Sep 2013|Vol 10|Iss9

   
 
Case
 
   
A Case of Enlarged Uterus
 

 

Dr. Anuradha Raja, BHMS
Plot No 20, SMESC Colony,
North Extension, (Opp) Simco meter,
Trichirapalli - 620021.
Phone: 9894833163
Email:dr.anuraja1997@gmail.com

 
s  
 

        A female aged 31years fat, fair, good looking married woman presented with excessive bleeding every month especially after her second delivery since 1 year.

Past History

      No H/O acute /chronic illness in the past.

Family History

      Her father is hypertensive.
      Mother is suffering from cervical spondylitis.

Treatment History

      Consulted the Doctor who had attended her delivery /taken some allopathic medicines/ not given much results .

Obstetric History

      Gravida-2, para-2, abortion-0, stillbirth-0, living-2
      Last child birth-2yrs both normal deliveries.

Mental Generals

      She has become mentally depressed as her husband has gone abroad 10 months back.
      Very sensitive/easily gets tensed up even by trivial things .

Physical Generals

Appetite —Normal
Thirst —Normal
Aversion —To smell of cigarette
Bowels —Passes motion immediately if she fears about something.
Stools —Loose /semisolid
Urine —Normal
Sleep — Disturbed due to grief

Menstrual History

      Gets periods once in 21 days /flow excessive for 7days /with clots
      Becomes weak during and after periods –since 1 year.

Physical Examination

      WT-79Kgs BP-110/70 mmHg CVS /RS -NORMAL
      P/A: Abdomen is soft /bulky /tenderness in lower abdomen /lt iliac fossa.

Investigation

      SCAN- bulky uterus /right adnexal simple cyst (Refer Plate I)

Prescribing Totality

- Aversion to smell of tobacco
- Symptoms started from grief {after her husband’s departure}
- Sleep disturbed due to grief.
- Loose stools from fear.

Management

      She has been advised to engage herself in car driving and yoga.Advised her to think positively and Psychological support has been given to get rid of her grief.

First Prescription                        24-12-2012

Rx
Ignatia 200 /3d 1-1-1
Followed by placebo /30d
Fraxinus Q 10-0-10 drops

She came after 1month. Her LMP-18-01-13. She didn’t get much improvement
Clots slightly reduced. Sleep little bit improved.

Follow Up-1                                28-01-13

Rx
Ignatia 1M/3d 1-1-1
Followed by placebo /30d
Fraxinus /Q 10-0-10drops

On her next visit I came to know that she got good improvement
Lmp-15-02-13 /bleeding reduced, with small clots for 5 days.
She did not go to toilet as frequently as earlier. Sleep-normal.

Follow Up-2                                 28-02-13

Rx
Placebo/30d

Her menses appeared on 13-03-13. Very normal flow without any clots.Motion -twice a day.


Follow Up-3                                02-04-13

Placebo was repeated for 1 month.
Ultra sono graphy of pelvis was advised. Scan-taken on 18-05-13 revealed normal uterus and ovaries. (Refer Plate II)