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Complete case history : chronic oral ulcers with pain in abdomen

Name : [removed by moderator]
Sub: Chronic oral aphthous ulcers for 7 yrs (increasing in intensity), urticaria for six months (3-4 times a day) � resolved with homeopathy, motions 7-8 times daily for 1 yr,ulcer in ileum six months ago, constant pain in rt side ileum area for past three months, low grade fever for 1 month
Concern : History of autoimmune disorders in maternal side with mother having Takayasu�s Arteritis
Gender: F
Age: 17 ½ yrs
Body Type: A
Height: 5� 2�
Weight: 48 kg
General appearance: wheatish complexion, slim, skin looking dull now, tired looking

Have you used homeopathic medicines before? If so what, and what homeopathic potencies did you use?
Nux vom 200, Aloe 200, 1M; Acid Nitr 30 (currently taking)


Please answer the following questions in a descriptive manner after careful analysis and recollection of previous experiences and happenings.

1. Describe your main suffering?
I�ve had oral ulcers for 7 years with not a single ulcer free day for over 4 years. The pain has increased over time with ulcers in throat & inside behind ear at times. I�ve been passing stools 7-8 times daily for over 1 year with mucous discharge for 2 months. The stools vary in texture/colour from watery to solid even in a single day. A colonoscopy six months ago showed an ulcer in the ileum which a subsequent colonoscopy has shown to have healed . My current main problem is a constant pain in the right side (where the ulcer was) for over 3 months. The pain never goes away but only improves with a pain killer. Low grade fever with headache and body ache has begun over the past 1 ½ months.

2. What other physical sufferings do you have in your body?
Pain in rt side abdomen, head ache, body ache, pain due to oral ulcers

3. What mental sufferings / feelings do you have associated with your physical sufferings?
Frustration on being unable to work as hard as I want to and perform as best as I can. I feel limited by my lack of energy and inability to sit and study (I�m facing my XII board exams and it is imperative for me to be well).

4. What exactly do you feel when you are at your worst? Describe the sensation in your own words.
Extremely low and weak � unable to sit, a hot pack in the abdomen feels good. If I lie on my stomach I get some relief for a while. I try not to take a pain killer unless the pain is really unbearable.I need my family around me and do not like being alone at such times.

5. When did it all start? Can you connect it to any past event or disease?
It started 10 yrs ago with frequent ear aches which stopped and almost at the same time the oral ulcers began 7 yrs ago. Ever since I do not recall a single ulcer free day in my life. Also as far as I can remember, cold has always affected me and my extremities are always icy cold to touch even in summer.

6. Which time of the day you are worst?
I am worst in the night after about 9 pm although the pain in the abdomen is always there and the recent body ache also persists all the time.

7. What are the things which aggravate your suffering and which are those which ameliorate the same? Example- time, temperature, pressure, rubbing, washing, eating, tight clothing etc.
Cold weather, cold drinks (esp aerated),spicy food, onions, capsicum, rice, khichdi, tight clothes aggravate my problem. Rubbing also is not comfortable. Cheese, Chinese food esp noodles sometimes aggravates oral ulcers.
Hot pad, pressing of feet, legs, hands (esp joints � ankle, knee,wrist) gives relief. Warm room close to the heater gives relief. I normally drink very less water and even drinking excess water makes me uncomfortable.

8. Do your think your sufferings have relation to any external stimuli (like, change of place) or any internal biological changes in the body, like, menses (in females)?
The oral ulcers have always been there regardless of place of stay and seem to be aggravated by certain foods. The urticaria which I had for six months started while I was on a vacation, continued after I returned home and also followed the same pattern when I went for another longish holiday. I used to need to take 2-3 cetzines a day. Afer some homeopathic treatmen they went away after six months. My recent stomach problem is the same wherever I go. My periods which had been very irregular ( 15 -20 days cycle) for over 1 ½ yrs has become ok for 3 months now.

9. When do you feel better, during hot weather or cold weather, humid or dry weather?
Hot and dry.

10. Describe your general mental set up? Are you Moody, Arrogant, Mild, Agreeable Changeable, Nervous, Suspicious, Easily offended, Quiet, Arguing, Irritating, Lazy etc.
Perfectionist (Type A personality), stubborn, very reliable (if I take a responsibility I will do it no matter what � and do it well) � for this reason I can never delegate work and do everything myself, very neat & particular about keeping things in proper place � hate untidiness and messiness. A bit hyper, irritable if things don�t go as I plan, do not share problem easily, do not show my frustration, make friends easily and will do anything for them.

