Name: S. D.
Date -15/06/2017
Age-48years – Sex-Male
Occupation – Retail Store
Married
Diagnosis- Venous ulcer since 6 years
Description of case
This is a case of unhealed venous ulcer for the last 6 years. His doctor advised him to go for amputation of a limb because it can lead to gangrene. He is als diagnosed with:
– Diabetes Mellitus since last 10 years,
-Hypertension since last 10 years.
-Hypothyroidism since 6 years.
-Venous ulcer since 6 years.
Chief complaint
He consulted me for severe burning pain in the ulcer on right lower limb. He sat on the examination table and was continuously rubbing his affected leg with his hand.
Dr. please do something for this burning pain. Since last night I couldn’t sleep due to this burning pain in my right leg. I was doing this rubbing since last night- burning is so severe as if someone has put some red pepper on my ulcer.I am rubbing continuously since night and now it’s intolerable. Do something for this burning.
D- How did it start?
P- I have my own vegetable shop and yesterday; I had hard work in shop so there is swelling over the limb and pain increased. It happens every time whenever I do hard work but this time it increased a lot.
D- Since when is this ulcer from?
P- More than 6 years. Actually I was traveling by bike and I had an accident so that time there was a burn and since then my injury never get healed. Afterwards it turns to ulcer and I took many medicines but no result.
Modality-
Aggravation- Night, touch, walking, standing,
Amelioration- rubbing, upright position of a limb
Observation– Ulcer has thin watery discharge from it, offensive odor, yellow debris in it, sensitive to touch, painful on touch. He was not able to narrate any symptoms due to severe burning pain.
PAST HISTORY- Jaundice 2 years back.
FAMILY STORY :FATHER- Died due to Heart attack
MOTHER- Asthma and HTN
PHYSICAL GENERALS:-
APPETITE- Good DESIRE- spicy +++, sour+++ AVERSION- sweet++
THRIST- thirsty+++ URINE- n STOOL- hard stool
SLEEP- disturbed due to pain
DREAMS- no
THERMALS- Hot
Perspiration – profuse and yellow stain on clothes
Rubrics-
Skin; Burn; fail to heal, or ill effects
Skin ulcer; old
Skin, pain, burning smarting, night
Skin, pain burning, smarting, touch on
Pain. Burning, smarting, peeper, as from
Generalities, pain, run, rubbing, massage, amel
Skin, ulcers, discharging, suppurating, watery
Understanding and Analysis of the case-
In any acute pathological case the following points are important:
Etiology, diagnosis, observation, modality, mental state.
Following points are important:
- Etiology- burn (old)- fail to heal
- Diagnosis– Ulcer due to burn not a venous ulcer.
- Observation– thin/watery discharge from the ulcer
- Modality –
Amelioration- Rubbing,
Aggravation- touch, night, walking
Burning pain and amelioration rubbing by hand
References for the differentiation of remedies between Causticum and Arsenic Album. Book :Phatak Materia Medica. One of the best remedies in unhealed ulcer is Causticum.
| 15/06/17 | Considering above understanding | Causticum 200+6+1dr
3 doses a day |
| 21/06/17 | His burning is reduced.
No pain at night and he has sound sleep at night. Edema over the limb is reduced. Ulcer is becoming dry. |
Sl+6+1dr |
| 23/06/17 | He is feeling better. Burning pain is reduced, irritability is also reduced, if he walked for a long distance then there is a swelling on the leg otherwise it’s better than before. RBS- 252mg/dl.
Acidity since morning and heart burn. |
Sl+6+1dr |
| 25/06/17 | No pain at all and dryness over ulcer- no discharge. Swelling is reduced. | Sl+1/2dr |
| 28/06/17 | He is feeling better. He started exercise. Mid gastric accumulation due to non-veg food. | Sl+6+1dr |
| 07/07/17 | Mild burning pain around the ulcer but edema over leg is on and off. Irritability increased. He had fight with one costumer since then anger increased. | Caust200+6+1dr |
| 12/07/17 | He is feeling better. no acidity, ulcer is reduced. | Sl(visit) |
| 19/07/17 | Ulcer is reduced. No burning pain- edema is reduced- no pain while walking- sleep is sound. Appetite is good. | Sl+6+1dr |
| 27/07/17 | He is feeling good- he feels confidence about ulcer- it will get cure. Irritability is reduced. RBS- 211mg/dl | Sl+6+1dr |
| 10/08/17 | Edema is increased but ulcer is reduced – no swelling, mild itching and dryness around the ulcer- skin become shiny and healthy. | SL+6+1DR3d |
| 08/09/17 | He has swelling on the lower limb- no burning sensation in it, mild itching in it but no any pain. | Sl+6+1dr2d |
| 27/10/17 | Mild burning sensation in the limb due to over work- yesterday night he was working in the shop and he had lifted heavy thing since then there is swelling over the limb. | Sl+6+1dr2d |
| 14/11/17 | No burning sensation in lower limb- mild twitching in the limb. | Sl+6+1dr |
| 21/11/17 | He is doing well. RBS is 190mg/dl.
Heaviness in the body. No pain in the leg. |
Sl+6+1dr4d |
| 12/01/18 | He stopped eating tobacco- feeling energetic and happy. No ulcer at all. Sometimes there is swelling over the limb. | sl+6+1dr |
| 06/05/18 | He is feeling better, | Sl+6+1dr2d |
