26 year old male
C/o :-
- hemetemesis, 2 episodes on the same day.
- Distension of abdomen since 7 days with generalised pain.
- Black coloured stool since 2 days.
- No fever / chills.
- No pedal oedema.
- No dyspnoea.
- No other complain.
- Pt. is chronic alcoholic, seems like in delirious state because of withdrawal effect of alcohol as he is not able to consume alcohol since 4-5 days.
- wants to get well soon and go home.
- Thirsty.
- kicks off his cloths and tries to run away from bed.
On investigation :-
- Abdominal and pelvic ultrasound shows hepatomegaly with fatty changes, with early changes of cirrhosis.
- Spleenomegaly.
- mild ascites.
- Liver function test shows,
- S.Bilirubin -
- Total - 6.31 mg/dL
- Direct - 2.72 mg/dL
- Indirect - 3.59 mg/dL
- SGPT (ALT) :- 22 U/L
- SGOT (AST) :- 290 U/L
- S.ALP :- 288 U/L
- S.protein :-
- Total protein :- 7.4 gm/dL
- Albumin :- 3.4 gm/dL
- Globulin :- 4 gm/dL
- Albumin-Globulin Ratio :- 0.57
- Haemostasis profile shows,
- Prothrombin time :- 17.5 sec
- INR :- 1.2
- PT Control :- 14.7 sec
- ISI :- 1.10
- APTT
- patient's value :- 33.1 sec
- control :- 30.0 sec
- Biochemistry report shows,
- Anions
- S.Sodium :- 134 mEq/L
- S.Potassium :- 4.6 mEq/L
- S.Creatinine :- 1.2 mg/dL
- Complete blood count shows,
- Haemoglobin :- 8.9 gm/dL
- Total WBC Count :- 8500 / micro litre
- Neutrophils :- 74%
- Oeosenophils :- 03%
- Basophils :- 00%
- Lymphocytes :- 20%
- Monocytes :- 03%
- RBC Count :- 2.67 millions / micro litre
- Hematocrit (PCV) :- 25.8 %
- MCV :- 96.4 fl
- MCH :- 33.4 pg
- MCHC :- 34.7 gm / dL
- RDW - CV :- 17.1 %
- Platelet count :- 52000 / micro litre
- Mean platelet volume :- 8.4 fl
- PCT :- 0.04 %
- PDW :- 13.6 10
- Biochemistry Report shows,
- Anions :-
- S.sodium :-134 mEq/L
- S.potassium :- 4.6 mEq/L
- S.creatinin :- 12 mg / dL
- Urine analysis shows,
- Amount :- 10 ml
- Colour :- Deep yellow
- Appearance :- Turbid
- Reaction :- 6.0
- Specific gravity :- 1.020
- Chemical examination :-
- Albumin :- 2 %
- Glucose :- Nil
- Urobilinogen :- Normal
- Bilirubin :- 1 +
- Ketone :- Absent
- Blood :- Absent
- Microscopic examination shows,
- Pus cells :- 10-12 / HPF
- RBCs :- 35-40 / HPF
- Epithelial cells :- 1-2 / HPF
- Casts :- Absent
- Crystals :- Absent
- Bacteria :- Absent
- Trichomonas :- Absent
Does these details are enough to initiate treatment?
please, give your expert opinions through comment(s)...
- If NO, what should be further questions / investigations?
- If YES, what should be further management?
please, give your expert opinions through comment(s)...
chelidonium will help.
ReplyDeletechelidonium in which potency? what about repeatation? if it is possible, can you please explain why chelidonium?
DeleteI'll be short. to be precise, most of the symptoms are pathological. fortunately hematemesis is both pathological as well as subjective symptom. other than that there is the inability to remain lying in bed (at night?). hence we can make an attempt to prescribe the similimum. but nevertheless it will be only probabilistically correct. it is not our aim.
ReplyDeleteat least we need to know whether the pt is hot or chilly. the throwing bed clothes need not mean that the pt is hot, it could be an act to prepare himself for getting out of bed.
also the time of aggravation could be the time at which the patient tries to get out of bed. ( modality can't be ascertained by direct questions, we have to imply the same from presenting symptoms. but such symptom is missing or lacking here.)
So, we need
thermals
appetite
thirst
concomitants if possible
so, with these particular details we can't / should not initiate any treatment?
DeleteWe give plumbum metalicum
ReplyDeletehere, why plumbum metalicum? in which potency? what about repeatation?
DeleteWhen we have clear cut vision so give it. ....
ReplyDeleteThanks Dr k.t.
Keep it up. ...jay hahneman jay homoeopathy
sorry hero, but i am learning to get clear cut vision! :)
Deletetreatment was mean to be initiated even before investigations with the help of clinical examination, which is not even mentioned here anywhere!!!