- How do you feel before or during a thunderstorm?
I do not like them. No other feelings.

- Do you like being consoled during your tough times?
I keep away from others for a while � do not particularly like being consoled.
- Are you sensitive to external stimuli like smell, noise, light etc?
My sense of smell is less acute than normal. I like peace unless it is music of my choice. Cannot sleep with the light on � like a dark room to sleep.

- Do you have any typical habit or gesture like nail biting, causeless
Weeping, talking to one self etc?
I used to bite my nails till two months ago. Gave up the habit recently. Do not talk to myself or weep ever. Do not like to wallow in self-pity.

- How do you feel about your friends, family, your children and especially your husband / wife?
I love my family � parents and brother. Am fondest of my father, very close to mom from whom I get comfort when unwell. Am close to my brother esp after he left for college. I like meeting the rest of our extended family and look forward to spending time with cousins.

11. What are your fears and do you dream of any situation repeatedly?
I have never had dreans. My only fear is of my performance in the forthcoming exams for which I am unable to study because of all these health problems. I have a fear of water- hate swimming (am sort of glad that freq ear infections meant no swimming lessons) � and the aversion shows in my bathing habits (although I bathe daily � it is not out of my free will )

12. What do you crave for in food items and what are your aversions?
I love cheese and Italian food in particular. I hate spicy food, dal, onions, capsicum & Chinese/Thai food. I prefer bland food � do not like excessively salty or sweet food.

13. How is your thirst: Less, Normal or Excessive?
Less

14. How is your hunger: Less, Normal or Excessive?
Less

15. Is there any kind of food which your body can�t stand?
Spicy, Chinese noodles, raw onions, fried food.

16. Is your sweat normal or less or more? Where does it sweat more: Head, Trunk or Limbs?
Less � I hardly sweat even in summer.

17. How is your bowel movement and stool type?
Pass stools 7-8 times daily. Earlier they used to vary from semi-solid to solid lump. For past month, only loose, dark coloured with mucous � no blood in stool test. I very rarely need to get up in my sleep to pass stool but in school need to go 2-3 times.

18. How well do you sleep? Do you have a particular posture of sleeping?
Poorly. Pain keeps me restless. Sleep better when I am with my parents. Prefer to press the pain against a pillow or sometimes sleep on stomach.

19. Do you think you are able to satisfy your sexual desires in general?
I am only 17!!!

20. Do you have any strange, peculiar or unusual symptom or feelings? How are you different from others?
I am not content with half measures and think that it is better not to do something if it can�t be done well. I feel really cold and my hands and feet and nose are icy to touch. Nothing seems to give me relief from my pain � that irritates me.Even the fever and body/head ache along with it do not respond to Crocin and seem to follow the same pattern of rising till evening and becoming 99 when I wake up. I feel frustrated that no medicine � allopathic/homeopathic or any other has been able to give me any relief.

21. What medications have been taken earlier by you to treat the diseases and do you have any particular symptom surfacing after the medication?
I have taken Aloe 200/1M, Bryonnia, Acid Nitr 30 (taking currently). Our family homeopath has given some other med but I do not know the names.

22. What major diseases are running in your family?
My mother has an autoimmune disease of the arteries � Takayasu�s Arteritis. There is a history of autoimm diseases in her side � eczema, pemphigus, cancer etc. Both parents are diabetic, father hypertensive.

23. Describe, how do you look like? Describe your overall appearance.
I am slim, av height, pleasant looking. Have lost weight over 3-4 yrs and look weak with skin that seems to have lost the glow it used to have till 2 yrs back. My hair is thin but shiny, teeth clean but not sparkling as they used to be.
(For Females)
24. If your menstrual cycles are not normal, please describe the irregularities, like pains, moods, flow type, clots etc.
For about 1 ½ yrs my cycle has been irregular (10-15 days cycle) with heavy flow, clots etc. No mood swings during the cycle. But for 2 months the cycle is 30 � 35 days

25. What major diseases have you had in your life and when. Please write them in a chronological manner.
2000 � severe ear infection
2004 � oral ulcers begin
2006 � urticaria for 6 months
2008 � dengue
2009 � stool 7-8 times daily, ulcer in colon
2010 � pain in rt side abdomen
 
  bhuvijain on 2011-01-11
This is just a forum. Assume posts are not from medical professionals.
Take a single dose of arsenic alb 30
SINGLE DOSE: 4-5 drops of Arsenic Alb 30C Dilution in 15-20 ml of water to be taken on empty stomach in the morning
Take such doses for 7 days then report threreafter
Regards,

