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Case 101: I have Fibroids...

Mrs YIK, 38yrs, Non-veg, Married Muslim, Fashion Designer cum Home Maker, came on 02/03/2007 with the following complaints

CHIEF COMPLAINT

LOCATION

SENSATION

MODALITIES

CONCOMITANTS

FEMALE GENITAL 
TRACT
Since 2004

Fibroids 3+ Menorrhagia X 2days3
3 pads at a time, changes every 2 hrs.
Bright red blood, sometimes clots and offensive

< Morning 3+

Adv: Rx but pt refused
Menorrhagia + Dysmenorrrhoea sine Menarche
1992 Dysmen > for 2yrs
19994Post delivery- Rec of Menorrhagia
Tab. Ovaral G since 2004

GENERALITIES

Body puffiness

A/F Hormonal pills

 

RESPIRATORY TRACT
Since approx. 1996
1/15days X 2-3 days
Unilateral either R or L Forehead
Eye

Sinusitis 
Pain 
Sneezing

> Crocin
A/F Cold water
< Fan, A/C
No < Ice-cream

Took Hom Rx X 6 months but no >.

PATIENT AS A PERSON
WEIGHT: 70kg constant
BUILT: Stocky
Obese. Gained 5kg in 3 yrs
APPETITE: N
THIRST: 6-7 gl/day
DESIRES: Hot food and drinks
 3+, Sweets
AVERSION: Sweets2+
TONGUE: Coated
STOOL: 1/day
URINE: 5-6/day
SKIN: Fair, Redness < Sun
HAIR: Loss3+. Graying colors every week
EYES: Hypermetropia
OEDEMA: After HRT
PERSPIRATION: Armpits
MENSES: C/C. Before menses
Irritable3+, Mood swings3+, Heavy breast3+
During menses
all symptoms >. THERMAL: C2H3 CH4. Likes winter > 3+, Likes fan3+, Likes open air. Love to cover
BATH: Warm water
SLEEP: 7hrs. Lies on back. P/H disturbed sleep and tossing in sleep
DREAMS: Unremembered 
MIND: Irritable at trifles, Brooding, Does not make friend easily, Affectionate children hugs children, Fear of dogs and darkness. Perfectionist, things has to be in place. Contradiction <. Weeping > alone 

SEXUAL HISTORY: Desire , 1/week. Dryness after HRT



OBSTETRIC HISTORY: P2G3A1
1st Pregnancy induced abortion
1st child
FTND. Male
2nd child
LSCS due to cord strangulation. Female

LIFE SPACE INVESTIGATION: The pt was born in the year 1965 in Assam. She is 4th of 6 siblings. Average student. Was a sports person. Liked Basketball. Initially like a tomboy. Fa expired in 1979. It didn’t affect her much. She was too small and it was a joint family. Initially she was like a tomboy. Closest to youngest Sis. She had an arranged marriage in 1988 and came to Mumbai. In 1999 Mo expired which affected her much. Br expired in 2001 due to MI/CCF.

REPERTORIAL TOTATLITY

1.     Irritable at trifles

2.     Brooding

3.     Grief

4.     Fastidiousness

5.     Fear dogs

6.     Fear dark

7.     Cries, alone when

8.     > Alone

9.     Breast, heavy < Menses before

10.  Fibroids

11.  Menorrhagia

12.  Obesity

13.  Headache < Sun

TREATMENT & FOLLOW UP

DATE

SYMPTOM

REMEDY

02/03/07

Sinusitis

Kali-bi 200 HS 1P=4
Pla pills 1-1/7days
Sabina 200 4P; 1P=4

16/03/07

Bleeding with backache. Sneezing on 15/03, running nose, A/F Cold. Stool N. Allergic Rhinitis 1/3wk. < A/C, Wet+, Headache in Sun L0. Hair fall L2. Dry Vagina L0. Tongue coated, Thirst++.

Kali-c 200 1st dose
Pla pills 3-3/7days
Bry 200 3P; 1P=3

20/03/07

Cold since 19/3. Lachrymation, sneezes, thirst+. Watery discharge, heavy head.

Ars-alb 200 3P; 1P=3

23/03/07

> Cold

Tub-b 1M 1st dose
NIH 200 6P
Pla pills 1-1/7days

30/03/07

>. Cold L0. PMS +, Allergic rhinitis >. Hair fall L0. Sun headache L0. Swelling L0. Menses expected

Kali-c 200 3P
Pla pills 3-3/7days
Sabina 200 4P; 1P=4
Mag-p 6X SOS if pain

06/04/07

Fibroids +, PMS and breast pain L5, SwellingL7. Menses 01/04 4/28days

Tub-b 1M 2nd dose
1st week, Kali-c 200 3P
Pla pills 3-3/7days
2nd week, Kali-c 200 1P
Pla pills 3-3/7days

21/04/07

Fibroids

1st week, Thuj 200 1st dose Pla pills 3-3/7days
2nd week, Kali-c 200 1P
Pla pills 3-3/7days
3rd week, NIH 200 1P
Pla pills 3-3/7days
4th week, NIH 200 1P
Pla pills 3-3/7days
5th week, NIH 200 1P
Pla pills 3-3/7days

15/06/07

Fibroid +, Hormone L0, Dysmenorrhoea +, Backache+

1st week, Kali-c 200 3P
Pla pills 3-3/7days
2nd week, Thuj 200 2nd dose
Kali-c 200 3P
Pla pills 3-3/7days

29/06/07

PMS L5, Fibroid L5, Sinusitis L0/2weeks, Wet and A/C < L0, Hair fall L0/month, Headache L0/month, Graying of hair L5, Vagina dryness L5, Skin red in Sun L5. Dysmenorrhoea L5, PMS and breast pain L0,
Backache L8

1st week, Kali-c 200 1P
Pla pills 3-3/7days
2nd week, Kali-c 200 1P
Pla pills 3-3/7days

13/07/07

Very bad. Menses on 1/7. 3 pads/d X3days

1st week, Tub-b 1M 3rd dose
Pla pills 3-3s/7days
2nd week, NIH 200 3P
Pla pills 1-1/7days

03/08/07

>. Headache and Sinusitis > 3+. Menses 2½/26 days

1st week, Kali-c 200 3P
Pla pills 3-3/7days
2nd week, Tub-b 1M 4th dose
Pla pills 3-3/7days

17/08/07

3+.

1st week, NIH 200 1P
Pla pills 3-3/7days
2nd week, NIH 200 1P
Pla pills 3-3/7days

Dr Sushma Jaiswal