NAME : XXXXXX AGE : 48 years SEX : Female
ADDRESS : XXXXXXXX
OCCUPATION : Housewife
MARITAL STATUS : Married
RELIGION & NATIONALITY : Sikhism
REGISTRATION NO. : XXX
DATE OF CASE TAKING : 10 th March , XXXX
PRESENTING COMPLAINTS
HISTORY OF PRESENT COMPLAINTS
Patient was apparently well 9 – 10 years back when she gradually developed pain in the back . Patient is also complaining of white discharge from vagina since 5 years .
Pain in the back
Location – Sacococcygeal region
Sensation – Dull , aching , continuous pain
Aggravation – Walking ( 3+) , Movements ( 3+) , Lying on back , Sitting for a long time
Amelioration – Hard pressure
Profuse white discharge from vagina
Colour – Like white of an egg
Consistency – Stringy , mucus type
Amount – Profuse
Smell – Non – offensive
Staining – Stains linen white , starchy
Aggravation – Night
Associated symptom – Extreme prostration followed by discharge
PAST HISTORY
Any major illness – Jaundice – 8- 9 years back
UTI – 3- 4 years back resulting in loss of control over sphincter and decreased urinary output
History of operations – For renal calculi – single stone , black coloured
Vaccination – Taken during childhood
Skin disease – No history
Allergy – No history
Exposure to X-Rays – Done for detecting renal calculi – KUB region
Drugs used / addicted to – No drug addictions
FAMILY HISTORY
Father – Died ; History of kidney troubles , diabetes , hypertension
Mother – Alive ; History of kidney and liver troubles , diabetes
2 Sisters , 1 Brother
Brother – Died in an accident
1st sister – History of skin problems
Youngest sister – Alive and healthy
PERSONAL HISTORY
Developmental landmarks – On time
Habits / Addictions – No addictions
Diet – Non-vegetarian
Marital status – Married
Occupation – Housewife
Environment – Congenial
GYNAECOLOGICAL HISTORY
Menarche – 12 – 13 years
Cycle – 29 – 30 days
Duration – 4 – 5 days
Character – Bright red blood without clots , non-offensive
Amount – Moderate
Pain – Absent
Inter – menstrual bleeding – Absent
Aggravation – Least physical and mental exertion
Leucorrhoea
Quantity – Profuse
Colour – Like white of an egg
Odour – Non-offensive
Character – Stains linen white and starchy
Relation with menstrual cycle – Between menses
Aggravation – At night
OBSTETRICAL HISTORY
G 4 P 4 A 0 L 4
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PHYSICAL GENERALS
Thermal reaction – Chilly
Appetite – Increased ; Desire to eat but eating aggravates indigestion
Thirst – No change . 1 – 1 ½ liter / day
Cravings – Sweets
Aversions – Sour
Intolerance – Cucumber
Urine
Frequency D 4-5 N 0-1
Smell – Offensive ( 2+)
Pain, burning – No pain or burning
Flow – Continuous flow ; Pressure and output decreased
Colour – Pale yellow
Stools
Frequency : D 0-1 N 0
Character – Hard , dry stools ; at an interval of 2 – 3 days ; Rarely requires mechanical removal
Pain, burning – No pain or burning
Sleep – Sound refreshing sleep for 6 – 7 hours .
Dreams – Dreams of falling in gutter ( water ) from height
Perspiration
Location – Any part of body
Amount – Moderate
Smell – Non – offensive
Staining – Non-staining
Seasonal variation – More in summers
MENTAL GENERALS
GENERAL PHYSICAL EXAMINATION
Built – Ectomorphic
Nutrition – Average
Pallor – Mild
Icterus – Absent
Cyanosis – Absent
Pigmentation – Absent
Clubbing – Absent
Oedema – Absent
Tongue – Clean and moist
Pulse – 74 / minute
Blood Pressure – 122 / 84 mm Hg
Respiratory Rate – 14 / minute
Tongue – White coated
Lymph glands – Non-palpable
SYSTEMEIC EXAMINATIONS:-
GYNAECOLOGICAL EXAMINATION
PS-
PV:-
ABDOMINAL EXAMINATION
Inspection
Palpation
Percussion
Auscultation
RESPIRATORY SYSTEM EXAMINATION
Inspection
Palpation
Percussion
Auscultation
CARDIO-VASCULAR SYSTEM EXAMINATION
Inspection
Palpation
Percussion
Auscultation
NERVOUS SYSTEM EXAMINATION
Sensory Function
Motor Function
Reflex Function
Functioning of cranial nerves – normal
EXAMINATION OF BACK
Inspection
Palpation
Movements
INVESTIGATIONS DONE
Blood – Hb – 8.5 gm %
TLC – 7500 / cu mm.
DLC – N 53 L 42 E 3 M 2 B 0
ESR – 34 mm
Urine – Routine – acidic
Microscopic examination – WBC – 1
Epithelial Cells – 6 – 7
Bacteria – Low
Ultrasound – Whole abdomen
Liver , Gall bladder , Pancreas , Spleen , Kidneys – NAD
Urinary Bladder – Over – distended
PROVISIONAL DIAGNOSIS
Cervicitis and vaginitis
DIFFERENTIAL DIAGNOSIS
MANAGEMENT
REMEDY INDICATED
RX
Causticum 200 / TID / 1 day
SL 30 / TID / 7 days
JUSTIFICATION