Dr. Yogesh
 
yogeshrajurkar last decade
Thanks doc, shall start tomorrow ... Hope this will work.
 
bhuvijain last decade
Dear Doc,
I have taken ars alb as advised by you. The fever pattern shows a slight improvement with lower peaks and longer fever free duration.
However, my symptoms of body ache and pain in the head(the whole head - i like someone to press it - are worse. The pain in abdomen has also increased. Oral ulcers are same. Overall, I would say I feel more or less as before.
 
bhuvijain last decade
Bhuvijain,
Dissolve 4-5 drops of arsenic alb 30 in half a cup of water
Stir it with a spoon vigorously for 5-10 minutes.
This increases the power slightly making it 31.
Take this dose in the morning on empty stomach.
Report in 4-5 days
Regards,

Dr,. Yogesh
 
yogeshrajurkar last decade
Dear Doc,

I had forgotten to mention that Niharika has been getting small brown marks in her nails since 2 months n these marks hurt when pressed. She has also had very low serum ferritin levels(as observed since past two years). Her levels b4 that are not known. But haemoglobin by and large has been alright.
I have made a detailed case history with blood test trends which I could mail to you.
Regards,
Bhuvijain (M/O patient)
 
bhuvijain last decade
Dear Doc,
She has taken doses so far of stirred Ars 30. Her symptoms seem to have worsened with fever peaking at 99.8 (for a short 1 hr period) and head ache n body ache worse than b4. She is giving her XIIth boards and stress could be a cause for aggravation. She is quite unable to do any normal studying - and it is imperative that she is up & about asap.
Just to add - I am severely allergic to sulphur(allopatic) and would never want to try that on her.
Thank you for sparing yr precious time to take on her case,
Regards,
Bhuvijain
 
bhuvijain last decade
Bhuvi,
This is important:
When she has fever how is her condition( physically & mentally)?
Is she irritated, dull , lamenting weeping, anything else like restless?
Please describe in detail.
Regards
Dr. Yogesh
 
yogeshrajurkar last decade
Dear doc,

She is mentally very strong. Never complains - only tells me bcoz I've asked her to keep telling me her symptoms. For the past 4 months or so, there is a slight frustration at not being diagnosed. She is not scared that she might be having some major problem - just wants a diagnosis so there is a treatment and she can carry on with her work. She gets irritated more because of the helplessness than anything else. She is not the weeping kind at all - mentally very strong. When she has fever the headache worsens and she feels like sleeping. Unless she can't help it (like she has an exam or something) she is averse to any medication like crocin for fever or spasmoproxyvon for stomach pain.

Regards
Bhuvi
 
bhuvijain last decade
Bhuvi,
Why is she averse to allopathic medicine?
Why does she hide her sufferings from others?
Does she have a strong sense of responsibility?
Any greif or emotional turmoil she has suffered at the start of all her suffering?
Also report with her present condition I will most propabably change the remedy.
Regards,

Dr. Yogesh
 
yogeshrajurkar last decade
Dear Doc,
1.Why is she averse to alopathic meds?
She has seen me be on steroids (for my autoimmune disorder - Takayasu's arteritis) for 10 yrs and has seen in close quarters the side effects caused by alopathic drugs in the long run. So she is averse to unnecessary medication. Also, my husband's side of the family are all strong believers of homeopathy & we always resolve minor problems with homeopathy.

2. Why does she hide her sufferings from others?
It is not as though she hides her sufferings so much as she does not want to make a big fuss about it. I guess this is something both parents follow - we do not fuss about our health issues and remain cheerful thru all our troubles. She only tells us when she thinks things r getting out of hand and something should be done to get relief.

