Case Study On Gastrointestinal Tract

Personal data of the patient:
Name of patient: xyz
Age: 28 years
Sex: Female
Religion: Hindu
Nationality: Indian
Marital status: single
Occupation: Job
Family size: 5 member
Diet: vegetarian
Presenting complaints

Complaint with duration	Location and extension	Sensation, character and pathology	Modalities Ailments from	Concomitant, associated symptoms with duration
Weakness, Nausea, Anorexia Last 7 – 8 days	GIT, Right hypochondrium Oesophagus Skin Lower abdomen	Heaviness Pain in the abdomen Itching Nausea Constipation	< after eating > by open-air, at night, cold application	Fever Headache Bodyache

History of Presenting complaints: Before 7 – 8 days patient have complained of mild abdomen discomfort with abdominal pain, then gradually realized like nausea, vomiting, icterus, fever.
Personal History: No abnormality detected.
Family History:

• Father: Hypertension
• Mother: Diabetes
  Physical Generals:

Appetite	Decreased
Thrist	Increased (3-4 lit/day)
Desire	Cold Drinks
Aversion	Fatty foods
Bowel	Constipation on an alternate day
Urination	5 – 6 times/day
Perspiration	Normal
Sleep	Disturbed due to itching
Habits / Addiction	Not specific
Others	Not specific

Character:
Duration: 30 days

Quantity: profuse

Consistency: partly fluid & clotted

Colour: Dark red

Mental Generals: Fear of death
General Examination:

• Conscious/ unconscious        : conscious
• General appearance : fair
• General built & nutrition       : Intellectual B.Com
• Height                                      : 160 cm
• Weight                                     : 68 kg
• Skin ( pigmentation, hair, warts, etc.): Itching & pale
• Nails                                        : Yellow
• Gait                                         : Normal
• Blood pressure                        : 130/90 mm of hg
• Pulse                                       : 86/ min
• Temperature                           : 99.2° F
• Respiratory rate                      : 18/ min
• Others                                     :- Normal
  Systemic Examination:

SYSTEM	FINDINGS
Respiratory system	B/L A/E present
Cardiovascular system	S1 S2 heard
Nervous system	No abnormalities seen
Gastro intestinal system	P/A Right hypochondrium tenderness present
Genito urinary system	Urine yellow
Lokomotar system	No abnormalities seen
Others	No abnormalities seen

PROVISIONAL DIAGNOSIS: GIT Infection
Analysis and Evaluation of Case:
(A)  Classification of symptoms :

1. Fear of death (UMS)
2. Appetite decreased (UPGS)
3. Stool constipated every alternate day (CPGS)
4. Sleep Disturbed due to itching (CPGS)
5. Weakness (CPGS)
6. Pain & heaviness in the abdomen (CPPS)
7. < after eating (UPGS)
8. > by rest, cold application & open-air (UPGS)

1. Mental symptoms: Fear of death
2. Physical general symptoms :
   Appetite decreased
   • Stool constipated every alternate day
     • Weakness
     • Sleep disturb due to itching
     • < after eating
     • > by rest, cold application & open air
3. Physical particular symptoms: Pain & heaviness in the abdomen
   Totality of Symptoms

• Fear of death
• Appetite decreased
• Stool constipated every alternate day
• Sleep disturb due to itching
• Weakness
• Pain & heaviness in abdomen
• < after eating
• > by rest, cold application & open air

Potency selection: Here, in acute condition susceptibility is high. So, potency also high & due to acute condition repetition is frequently.
Prescription: CHELIDONIUM 200 – 4-4 pills BD for 3 days SL × BD – 4-4 pills BD for 5 days.
GENERAL MANAGEMENT AND AUXILIARY MEASURES:

• Take lots of liquid
• Advice for an only semi-solid or liquid diet
• Rest for 4-5 days
• Avoid spicy and fried food

DATE	CHANGE IN SYMPTOMATOLOGY	FURTHER ADVICE (regarding prescription including justification, general management, investigation etc.)
16/09/2019	Sleep is good	Rx. SL × BD – 4-4 pills for 3
	Itching is relieved	days
	Stool is normal
	Mild weakness
	Mild pain is present
21/09/2019	All Complaints are relieved	Cured

Guided by Dr Ratna Bhatt MD (Hom.) (practising for 10 years) Lecturer at Ahmedabad Homeopathic medical college
Case study by Shweta G. Patel 4th year BHMS at AHMC