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Case Study : HYPOTHYROIDISM

History

A 34 year old female came for treatment of Hypothyroidism. She is a K/C/0 HYPOTHYROIDISM since 8 years which was agg since 1 year. H/O Gestational hypothyroidism. Pt was not on any allopathic medication.(Had started with allopathy but later stopped) ASSOCIATED COMPLAINT:
  • Tendency to cold and cough since childhood.
  • K/C/O Cervical spondylosis since 2 years.
  • A/F- H/O fall. Complaints of Vertigo/Tingling and Numbness B/L hands/ Tinnitus
MENSTRUAL AND OBS HISTORY: MENSTRUAL HISTORY :
  • Cycles Regular.
  • Menses bright red/ delible/ N.O/ No clots.
  • Before menses- Tenderness of mammae/Backpain/Legpain
  • During menses- Backpain/Legpain
OBS HISTORY : G3P2A1L2 A1- Miscarriage in 2nd month L2- FTND

P/H & F/H :

P/H : Koch’s cervical node
Jaundice
Malaria

F/H : Aunt Ca buccal cavity/T.B
Father HTN
Mother Hypothyroidism
PHYSICAL GENERALS
THERMALS
  • APPETITE : Normal
  • LIKES : Sweets+/Egg+/Milk
  • THIRST : ↓
  • PERSPIRATION : Profuse/on back/Offensive/N.S
  • SLEEP : On right side/Snoring
  • STOOL :Unsatisfactory stools/Straining
  • URINE : Normal
CHILLY ++/Likes summer(I like sunrays at home)
MIND
  • Loud noise+ – fears that things will fall/palpitations(Incidence of vibrations in building due to loud noise)
  • Desires company+ – I cannot go out alone. If I go office alone, I wont take halts in between.
  • Occ striking anger/Grinds teeth in anger/Trembling of extremities(during arguments)
  • Stress related to kids and job.i don’t know how to manage as I don’t get leaves from job easily.
  • Nervousness in interview and in company of new people. If I am comfortable with something I wont leave that place/job.
  • Talking amel
  • Earlier used to cry a lot but now stopped.
  • Restlessness of feet with anxiety.
  • if I am angry/disturbed, 2-3 days I will think and after that speak
  • Fear of heights+
  • Fastidious+
  • Yielding disposition
  • Issues with M.I.L but doesn’t speak much.
  • Introverted.
  • Childhood : Mother had leftus when I was young. I used to live paternal aunt. She tried to remove me from school, so I ran and told dad about this. He came and left us with maid.
  • I feel I have suffered since childhood. I don’t want to work but I have to as I don’t have any support.
  • I have been doing things on my own.
  • DREAMS – Fallling(waking up)/Water bodies+/Snakes

PRESCRIPTION

Rx,
Mag carb 200(1p)
S.L 200 (1d) 5-0-5
Date
Prescription
Follow up
23/03/20
->-
Rx,
Mag carb 200(4p)
S.L 200(2d)4-0-4

07/04/20

Left sided headache
Rx,
Ct all×1 month

05/05/20

Tingling and numbness
Rx,
Ct all×1 month

08/06/20

Headache 40% >
Rx,
Mag carb 200(2d) 2-2 weekly
S.L 200(2d)*6 4-0-4

18/08/20

->-
Rx,
Ct all×3 months

18/12/20

Headache ->>-
Vertigo+
Tinnitus +
S. Iron reduced
T.S.H 5.6
Rx,
Mag carb 200(2d) 2-2-2 weekly
S.L 200 (2d)*6 5-0-5
Kali mur 6x (2d)*12
01/03/21
Headache-o-
Vertigo-o-
Wt increased 65kgs
Rx,
Mag carb 200 (2d) 2-2-2 weekly
S.L 200(2d)*6 5-0-5
Tuber k 1M (1/2d) 3 pills every10 days

01/07/21

Headache-o-
T.S.H 5.21
Increased work stress
H/O Miscarriage
Recurrent cold-o-
Rx,
Ct all×3 months
23/10/21
Headache increased since 1 month
Cx swelling
Pain in eyes
Wt lost
Tingling-o-
Rx,
Ct all×3 months
02/03/22
Headache-o-
Cx pain->-
Constipation+
Rx,
Ct all×3 months
04/07/22
T.S.H 6.39
T.S.H 5.6
L.M.P- 02/06/22 03/07/22
Headache-o-
Cx pain-o-
L.B.P since 1 week
hot fomentation Xray shows reduced gap
Rx,
Mag carb 200(2d) 3-3-3 weekly
R.T 1M+Calc flour 200(2d)*6 5-0-5
Scalptone 1-0-1