Mr S.M., 36 years old, PIN: 16385 visited the clinic on 2 July 2011 for his complaints of cervical spondylitis since last 10 years.
Mr. S.M presented with pain on the left side of the cervical spine, although the pain was intermittent but he was more worried of the persistent numbness that he was experiencing on the left thumb and left index finger. He was a soft ware engineer by profession and his job required him to be on the desk in front of the PC most of the times. A MRI ws done which showed a reduced space in C5 and C7 vertebra which was suggestive of cervical spondylitis.
He was started on Nsaids (non steroidal anti inflammatory drugs) and painkillers for it. He had started using a cervical collar for it. All this didnt give him much relief in the numbness and he couldnt tolerate even carrying a laptop bag on his shoulders.
On further questioning, he mentioned about the numbness and the heaviness increasing more in winters and cold weather. The pain was more on lying on the right side.
With these details, we had to explain to him about the scope of homeopathy in cervical spondylitis and the importance of a detailed case taking.
Hie case was investiagted further and further medical details were asked.
He was a non-vegetarian and his appetite was average. He had no specific likes and dislikes in food and drinks.
His thirst for water was average. He had excess sweating all over the body. His urine and bowel habits were normal. Thermally he was a chilly patient. His sleep was sound.
In appearance he was tall and lean framed.
He was working as a S/W engineer in IT pvt firm and wife was a house wife. His parents lived with him.
As a person he was jovial by nature and he would get along well with everyone in office. But his main stress was that he couldn't tolerate corruption. Amongst colleagues even with superiors if there was some unjustly things happening he would raise his voice. He said I would go to the root cause and find out the person responsible for it and ask him to take responsibility of his wrong action.
He also had a similar approach at home so there were a lot of difference of opinion with his father to the extent that he is not in talking terms with his father at present.
These stresses would cause a lot of strain and would also increase the spasm on the cervical muscle and increase the numbness.
He was explained about the effect of the mental and physical stress on the cervical muscle spasm and he was counselled about keeping a calm mind and tackleling the situation more patiently.
At 2 months follow up (24 September 2011), Mr S.M reported relief in the cervical pain and the numbness.
At 4 months follow up(22 November 2011), Mr S.M reported slight increase in the pain and the numbness. He explained about the effect of weather changes(winter) which was acting as a trigger factor in his case. His need for painkillers had increased and he was again becoming sceptical about the treatment. He was counselled about the common triggers factors in case of cervical spondylitis and the medicines were enhanced based on the feedback and he was asked to keep a calm mind.
At 6 months follow up (21 January 2012), Mr S.M reported good improvement, the pain and stiffness is less. He didn't require to take any painkillers in last 2 months.
At 8 months follow up (21 March 2012), Mr S.M reported that the pain and numbness is much under control and mentally he feels more relaxed and now able to work for long hours on the PC without much discomfort. Although he reported that there is some increase in the pain and numbness when he lifts heavy weights on the shoulders. He was prescribed medicines based on this feedback.
At 11 months follow up (11 June 2012), Mr S.M reported that the pain and the numbness is much better. He has stopped taking painkillers almost 6 months back and he doesn't need to use the cervical collar. He has been asked to continue the treatment as his occupation is one of the causes and can act as a trigger factor for his cervical spondylitis.
Uploaded by Dr Z.A