ReplyDeleteanyways, these details are enough to begin treatment plan.
without wasting any more time, initiate with guidance of complete bed rest till improvement, salt restricted diet with controlled protein intake. strict restriction for alcohol.
begin with vitamin B complex and diuretics and keep him under observation.
try to find out if there is presence of any other responsible causative agent(s), if it is there try to remove that cause.
thank you sir, for your valuable opinion. i completely agreed that clinical examination should be given prior importance than laboratory investigations.
Deleteactually i do not know much about allopathic treatment but with my poor knowledge i am aware that diuretics will help to reduce ascitec fluid.
vitamin B complex will improve essential enzymatic actions.
diet and bed rest will help to rehabilitate.
here, i doubt strict alcohol restriction will be beneficial??
doubt arise as patient is chronic alcoholic and there is already visible delirious state because of withdrawal effect of alcohol.
dear karnav,
Deleteit's just like double edged sward though yes, strict alcohol restriction will be beneficial as you may will be able to control withdrawal effects but you will not be able to control advanced cirrhosis.
don't worry about your poor knowledge about allopathy, its still better then my knowledge about homoeopathy!
thank you sir!
Deletewe can initiate treatment, but it would be a trial and error method. if the first remedy fails there are chances we lose the patient.
ReplyDeletefor example if we give arsenic alb thinking the patient is chilly, it could be he is hot and needs sulphur therefore no reaction from ars alb. on the otherhand if we give sulphur bcoz he threw away bedclothes, it could be indicating restlessness as I've already said, and not due to cold. hence sulphur would aggravate. so, whatever remedy we give, there is risk.
the anonymous commenter is right about chelidonium only if the aggravation time is 4am, and there's pasty yellow stools and/or urine, patient desiring hot food and water.
when all these symptoms are very easy to ask and ascertain from the patient, why should we take the risk of trying any remedy to which we are biased ? it is explicitly forbidden by the master teachers.
got it sir, so, it is better to hold on our treatment plan and should try to ascertain some more details
Deletethank you for your valuable opinion.
Case is clear
ReplyDeleteThirsty
Hot
Liver cirrhosis
Bleeding tendency
Anaemia
Splenomegaly
Proteinurea
Ascites
Alcoholic
Acetic acid 6, qid , f up 1 WK after.
All general guidelines like abstinence from alcohol, low fat, low protein diet, less fluid, rest, B12 supply, etc.
Amazing!!
ReplyDeleteThank you very much Dr.Dhrupad sir for your precious answer.
I must apologies that follow up will not be possible because of various practical problems! Sorry for that!
Once again, thanks a lot.
yes acetic acid may be the similimum. the jumping out of bed is a peculiarity. such peculiar symptoms always are the best guides. Dr.Drupad has good knowledge of the materia medica.
ReplyDeleteOnly the craving for alcohol is not a symptom belonging to acetic acid. absence of a symptom is not a contra indication of course. here it is not absence but presence of a symptom not quite belonging to the set of symptoms indicating the principal remedy. it is here we have two think of a complementary which takes care of such remaining symptoms.
Call it the orientation of the patient if you like. it is the direction the totality is likely to take after giving the indicated remedy. in this fashion if china is taken to be the complementary, it fits the remaining symptoms.
It is always worth considering two remedies or remedy pairs for covering the entire totality wherever a single remedy doesn't fit the description well.
Dear Dr Vyanktesh, thanks for complement but I am not really good at mm, and I see how wonderfully you always use relationships of remedies.
ReplyDeleteDear Karnav,
It is not always necessary to have complete picture. When a beginner is taking case there are always probabilities of having incomplete picture. But we need a vision to see what is not given.
Here we have principally taken pathological viewpoint of prescribing and hence low potency, and anyways patient is in a critical condition. At such time it will be criminal to give higher potency and foolish to keep on looking for peculiarities and wasting time.
Closest remedy, judicious dose and repetition followed by re case taking when vitality is regained will get us the best recovery.
Respected Dr. dhrupad sir,
Deleteis there any chance for presence of peculiar symptoms in case of critical condition!?
if yes, what should be done for selection of potency?
More advanced pathology lower the potency.
DeleteEven if there is presence of peculiar symptoms?
Deletein extensive tissue pathologies there are likely, less characteristic symptoms of the remedy relationships instead of the peculiars. for example pneumonia where sulphur mother tincture is needed, patient will be chilly instead of the characteristic "hot" sensation. that is why materia medica lists less characteristic symptoms which are quite opposite to the characteristics. in such circumstances the past history agreeing to the sulphur type, or previously well acted remedy like Lycopodium will guide us to sulphur
ReplyDeleteIn all cases this rule may not hold true, like Natrum Mure. though the patients are usually hot, extreme chilliness even during the day is also a possible symptom ( in emaciated). but here I'm not sure whether lower potencies are better than the higher. Homeopaths are expected to use any and every method of arriving at the similimum.
errata.
ReplyDeletein the second line above please read - less characteristic symptoms of the remedy - ( not remedy relationships)
Really sir, sometimes it becomes too much confusing!
ReplyDeleteI think there isn't anything like lower potencies are better than higher or even reverse! In my sense both are beneficial IF given correctly, and both can be harmful IF given improperly.