swelling over chin bilaterally | >35% | Rubrum 30
3–3–3 x 1 month |
| Puffiness of face and swelling of full body | >> | |
| Swelling of interphalangeal joints of both hands. | > 100% | |
| Headache (Vertex)
Sensation – as if heat is coming out of vertex. |
> 40% | |
| App – Good Thirst- 2 litre/day
Urine, Stools – No complaints |
||
| Mind: Increased sexual desire, wants to get
intimate with husband daily. |
(started after
Calc carb 0/2) |
Third Follow up: 01/12/18 – Sat
| SYMPTOMS | INTERPRETATION | PRESCRIPTION |
| ℅ swelling over chin bilaterally | > 40% | Rubrum 30
3–3–3 x 1 month |
| Puffiness of face and swelling of full body | SQ | |
| Headache (Vertex)
Sensation – as if heat is coming out of vertex |
Absent | |
| App – Good Thirst- 2 litre/day
Urine, Stools – No complaints Sleep – good Weight – 58kg |
THYROID EXAMINATION
No visible swelling No visible swelling on act of swallowing Thyroid gland not palpable. |
|
| MIND: Very sensitive, thinks over past,
Needs Husband every time. |
||
| VITALS
P- 63 b/min ; BP- 110/70 mmHg RR- 14 respiration/min |
Fourth Follow Up: 05/01/2019 – Sat
| SYMPTOMS | INTERPRETATION | PRESCRIPTION |
| ℅ swelling over chin bilaterally | > / SQ | 1. Belladona 200
3–3–3 x 2 days 2. Rubrum 200 3–3–3 x 1 month
3. Belladona 1M / sos (½ dram) 3pills to be taken if Headache is not Ameliorated with Belladonna 200 |
| ℅ Puffiness of face and swelling of full body | >10 % | |
| ℅ Headache -aggravated x 2 days
A/F- stress Sensation – as if heat is coming out of vertex when she touches the scalp |
<< | |
| App – Good
Thirst- 2- 3 litre/day Urine, Stools – No complaints Sleep – good Weight – 58kg |
THYROID PROFILE 1 (Shows during 4th Follow up)
| 7.12.18 | ||
| T3 | 87 ng/dl | 60-200 |
| T4 | 6.1ug/dl | 4.5-12 |
| TSH | 19.69 u IU/ml | 0.3-5.5 |
Fifth Follow Up : 02/02/2019 ; Sat
| SYMPTOMS | INTERPRETATION | PRESCRIPTION |
| ℅ swelling over chin bilaterally
(1x1cms on each side) |
> 50% | Calc carb 0/3
1 tbsp / OD x 15 days Rubrum 300 3–3–3 x 1 month |
| ℅ Puffiness of face and swelling of
full body |
>30 % | |
| ℅ Headache | Absent | |
| App – Good
Thirst- thirsty Urine, Stools – No complaints Sleep – good Weight – 58kg |
Sixth Follow Up : 02/03/2019 ; Sat
| SYMPTOMS | INTERPRETATION | PRESCRIPTION |
| ℅ swelling over chin
bilaterally |
> 70% | Calc carb 0/4
1 tbsp / OD x 15 days
Rubrum 30 3–3–3 x 1 month |
| ℅ Puffiness of face and
swelling of full body |
> 60 % | |
| App – Good
Thirst- thirsty Urine, Stools – No complaints Sleep – good |
Seventh Follow Up : 06/04/2019 ; SAT
| SYMPTOMS | INTERPRETATION | PRESCRIPTION |
| ℅ swelling over chin
bilaterally |
> 80% | Calc carb 0/5
1 tbsp /OD x 15 days
Rubrum 30 3—3–3 x 15 Days
Calc carb 0/6 1 tbsp /OD x 15 days |
| ℅ Puffiness of face and
swelling of full body |
> 80 % | |
| App – Good
Thirst- thirsty Urine, Stools – No complaints Sleep – good Weight – 57kg |
THYROID PROFILE ( DATED : 15.4.19 )
| 15.4.2019 | ||
| T3 | 81 ng/dl | 60-200 ng/dl |
| T4 | 5.9 ug/dl | 4.5-12 ug/dl |
| TSH | 5.86 u IU/ml | 0.3-5.5u IU/ml |