3. Does she have a strong sense of responsibility?

Towards school work, studies etc. If a task is assigned o her at home, she does her best to do it - and do it well. Otherwise, by God's grace, circumstances are such that her life other than the physical ailments, is happy and cushy and responsibility free.
4. Grief etc?
None that I know of. Maybe some minor teenage crushes that I do not know about. Nothing serious. Perhaps one factor may have affected her and that could be my health issues that began when she was small. Perhaps seeing me having problems due to steroid use may have triggered the fear of losing me. I do not know since she never verbalized the fears. But my husband & I have never made my health to be an issue of worry - we laugh about things and our kids think all is well.
5. Present condition

I have observed that her fever is below normal(98) at about 10 am. By aft it rises to 99 - 99.2. Eve stays at 99.2. Strangely bet 9.30 and 10.30 at night it peaks at 99.8 and falls to 99 by 11pm. After about 12.30am in the night it falls to 98.6. Not seen until morning thereafter. We had earlier not been noting the fever bet 9.30 and 10.30 pm so I do not know if it was always so or recent.

Earlier (b4 ars alb was started), she used to have fever (99- 99.2) on waking which used to rise upto 99.4-99.8 at night. I had not been observing the pattern so much in detail then so cannot give much info.Ars alb given for a total of 10 days - 7 days ars 30, three days ars alb31 - stirring)

Her oral ulcers have increased in number since past 2 days. Coincidently, acupressure has also been started on her.

Body ache, head ache remain the same. She is unable to put in longer hours of work - tires easily. Appetite is low as usual. fussy about food.

P.S. We used to ry and give her Merc sol in the initial days of oral ulcers many years ago and always noticed a lot of aggravation with the same.

I would again like to thank you for sparing your precious time and looking at my daughter's case. We really are at our wits end having drawn a blank with alopaths, loads of homeopathy acupuncture acupressure and what not. I hope your medicine works.

Cheers,
Bhuvi
 
bhuvijain last decade
Dear doc,
Body ache n stomach ache r a little more than usual since yesterday. Although her VIT b12levels r ok I was planning on giving her a single dose of higher dose of the same to see if her oral ulcers improve with d same. Pl advise
Regards
Bhuvi
 
bhuvijain last decade
Bhuvi,
OK
Give her the next potency.
Give ars alb 200C but just a single dose only once dont repeat And report in 2 days
Regards,

Dr. Yogesh
 
yogeshrajurkar last decade
Thanks doc,
Will do
Bhuvi
 
bhuvijain last decade
Dear doc,
The night before giving her the single ars dose her body temp dropped to 97 at11pm. Subsequently After the ars her body temp has been following the pattern of 99 to 99.2 on waking rising unto 99.4 during the day and a sudden drop to 97 or so at 11 pm accompanied by extreme weakness and severe body ache.

A couple of months ago she used to get blue black marks like purpura in her hands and legs. They had stopped since some time. Yesterday two new marks appeared on her legs. They are tender to touch. Her body ache is really weird it's like the fleshy parts of her hands n legs like being kneaded.

Mentally also she is not looking very perky. Could be the fact that exams are barely round the corner and studies are in bad shape. An unhappy situation for anyone ESP a good student like her. She has so many dreams and no energy to follow them. I think she is feeling a bit weepy also.

Gave her b12 last night. She has yet to wake up for me to note the effect of the same. Pl advise on further course.

Could this fluctuating body temp be the cause of her weakness.

Regards
Bhuvi
 
bhuvijain last decade
Dear doc,
Her oral ulcers are painful for the past three days ESP two on tongue. Body ache esplegs is at it's worst today withtheblue marks having increased from two to four since yesterday.

I used to get such marks on my body as a child and it was later diagnosed as calcium deficiency.

Pl advise
Bhuvi
 
bhuvijain last decade
Dear doc
Her body ache is worse she keeps wanting someone to press her legs arms shoulder etc. Fever fluctuates from97 to 99.4 in a single day.
I am getting worried now since she finds herself unable to study for more than 2 hours in the whole day.
She is a child who used to study for hours on end for her xth board exams. Physical health aside I think her concentration is also affected besides her memory. She is finding it difficult to retain stuff read the previous night. Maybe the stress is also causing this.p L advise asap
Sincerely
Bhuvi
 
bhuvijain last decade
Dear Doc,
I had complete blood work up done for my daughter - CBC, LFT KFT electrolytes Iron etc. All are normal except Serum Ferritin which is 9.6 (it was 10 in Sept'10). Her ferritin levels have always been low (at least since three years - don't know about before).

Urine routine has shown 'Budding Yeast present'.

Pl advise
Bhuvi
 
bhuvijain last decade
She has been complaining of band type headache and some dizziness while getting up. Oral ulcers are hurting more these days. I hope you are well doc, haven't heard from u in a while. Pl respond.
 
bhuvijain last decade

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